The Socio-Spatial Contexts of HIV Risk for People Who Inject Drugs in Public Spaces in Nigeria

Abstract

This article explores the socio-spatial factors shaping HIV risk for people who inject in public settings in Nigeria. It draws on thematic coding and analysis of qualitative interview accounts of people who inject drugs (PWID) in public spaces (n = 29) recruited via snowball sampling. Drug injecting took place in diverse spaces (“bunks,” uncompleted buildings, motor parks, and night life environments) that enabled PWID to conceal illicit drug use in public settings. Public injecting resulted from intersecting socio-structural factors, including housing instability, resource constraints, and marginalized forms of drug use. Conversely, the practice was preferred as a beneficial and socially meaningful experience. Although PWID recognized the risks associated with public injecting and enacted risk reduction practices (e.g., using sterile syringes, rinsing syringes), risk reduction was undermined by socio-spatial factors including social discrimination, lack of essential amenities to enable safe injecting, poor access to sterile injecting equipment, and fear of disclosure and police arrests. These factors reproduced an environment of pervasive risk that compromised risk reduction and fostered risky practices such as rushing injection and sharing injecting equipment. There exists a need to create enabling environments for health by enabling access to secure accommodation, implementing safe injecting environment interventions, and exercising discretion in policing to enable access to essential harm reduction services for PWID.

Keywords

HIV health injecting drug use risk environment public space Nigeria

Introduction

Place has long been recognized as an important determinant of health (Braveman & Gottlieb, 2014; Cohen et al., 2003; Fitzpatrick & LaGory, 2003), and place-related factors, including physical characteristics, social networks, and access to resources, have been implicated in the production of health inequality (Browning & Cagney, 2003; Curtis & Jones, 1998). Specifically, spatial segregation has been identified as a mechanism producing health inequalities among socially marginalized populations such as homeless persons, sex workers, and people who use drugs (PWUD). In regard to PWUD, studies show how the physical settings of injecting drug use, such as shooting galleries and public injecting environments, constitute environmental determinants of health risks for people who inject drugs (PWID; Carlson, 2000; Rhodes et al., 2006; Small et al., 2007). This study explores the socio-spatial contexts of HIV risk for PWID in public spaces.

PWID frequently in public settings are at high risk of abscesses, vein damage, blood-borne infections, and overdose (Darke et al., 2001; Dovey et al., 2001). Health harms linked to public injecting result from lack of privacy, poor hygiene and amenity, and fear of interruption and disclosure, which encourage rushed injection, with increased risk of “missed hits,” and disruption of safety and hygiene routines (Rhodes et al., 2006; Small et al., 2007). Public injecting encourages high-risk practices, including sharing of needles and syringes and other drug equipment such as cookers, filters and water, and the distribution of drug solutes to associates with previously used, and potentially contaminated, syringes (Bourgois & Schonberg, 2009; Hunter at al., 2018; Rhodes et al., 2008). Experiences of place are therefore important determinants of health for drug-using populations (Tempalski & McQuie, 2009).

Risk associated with public injecting is linked to fear of interruption during injecting, particularly that associated with police intervention (Rhodes et al., 2006). PWID who inject in public spaces experience increased exposure to police and are therefore disproportionately impacted by policing (Markwick et al., 2015). Diverse policing strategies (e.g., crackdowns, spatial police interventions) are linked to increases in unsafe injecting practices, HIV transmission, fatal and nonfatal overdose, and low access to harm reduction and health care services (Beletsky et al., 2014; Bohnert et al., 2011; Friedman et al., 2006). Fear of police arrest and incarceration increase HIV risk for PWID by discouraging them from carrying sterile equipment and fostering risky practices such as rushed injection and syringe sharing (Aitken et al., 2002; Rhodes et al., 2003; Sarang et al., 2010; Small et al., 2006).

Injecting drug use in public settings has been described as the outcome of “situational necessities” such as homelessness, dependence, opportunity, and an urgent need to use drugs out of “cravings” or to reduce or prevent withdrawal symptoms (Rhodes et al., 2007). Studies associate public injecting with homelessness and unstable housing (Briggs et al., 2009; Hunt et al., 2007; Marshall et al., 2010; Sutter et al., 2019). The link between homelessness/unstable housing and elevated patterns of health harm among PWID, including HIV and HCV transmission associated with drug injecting, has also been demonstrated (Galea & Vlahov, 2002; Kemp et al., 2006). PWID who are homeless face higher risk of sharing syringes and other injecting equipment, and of disease transmission (Corneil et al., 2006; Song et al., 2000; Wright et al., 2005). Yet while public injecting spaces are highly regulated and impacted by socio-structural forces, they are not predetermined by these forces but are rather constructed and shaped in and through their use (Ivsins et al., 2019). The use of public spaces for drug injecting is not solely the outcome of necessity but may also be seen as a dynamic experience involving socially constructed meanings tied to places (Fast et al., 2013).

Research Gaps

The bulk of research on public injecting has been conducted in Europe and North America, with some work done in Australia (e.g., Dovey et al., 2001; Malins et al., 2006). As expected, these studies describe public injecting settings that are common in western societies, including public toilets, lane ways and alcoves, and public or private car parks. While research on injecting drug use in Africa has burgeoned within the last decade or so, especially in East Africa (2016; Beckerleg et al., 2005; Guise et al., 2015; McCurdy et al., 2005; Rhodes et al., 2015; Syvertsen et al., 2015; Syvertsen et al., 2016), there exists a paucity of research on the spatial contexts of drug injecting. To the author’s knowledge, the only study from the region that addresses the physical environment of injecting is McCurdy et al.’s (2005) analysis of youth hangouts in Dar es Salaam, Tanzania, as a socio-spatial context of drug use initiation and transition to injecting. There is a lack of African research that explores the relations between place, drug injecting, and health risks, particularly how socio-spatial factors shape HV risk for PWID.

In Nigeria, the spread of HIV and other blood-borne diseases associated with injecting drug use has long been recorded (Dewing et al., 2006; Eluwa et al., 2012). There are an estimated 80,000 PWID in Nigeria, which is about 0.1% of the adult population (United Nations Office on Drugs and Crime [UNODC], 2019, p. 12). About 9% of PWID report living with HIV and 2.3% with hepatitis C (UNODC, 2019, p. 35). Nearly half of PWID report having shared injecting equipment (UNODC, 2019, p. 32). Group dynamics, withdrawal/cravings, and fear of police arrest have been shown to increase HIV risk for PWID by constraining their capacity to enact risk reduction and encouraging risk practices such as syringe sharing (Nelson & Abikoye, 2019; Nelson & Brown, 2019). While studies have reported injecting drug use among socially marginalized populations such as female sex workers (Adelekan et al., 2014) and homeless populations (Nelson & Brown, 2019), how the experience of public injecting spaces shapes HIV risk for these populations has yet to be examined. Such findings have the potential to inform and enrich harm reduction interventions for PWID in Nigeria.

Study Objective

This study draws upon qualitative data from interviews with PWID in a Nigerian city to explore socio-spatial factors that shape HIV risks for PWIDs in public injecting settings. The study shows how social and spatial factors undermined risk reduction and contributed to elevated patterns of drug and health harms by encouraging high-risk behaviors such as hurried injecting and sharing of syringes and other injecting equipment. Apart from contributing a perspective from Africa on the interplay of place, drug injecting, and health risks, the study expands upon the existing literature by documenting unique public injecting environments in Nigeria.

Theoretical Framing

The interplay of place and socio-structural factors in the production of health risk among PWID who inject frequently in public settings highlights the importance of a relational understanding of place in connection to drug harms. This perspective emphasizes that the consumption of illicit drugs “occurs not only within those bounded areal units conceived as places but also in the dynamic unfolding of socio-spatial relations” (Williams, 2016, p. 1). Place does not simply provide PWID with a setting for the consumption of drugs but is also seen to comprise the “risk environment” (Rhodes, 2002). The “risk environment” provides a conceptual tool for exploring drug use and harms as they are constituted in and through socio-spatial processes (Williams, 2016). Conceptualized as “the space—whether social or physical—in which a variety of factors interact to increase the chances of drug-related harm” (Rhodes, 2002, p. 88), this heuristic “helps to overcome the limits of individualism characterizing most prevention interventions as well as appreciate how drug-related harm intersects with health and vulnerability more generally” (Rhodes, 2002, p. 85). Attentive to the reciprocal relationship between individual agency and environmental constraints (Giddens, 1984), it emphasizes how drug-related harms are structurally constituted in specific socio-spatial settings through the differential impacts of social, economic, and political processes, just as they are mediated by individual behaviors and interpersonal relationships (Duff, 2010; Moore & Dietze, 2005).

The work of Lefebvre (1991) extends understanding of the risk environment of drug-related harms by showing how “socially-produced spaces construct harmful practices” (Parkin & Coomber, 2011, p. 718). Lefebvre maintained that space is socially produced through three interrelated processes whereby space is continually being “shaped, reshaped, and challenged by the spatial practices of individuals and groups whose identities and actions undermine the homogeneity of the [urban space]” (McCann, 1999, p. 168). “Spatial practice” refers to the collective production of space through everyday activities. “Representations of space” addresses the way space is conceived, demarcated and administered by specialists (e.g., planners, architects) in the interest of the state. Finally, “spaces of representation,” or “lived spaces,” references everyday lived experience of space, which offers possibilities for resisting and transforming the exclusionary regimes fostered by representations of space. Urban space is therefore produced through the activities of a heterogeneous citizenship, where the struggle for the control of public space produces “new modes of inhabiting” (Mitchell, 2003, p. 18). For socially disadvantaged populations such as PWID and homeless populations, this process leads to spatial segregation and social exclusion. This helps to explain why homeless populations consume drugs in unsanitary and derelict spaces that increase drug-related harm (Dovey et al., 2001; Malins et al., 2006; Parkin & Coomber, 2011; Small et al., 2007).

Public injecting, as spatial practice, allows PWID to create spaces of representation and to insert themselves into public space (McCann, 1999). This does not, however, lead to social inclusion or the accommodation of difference. Instead, it reproduces “abject spaces” since public injecting is a transgression of spatial boundaries (England, 2008; Parkin & Coomber, 2011). Public injecting reproduces abject spaces because it defies the systemic order by refusing to adhere to clear definitions of space and bodies. Abject spaces are those in and through which marginalized populations (e.g., PWID, homeless populations) are condemned to the status of outsiders and stripped of their existing or potential citizenship (Isin & Rygiel, 2007). Public injecting settings are abject spaces because they transgress dominant socio-spatial orders by appropriating space for other than intended use. Both abject spaces (i.e., public injecting settings) and abject bodies (PWIDs in public settings) are subject to surveillance, policing, and control in ways that increase risk and harm (England, 2008).

Method and Data

Between October 2016 and February 2017, qualitative interviews were conducted with PWID in Uyo, the state capital of Akwa Ibom, Nigeria. The city has an estimated population of 309,573 persons. A large segment (51%) lives in absolute poverty (National Bureau of Statistics, 2010). An estimated 12.5% (352,000) of people aged 15–64 years use illicit drugs in Akwa Ibom State, including heroin and cocaine (UNODC, 2019, p. 24). The study aimed to describe the local risk environment of injecting drug use from the perspectives of PWID (Nelson & Abikoye, 2019). Ethical approval was obtained from the Health Research Ethics Committee of the Ministry of Health, Akwa Ibom State, Nigeria (MH/PRS/99/Vol. IV/224). Those currently injecting drugs, defined as having injected drugs in the past 30 days, were eligible to participate. To confirm that prospective participants were currently injecting, they were asked to show needle marks on their bodies as evidence.¹ Participants were recruited through snowball sampling, with a quota for female PWID. Four PWID were contacted through community-based drug services, the aims of the research were explained to them, and they were asked for consent to participate in interviews. Three participated and also referred other PWID, who in turn referred others. Data collection took place in two phases to allow for provisional coding to inform the direction of subsequent data collection. The present study is based on the accounts of 29 “public injectors” (including six females), drawn from a larger sample of 41 PWID. Being a public injector, defined as experiencing housing instability, engaging in precarious income-generating activities, and purchasing and consuming drugs in public settings (Moore & Dietze, 2005), was the criterion for inclusion. Consequently, 12 PWID who did not inject in public settings were excluded from this study.

Interviews were based on a topic guide, which was revised in the course of data collection and analysis. They began with a set of open-ended questions:

“Could you describe the place(s) where you inject drugs?”

“Can you tell me the risks you have experienced due to injecting drugs in this place(s)?”

“Could you explain why you continue to inject in this place(s) in spite of these risks?” and

“Could you describe how you seek to reduce these risks?”

Information on participants’ demographic characteristics and drug use patterns was also sought. Interviews were conducted in English at a local drop-in center for PWUD to ensure accessibility, safety, and confidentiality. All participants gave verbal consent prior to interview, aware that interviews were tape-recorded and that they could withdraw at any time. Interviews (which lasted between 40 and 75 minutes) were conducted in English by the author and a trained female outreach worker. Each participant received five hundred naira (₦500 or US$1.37) for transportation. The cost of transportation within the city was considered in determining the amount given.

Interviews were transcribed verbatim from digital recorders, and transcripts were cross-validated against the recordings for accuracy. Coding and analysis were undertaken on the transcripts to identify patterns of meaning, following the thematic analysis procedures described by Braun and Clarke (2006). Coding, based on key concepts and descriptions, was informed by the interview topics and inductive codes generated through immersion in the transcripts. A tentative coding scheme, developed after the first four interviews were transcribed, was independently assessed by two experts to improve analytic rigor (Syed & Nelson, 2015). Consequently, unreliable codes were dropped or merged, and the definitions of codes were improved. Coding was done manually by assigning codes to relevant portions of transcripts (Campbell et al., 2013). A second round of coding broke down the data into smaller units. The analysis emphasizes four interrelated themes: “injecting places,” “risky injecting practices,” “risky places,” and “rationalities of place.” Verbatim quotations are used to illustrate key themes, along with pseudonyms to protect participants’ identity. The quotations have been rendered so as to preserve participants’ speech patterns.

Results

Sample Characteristics

Participants (n = 29) were mostly male (n = 23) and between the ages of 26 and 35 years. About half had secondary level education (n = 15). Informal economic activities (e.g., petty trading and touting) were the most common livelihood strategy for participants. Some female participants were involved in commercial sex work (three out of the six), along with other income generating activities. Four female and 19 male participants had regular sexual partners. Multiple sexual partnerships were common among male participants, and two female participants reported exchanging sex for drugs. The majority of male participants had been injecting for more than 3 years, with high drug consumption levels (defined as injecting at least 3 times a week). Brown powder heroin (“Thailand”) was the most commonly injected drug, followed by crack cocaine (“Block”). Amphetamine-type stimulants were also injected, and multiple drug use was common. Most participants injected more than one drug (e.g., heroin and cocaine).

Injecting Places

As interviews proceeded, it became clear that some of the public injecting spaces reported in the western research literature (e.g., alcoves, stairwells, thoroughfares, and cars) were absent from participants’ accounts of where they inject drugs. There was a preference for more secluded locations, which could conceal drug use activities. Participants injected drugs in different public settings, the most common being “bunks.” Bunks are secluded locations where illicit drug trade and consumption take place on a regular basis. While some would only inject in bunks if they had an urgent need to do so, the majority of participants injected drugs in these setting regularly:

I inject in the bunks most of the times, in fact all times…once you go there and get your stuff, why will you leave? The anxiety to shoot is too much so you just do it there at once. (Godwin, male, 30)

The above quote by Godwin indicates that purchasing drugs at the bunk, along with craving (“anxiety”), facilitated injecting in this setting. Bunks are usually operated by a drug dealer or dealers. Godwin described a bunk thus:

It is the real place where people go to do drugs. What I mean is that it is like a market. Like there is market for food and other things that people buy. So there is a market for hard drugs. It is called “bunk.” There is always a dealer who sells drugs. He runs the place. He knows who comes there and who does not.

Drug injecting does not take place in all bunks. Participants described how most bunks catered for cannabis users, with a few persons snorting cocaine or ingesting prescription drugs. Drug injecting mostly occur in bunks that are located at the margins of the city (abject spaces), providing sufficient space for individuals and groups to prepare and inject drugs. Injecting bunks also provide a greater degree of organization and control when compared with other types of bunks (“the dealer and his boys [his paid staff] run the bunk”; Maxwell, male, 26). There are usually escape routes that provide safety in the event of police crackdown. According to Maxwell:

It is at the big bunk that people shoot-up. It is not the one behind somebody’s house. Nobody will inject there because it is not safe, if police come. It has to be far away from town and big so that people can have space…. You will see people everywhere cooking and injecting.

Apart from bunks, PWID also injected drugs in derelict (uncompleted or abandoned) buildings, particularly those located in emerging residential areas as these offer a greater degree of secrecy and safety than those located in more populated inner cities. Those who inject in these locations often disguise themselves as laborers to stave off suspicion and take turns to watch for possible intrusion. According to a participant, this is “so that police will not come and arrest people while they are shooting-up” (Itoro, male, 31).

Injecting drug use also occurs in latrines within “motor parks” (expansive garages for commercial transporters, which are distinguishable from car parks in developing societies). Here, injecting takes place late in the evening to avoid disclosure. Fear of motor parks as hideouts for “bad boys” (criminals) favors PWID as these spaces are avoided by members of the public after dark. Parks also provide accommodation for rough-sleepers, including homeless PWID:

If you go to motor parks in the evening, you will see people doing drugs. It is like a common thing in the parks. Some of them even sleep there because they have no place to sleep. Park is the best place ever for taking drugs. No policeman or anybody will come there to see what people do. People are afraid to go in evening. (Utin, male, 26)

Injecting drug use may also take place in nightlife environments (e.g., clubs):

You can take drugs, as per inject, at the club. Most of these clubs allow people to do drugs around there. I have not taken drugs there before, but I know it happens all the time because I know people who shoot there, like every time. (John, male, 28)

Public injecting drug use confers the benefit of protection from overdose because of the presence of other people. It, however, increases the risk of police crackdowns, syringe sharing, and transmission of blood-borne viruses. Public injecting therefore involves the interplay of risks and benefits.

Risky Injecting Practices

The interview accounts indicated that participants recognized the risks associated with public injecting, but they tended to minimize them as part of everyday life. “It is not a big deal” and “it happens like that sometimes” were common comments on the risks associated with injecting in public settings, which suggests a degree of normalization and acceptance of risks:

Like those of us who are on the streets, it [risk] is part of life. It is not a new thing. It is something you live with. When you are on the streets, you just take things as they come. (Ben, male, 29)

Risks were also described as an inevitable part of a drug use lifestyle. The inevitability of risk was a pervasive attitude among PWID, fostering a sense of futility that could undermine risk reduction. This attitude was most common in relation to the risk of HIV transmission:

I am not so much afraid of having AIDS. If you will have it, you will have it. There is nothing you can do about it. You try to protect yourself and all of that. But AIDS is there and it will come if it will come. (Rose, female, 29)

Although participants recognized the risk of disease transmission associated with injecting with potentially contaminated equipment, and attempted to mitigate this risk by using sterile syringes as often as possible, they were deeply concerned that it was impossible to consistently use sterile equipment and that the possibility of infection existed due to past or future unsafe drug injecting. The following comment shows how accounts can be fraught with uncertainty and contradictions regarding risk:

As in, nobody wants to get AIDS and die. You protect yourself. Me, I try to get new works. But I cannot say that I don’t have AIDS because what if I shot with someone’s works? What if I use tomorrow or I have used it before? So I cannot say. (Itoro, male, 31)

Syringe sharing was linked to the unavailability of sterile syringes in public injecting environments. Sterile syringes were purchased from dealers (“you can buy syringe from dealers”; Maxwell, male, 26), or obtained from a friend who has more than one (“a friend has more than one syringe so you get from him”; John, male, 28). But dealers may deplete their stock of syringes and friends may not have any to spare. Syringe sharing was therefore seen as an integral part of public injecting. John (male, 28) narrated his experience:

There was this day that I borrowed works to inject. The baron [dealer] sold everything out. I was so hungry [desperate] to shoot. I had the thing [drug] cooked and all, and I was looking for works. So I waited for this guy who was taking [drugs] to finish then I used his [equipment].

Syringe sharing was also linked to experiences of withdrawal. Participants described how an urgent need to obtain relief from withdrawal pains by injecting drugs may take precedence over concern about HIV transmission, resulting in receptive syringe sharing. For example, Rebecca stated:

If I am sick and I didn’t have a syringe, I will borrow from anyone. At that point, I am not thinking about HIV or any disease. I am thinking about how to get well. The suffering is too much. (Rebecca, female, 28)

Risky Places

PWID sought to reduce risk by rinsing syringes in water to disinfect them. Water is scarce in public injecting settings, and PWID may rinse multiple syringes with the same water, thereby increasing the risk of viral transmission through contaminated rinse water:

It is not easy to get water to wash syringe. You need a little to boil the drug to inject. It is not enough to wash the syringe. Sometimes we use little water to boil drugs and everybody will wash their syringes with it also. (Maxwell, male, 26)

Accounts emphasized that PWID do not carry syringes for fear of police search and arrest. A preference for sourcing syringes from the place where drug injecting takes place due to fear of police arrest, along with limited supply of sterile syringes, elevated the risk of syringe sharing:

You don’t carry syringe around because if the police find them, they will arrest you…. So I have to get new ones each time I go to the bunk. But if I can’t get a new one, I will have to use any one I find. I have no choice. I have the drug ready, but I have no works. I have to borrow from someone else to inject. (John, male, 28)

Public injecting was seen as inherently risky, despite risk reduction efforts. A fundamental source of risk was street-level policing, which was frequent and caused great consternation among PWID. Fear of police arrest compromised individual ability to practice risk reduction, encouraged hurried injecting and injecting with borrowed syringes:

As you are injecting, you know that police may come at any time. So you cannot be slow. You have to hurry. Mix your drugs and inject it without wasting time. If you do not have new works, you get old ones from others. (Itoro, male, 31)

PWID were also concerned about the risk of “missed hits” associated with rushing injection. This was amplified by the physical characteristics of the injecting environment, including lack of privacy and poor lighting, especially in the evenings. These factors increased the risk of missing veins, which could have serious health consequences including vein damage and abscesses:

Like I am there at this building shooting up. I am so afraid that I could be caught or it is dark and I cannot see things very well. I am trying to hurry and inject so I can get away from there. I might miss and hit my skin. It is so painful. (Ekarika, male, 33)

Accounts also emphasized poor sanitation and lack of hygiene associated with public injecting settings such as latrines and derelict buildings, which were seen as contributing to poor health for PWID:

It is a very dirty and smelly place. I mean the latrine. There is poo poo [feces] and pee [urination] everywhere. The whole place is so bad and you could get disease there. You manage to shoot-up there because you know that people do not come there like every time. (Oku, male, 27)

Public injecting settings also featured as places of risk in terms of patterns of drug use. Injecting in bunks, for example, encouraged the formation of new drug-using networks in which individuals “show each other love” when one urgently needs to inject due to withdrawal but cannot “score.” This led to more frequent drug consumption as a result of networking with “friends” to finance, score and share drugs, and to concern about being “cheated out.” As Ben (male, 29), remarked, “I usually do drugs more when I am doing with the group so I don’t get cheated out.”

Rationalities of Place

Given that public injecting was fraught with risks, interviews probed why participants continued to inject in these settings. Following Rhodes et al. (2007), public injecting was described as a response to “situational necessities.” A key factor was lack of accommodation, particularly for the homeless and those squatting with friends/acquaintances. For these PWID, public injecting was the only option. Comments like “what will I do?” and “I have no other place” were common.

Homelessness and unstable housing were seen as a major factor contributing to unsafe injecting in public settings, and there was recognition of the inevitability of other related problems such as theft, violence, and poor health. As Ben (male, 29) commented:

Injecting in a park is bad because you may get infection…. But it is not only disease o! You get sick because you are sleeping in cold. You have problem with “area boys” [criminal gangs] and police because you are like a thief.

Another factor was related to an urgent need to use drugs due to “cravings” and concern for moderating withdrawal symptoms. There was a tendency to elevate withdrawal pains above HIV infection because of its immediacy and acuteness compared with the former. As Rebecca (female, 28) put it: “HIV will take time before it shows…. It can be treated…. But cold turkey can kill you.”

Although public injecting was a result of need and constraint, it could also be chosen because of the potential benefits. For example, injecting drugs in bunks enmeshed individuals in subcultural norms of generosity and reciprocity, which guarantees free drugs and equipment on those occasions when one cannot score, particularly during withdrawal:

On this day, I went to the bunk. I was broke. I didn’t have a dime to score. Plus I was having pains all over. I knew that I will find someone to “show me love” [share drugs]. A friend told me “how far? I have some [drugs] left if you want.” (Ekarika, male, 33)

Reciprocity also provided safety in the event of an overdose based on the ethic of mutual help: “Anybody can ‘para’ [overdose] so help others so that others will help you” (Rose, female, 29). Injecting in bunks also provided an opportunity for PWID to interact with others, form friendships, and share crucial information and other resources such as temporary accommodation, food, and income generating opportunities.

Discussion

This article provides a detailed description of public injecting environments in Nigeria. Outdoor spaces where young people gather to socialize and inject illicit drugs (known as “magetos”) have been previously described in Dar es Salaam, Tanzania (McCurdy et al., 2005), but this study described only one type of injecting environment. Importantly, it did not explore how young people’s experiences of these spaces shaped risk in relation to injecting drug use. The accounts canvassed in this article describe public injecting settings that are different from “magetos” and other settings that have been described in the predominantly western literature. “Bunks” are distinguished from shooting galleries and similar injecting environments by their seclusion, organization, and relative safety. Public latrines in motor parks are similar to public toilets and car parks in western societies. But unlike similar amenities in western societies, these facilities are highly unsanitary, dilapidated, and in disrepair. These facilities are also unique in the way they link public injecting with homelessness, destitution, crime, and insecurity. What the spaces described here share with those in other societies is a high-level of socio-spatial segregation (Dovey et al., 2001; Malins et al., 2006; Parkin & Coomber, 2009; Wood et al., 2004).

The injecting environments described by the participants are derelict spaces. While offering limited personal privacy, they provide PWID opportunities to conceal their illicit behaviors in public space (Parkin & Coomber, 2009). The appropriation of public spaces for injecting is a transgression of public order, which reconstitutes “representations of space” as “lived space.” The transgressive character of public injecting makes these environments abject spaces, and those who inject there are abject bodies (England, 2008). This echoes Dovey et al.’s (2001) claim that it is not only the act of injecting but also its location that constructs identity by connecting it to derelict space, homelessness, and social marginalization. The social production of abject spaces and bodies is fostered by policing practices, which undermine risk reduction and encourage risky behaviors such as hurried injecting and sharing of injecting equipments. This is consistent with previous research that shows how policing practices in relation to public injecting increases HIV risk for PWID (Aitken et al., 2002; Rhodes et al., 2003; Sarang et al., 2010; Small et al., 2006). Physical environment interacts with enforcement-based policies and social discrimination to create a risk environment for drug harms. Drug harms are therefore not solely the consequence of the physical environments of drug use, but also of structural policies, norms, and practices comprising the broader risk environment.

The findings reported here support the view that public injecting is the outcome of “situational necessities,” including homelessness and unstable housing (Rhodes et al., 2007). Injecting in public spaces was seen as the product of constraint and need. The contribution of homelessness and unstable housing to high-risk drug use and health harms among PWID has been well documented (Briggs et al., 2009; Corneil et al., 2006; Song et al., 2000; Wright et al., 2005), and a case has also been made for the provision of housing as part of the production of “enabling environments” for health. This is relevant to Nigeria, where the provision of stable accommodation should be a major structural HIV intervention for PWID (Nelson & Brown, 2019). But notions of constraints and necessity in the accounts reported here overlapped with those of choice linked to the benefits of public injecting, particularly participation in cultures of gifting, exchange, and reciprocity, which protected PWID against overdose and withdrawal sickness in the context of resource constraints and lived experience of marginalized drug use. Studies show that injecting drugs in public spaces could be a dynamic experience linked to the socially constructed meanings attached to these places (Fast et al., 2013; Ivsins et al., 2019). Public injecting spaces are, therefore, not predetermined by socio-structural factors but constituted through their everyday use (Ivsins et al., 2019). Furthermore, the interplay of constraints and choice highlights the reciprocal relations between environment and agency, where agency is both constituted and constrained by environment (Giddens, 1984). It is important that local interventions recognize PWID’s capacity for agency and build on this capacity to reduce HIV risk. For example, needle and syringe programs could leverage the willingness of PWID to inject with sterile injecting equipment to prevent HIV transmission.

As the accounts highlighted, drug injecting takes place in derelict spaces characterized by poor sanitation and lack of basic amenities to enable hygienic injecting (Parkin & Coomber, 2009; Small et al., 2007). Socio-spatial dynamics of public injecting influence risk perception and foster a degree of normalization and acceptance of risks. This shows how risk perception and behaviors among PWID are situated within different injecting environments (Bourgois et al., 1997; Rhodes et al., 2006). Risks are seen as pervasive and integral aspects of an abject lifestyle. There is a sense of futility of risk reduction efforts due to the ubiquity and inevitability of risks. This is not to say that PWID are passive victims of risk environments. On the contrary, findings show individual and collective strategies for mediating and transforming risk environments, including the use of sterile syringes, rinsing syringes, and partnerships to score and use drugs and ensure safety at injecting sites. Yet while these strategies show agentive capacity, accounts show how socio-spatial factors, including scarcity of sterile syringes and amenities for safe and hygienic injecting, fear of disclosure and police arrest, constrain risk reduction.

Furthermore, withdrawal, disclosure, and police arrest were seen as immediate and consequential risks, trumping that of disease transmission associated with sharing of injecting equipments. Measures taken to reduce risk (e.g., concealment, urgency, speed) ultimately produced risk by fostering risky practices such as rushed injections, injecting in unhygienic spaces, and sharing of syringes and other injecting equipment (Fitzgerald et al., 2004; Parkin & Coomber, 2011; Rhodes et al., 2006; Small et al., 2006). Possible responses include establishing safe injecting facilities (SIFs) and provision of sterile injecting equipment in public injecting spaces via peer-led outreach services. Peer education could also help to change risk perception and encourage risk reduction practices.

Accounts highlight how concern about police arrest creates “geographies of fear” (England, 2008), constraining individual’s ability to practice safe injecting. Public injecting environments were described by participants as the target of police crackdowns, and fear of arrest deters possession of syringes, and encourages receptive syringe sharing, rushed injecting and other high risk injecting practices. Findings echo previous research on the social and environmental factors influencing risk within microenvironments such as public injecting settings. Concern about police arrest constrains access to sterile syringes and contributes to high-risk injecting practices such as receptive syringe sharing and “missed hits” owing to rushed injections (Aitken et al., 2002; Cooper et al., 2005; Rhodes et al., 2003; Sarang et al., 2010; Small et al., 2006; Small et al., 2007). Fear of police crackdowns may contribute to accidental syringe sharing as individuals hiding injecting equipment may unintentionally use another person’s syringe (Small et al., 2007). A previous study in Nigeria documented actual experiences of punitive policing, including frisking, physical violence, arrests, and confiscation of injecting equipment, which created an environment of fear that undermined risk reduction and increased HIV vulnerability for PWID (Nelson & Brown, 2019). Adopting discretionary policing strategies that prioritize public health could support safer injecting and enable access to harm reduction services without fear of arrest. Such changes require community support and are relative to wider reforms in law enforcement in Nigeria. The legal environment is changing in response to global momentum for reform (Nelson & Obot, 2020), and the data presented here could be used to anchor advocacy for the desired reforms.

While the findings from this study suggest the importance of socio-spatial processes in shaping risk reduction and risk practices within public injecting risk environments, a number of issues have not been explored in sufficient depth due, in part, to the small scale of this study. First, it is possible that there exist other public settings where injecting drug use takes place that have not been brought to light by the present study. Types of injecting spaces may vary across research sites (e.g., urban vs. rural sites) and sample size (a larger sample may reveal a wider range of injecting settings). Large-scale surveys are needed to identify these locations, while qualitative studies are suited to teasing out the socio-spatial dynamics of injecting and risks therein, providing deeper insights that could inform local interventions. Second, we know little about the intersections of place, drug injecting, and norms of reciprocity, including how place mediates the development and entrenchment of these norms and practices. There is a need for research engaging with these issues, including explorations of the potential challenges they pose to health education and the opportunities they provide for optimizing the effectiveness of such programs. Finally, but by no means the least, this study does not afford a detailed treatment of the ways gender mediates the experience of place in relation to public injecting drug use and health risks. This subject warrants further research, particularly in view of the critical role of gender in influencing injecting practices and risk management among PWID.

Conclusion

The study shows that public injecting is not a matter of individual capacity to exercise choice, but a product of agency and adaptation within the lived context of drug use, resource constraints, and housing instability. Although PWID recognized the risks associated with public injecting and enacted risk reduction practices, risk reduction was undermined by socio-spatial factors such as lack of essential amenities to enable safe injecting, poor access to sterile injecting equipment, and fear of disclosure and police arrests. These factors reproduced an environment of pervasive risk that adversely affected risk perception and fostered risky practices such as rushed injections and sharing injecting equipment. Creating an enabling environment for health is fundamental to reducing risk. This involves enabling access to secure accommodation for homeless drug using populations and establishing SIFs, which could reduce risk of HIV transmission, link PWID to treatment, and manage overdoses that could be fatal in other settings (e.g., abandoned buildings, nightlife environments). Public injecting environments themselves are also potential sites for interventions, including provision of sterile injecting equipment as well as peer-based interventions to improve knowledge and encourage adoption of safer injecting practices. The exercise of discretion in policing, to enable access to sterile injecting equipment without fear of arrest, is essential for achieving harm reduction and HIV prevention for PWID in Nigeria.

Footnotes

Authors' Note

I am responsible for all shortcomings in the work.

Acknowledgments

I am grateful to the Editor, David Moore, and the anonymous reviewers for their critical comments, which greatly enriched the article. The article also benefited from conversations with Nkoyo Nelson and Nsidibe Essien. The assistance of Imoh Michael during recruitment of participants is also appreciated.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ediomo-Ubong Ekpo Nelson

Note

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