C1. Introduction
C.2 Levels of Indigenous injecting drug use
C.3 Characteristics of Indigenous IDUs
C.4 Drug use and drug injecting
C.5 Sources of clean injecting equipment
C.6 Unsafe injecting and knowledge of risks
C.7 Education and other services

C1. Introduction

As indicated in section 1.4 of this report, several research studies have been undertaken in Australia over the past ten years or so among Indigenous IDUs in various geographical contexts. Given the difficulties of accessing this target group, such studies have typically relied on small sample sizes and on research methods that have been pragmatic in nature. While none of them individually provides definitive or representative data on the patterns of injecting drug use in Indigenous populations, together they offer a useful set of findings of relevance to the present study.

In particular, the following research studies have been considered in this review:
  • A 2005 study of 70 Indigenous IDUs in urban and non-urban settings in the ACT, NSW, Victoria, Western Australia and the Northern Territory. Conducted by the Australian Federation of AIDS Organisations (AFAO) and the Australian Injecting and Illicit Drug Users League (AIVL), the study recruited participants through AFAO and AIVL member organisations. A blend of quantitative and qualitative information was gathered from respondents1.

  • A 1996 study of 77 Indigenous IDUs in the Brisbane area. A structured questionnaire was administered by peer interviewers, specifically trained for the purpose2.

  • A series of cross-sectional studies conducted in Sydney between 1997 and 2001. Indigenous people who either inject drugs or participate in a methadone program were selected for interview. A range of methods were used to recruit people through services and word of mouth. The quantitative data obtained were analysed as three separate data sets, with sample sizes of 68, 121 and 233.

  • A 2001 study amongst 74 Indigenous IDUs in urban and non-urban areas of Western Australia. The study used peers interviewers to both recruit participants and conduct interviews, seeking both qualitative and quantitative data.4

  • A study among 307 Indigenous IDUs in metropolitan Adelaide, released in 2003. The study (based on fieldwork conducted in 2001) used peer interviewers to collect both qualitative and quantitative data from respondents recruited through a 'snowballing' process5.

  • A study conducted over two years and completed in 2004 in the ACT, based on qualitative and quantitative research with 95 Indigenous illegal drug users (IDUs and others). Participants were recruited via a variety of services and through word of mouth6.
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C.2 Levels of Indigenous injecting drug use

Most of the studies that are discussed here note the lack of reliable data on the prevalence of injecting drug use amongst Aboriginal and Torres Strait Islander people. However, as early as 1994 the National Drug Strategy Household Survey (1994)7 found that 3% of Indigenous people in urban areas reported that they had injected drugs (with 2% having done so in the last 12 months). This compared to 2% of the wider Australian population who reported having ever injected drugs, and 0.5% who had done so in the previous 12 months. Thus there has for some years been evidence to suggest that Indigenous people are over-represented in the IDU population8. Such evidence is supported by more recent research. For example, the NSW study released in 20019 found that Indigenous people were consistently over-represented in the IDU population across three separate data collections. The figures ranged from 15% at the lowest to 19% at the highest (much higher, obviously, than the approximately 2% of Australians identifying as Indigenous).

The National Centre in HIV Epidemiology and Clinical Research10 released data in 2005 that demonstrated that the percentage of blood-borne infections attributable to injecting drug use amongst Aboriginal and Torres Strait Islanders had risen between 1995-1999 and 2000-2004 from 7.5% to 20.6%. There was no comparable rise amongst non-Indigenous people.

The 2001 Western Australian study11 considered longitudinal hospital admissions data that in the researchers' view provided a fairly clear indicator that injecting drug use among Indigenous people had been increasing. They reported that between 1996 and 2000 there was a 125% increase among Aboriginal females and a 119% increase among Aboriginal males in hospital admissions for conditions thought likely to be associated with injecting drug use. These increases were 6.6 and 2.4 times greater than increases among non-Aboriginal females and males respectively.

While most NSP services do not routinely collect data to identify clients as Indigenous, their feedback provided to researchers across a number of these studies has indicated that increasing numbers of Indigenous people are being encountered. While this could of course reflect a pattern of increaseduse ofservices, it has generally been thought to indicate that Indigenous injecting drug use was on the rise.

A literature review conducted on behalf of Danila Dilba Medical Service in 200012 notes that 'a number of studies have found that injecting drug use is more prevalent in urban Indigenous communities than in rural Indigenous communities'13, and notes that the proportion of the Indigenous population who live in urban areas is around two-thirds.
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C.3 Characteristics of Indigenous IDUs

As noted above, the methodological limitations of past research studies mean that they cannot be expected to offer a reliable demographic profile of Indigenous IDUs; nor, of course, can they provide a reliable basis of comparison between Indigenous and non-Indigenous IDUs. Typically, research participants have been recruited through informal channels, although with efforts being made to ensure that a reasonable cross section of participants is included. The studies have engaged research participants via NSPs and other services and through informal networks of injecting drug users. It is clear that the 'samples' obtained in such ways are likely to be biased towards people who are accessing services. In any case, even if more rigorous recruitment methods could be adopted, there are of course no available data on the Indigenous IDU population that could be used to provide a basis for reliable sampling. While acknowledging these reservations, the following paragraphs summarise some of the results of earlier research involving Indigenous IDUs.

In terms of age, the past research indicates that a significant proportion of young people are represented in the Indigenous IDU population (a finding that is also widely reported for IDUs in general – see below). For example, the early Queensland study14 found that the mean age of first injecting was 17.8 years and that 39% of those included in the study had commenced injecting before age 16. Younger respondents tended to report a lower age of first injecting than did older respondents. The conclusion drawn here was that, at that time at least, there was a trend towards younger Indigenous people becoming increasingly involved in injected drug use.

The WA study15 found a similar pattern. The age at which the 74 respondents reported having first injected drugs ranged from eight to 42 years. Some 34% had first injected at the age of 14 years or less, and a further 40% between the ages of 15 and 19 years. The researchers also reported a trend for the age of first injecting to decrease over time – with only 13% of those now aged 30 or more years having started injecting before the age of 15 years, compared to 47% of those now aged 20 to 29 years.

The SA study16 found that the average age of first injecting was 18.3 years, while a small number of people reported being as young as 10 or 11 years when they first injected. Only 3% were 30 years or older when they first injected.

In terms of age of first injecting, these various findings suggest little difference in Australia between Indigenous and non-Indigenous IDUs, with numbers of other studies and reports referring to a mean or median age of around 18 or 19 years. For example the NCHECR National Data Report on the Australian NSP Survey 2003-2007 reports 18 years as the median age of first drug injection among the NSP clients surveyed17.

In terms of gender, some conflicting anecdotal evidence and survey data emerge from the literature. The NSW study18 found that (in the largest of the samples it analysed) there were roughly equal numbers of male and female Indigenous IDUs, while in the non-Indigenous sample there were about two-thirds males to one-third females. Other studies generally recruited larger proportions of males than of females (at about this same ratio of two-thirds to one-third). Additionally, service providers consulted as part of these studies were often of the view that more Indigenous males than females attended services19, but that women certainly made up a significant proportion of Indigenous IDUs. One study20 included a number (7%) of transgender people in its sample. Again the available information on gender suggests similarities between Indigenous and non-Indigenous IDUs; on the basis of the NCHECR Data Report referred to above it would appear that, overall, males account for approximately two-thirds of IDUs using NSP services21.

In terms of level of education, it has fairly consistently been reported that educational attainment among Indigenous IDUs is low by mainstream standards (as is also true of Indigenous Australians overall). For example, the WA study22 found that 48% of respondents had not completed Year 10 schooling, with a further 38% saying that Year 10 was the highest level attained. The Queensland study23 found that the average age of leaving school was 15, and that about half the respondents reported having had no further education after leaving school. However, in both these studies, small proportions had gone on to further education at a VET institution or university, and a handful of respondents were currently enrolled in high school or at a VET institution or university.

In the Queensland study24, 65% of those interviewed were unemployed and 25% had never had a job. A national study25 reported that 65% of its urban sample and 59% of its non-urban sample were employed – including those employed through the CDEP.

A history of incarceration was common amongst Indigenous participants in all of these research studies. For example, the national study26 found that 44% of urban respondents and 27% of non-urban respondents had spent time either in gaol or in a juvenile detention centre; some 10% had been incarcerated in the previous 12 months. The Queensland study27 found that 39% had been in detention at one time or another; this was particularly common amongst the younger respondents, with 50% of those under 21 having a history of detention. The NSW study28 found that the likelihood of past incarceration was higher in the Indigenous population than the non-Indigenous population (68% vs 49%). Other available data tend to confirm that Indigenous IDUs experience disproportionately high rates of imprisonment; for example, over the period 2003-2007 the percentage of all IDU respondents to the Australian NSP Survey who had been in prison in the past year ranged between 13% and 18%29.

Some of the earlier research reports (eg Something is Going to Get Us, 2005) emphasise that Indigenous IDUs are by no means a homogeneous population, and that harm reduction measures thus need to target both urban and regional populations, diverse age groups and the like.
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C.4 Drug use and drug injecting

Earlier Australian studies indicate that drug preferences and drug use are reflective of local conditions (eg local drug culture, supply and cost issues) and may well change over time. In general, however, while a large number of illicit drugs figure in the list of drugs reportedly injected, there is a strong prevalence of amphetamine use although a preference for heroin.

The 2005 national study30 found that amphetamines were most often the last drug injected (44%), followed by heroin (39%). There was a clear difference here between urban and non urban areas. Urban respondents (44%) were more likely than non-urban respondents (27%) to report having last injected heroin. In turn, urban respondents (35%) were less likely than non-urban respondents (64%) to report last injectingamphetamines.

The Queensland study31 found that all but one respondent had injected speed in the past, and 77% said this was the drug they had last injected. Some 66% had injected heroin, with 35% saying that this was the drug they last injected. A number said that they often used speed and heroin together in the same injecting session. Smaller numbers of people reported injecting other drugs including methadone, 'homebake', ecstasy, benzodiazepines, steroids, hallucinogens, cocaine and morphine.

The SA study32 found that 97% of respondents reported having used more than one drug in the past; the median number of drugs currently being used was four. Although non-injectable drugs such as cannabis figured prominently in the responses, 46% of respondents reported using both speed and heroin at least once per week. A high 82% said that they had injected heroin and 70% said they had injected speed. Heroin, however, tended to be the drug preferred – 56% preferred heroin as against 33% for speed.

The WA study33 found that 76% of those surveyed had injected more than one type of drug. By contrast with the studies conducted elsewhere in Australia, however, the WA study reported respondent 'ambivalence' towards heroin; only 19% had injected heroin on anything other than an experimental basis.

The SA study34 showed that among people who had injected heroin, only a minority had first tried it in some other form (eg smoking or ingesting it). Amphetamine injectors were much more likely to have first taken the drug via a method other than injecting; for example, 45% said they had snorted speed before they had tried injecting it.

The research presents a generally consistent picture of the circumstances in which people first injected drugs and continued to inject drugs. For example, the SA study35 found that 81% of first-time injectors received some assistance, 76% of these from another Aboriginal person – usually a relative (45%), friend (39%) or partner (14%). In the Queensland study36, 84% stated that their first injecting experience was in the company of a relative or close friend. Some 65% of respondents identified these 'helpers' as Indigenous.

The national study37 found that among various factors contributing to the commencement of drug injecting, exposure through social networks was significant. Friends and 'people I grew up with' were commonly reported as the individuals providing the first exposure to injecting drugs. Exposure through family was also identified: siblings and cousins were the relatives most often reported, though parents and uncles were also commonly mentioned.

The WA research38 provides some detail about ongoing injecting drug use and the environments in which it occurs. Relatively small numbers of the WA respondents said that they usually injected either alone (12%) or with their partners (12%). The majority (69%) said that they usually used with some combination of friends, family members and partners. Seven per cent said that they injected with 'anyone'. Two thirds (66%) of these WA respondents said that the groups with which they injected consisted solely of Aboriginal people. Some 18% reported that their injecting groups sometimes included non-Aboriginal people, while 16% said that they injected only with non-Aboriginal people.
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C.5 Sources of clean injecting equipment

The research provides a picture of accessing clean injecting equipment that reflects varying local circumstances and geographies as well as possible IDU preferences. For example the WA study39 reported that the majority of respondents (82%) obtained their needles and syringes from pharmacists; some 20% identified NSP services – which were at that time at a relatively early stage of development in WA - as their source of clean equipment. A number said that they also obtained equipment from friends or dealers. The WA study also sought to ascertain where people were not likely to go for clean injecting equipment. Some 32% identified one place or another, with pharmacies, hospitals and AMSs specified with equal frequency. No particular age differences were apparent in these results.

The early Queensland study40 found that at the time it was conducted pharmacies (69%) were the most common source of equipment. NSP services in various settings were used by just under half these respondents. Indigenous (35%) and non-Indigenous (14%) friends were also common sources for clean injecting equipment. Younger respondents were far more likely to rely on friends than to visit a pharmacy or NSP. The study found a strong reluctance to obtain clean injecting equipment from Aboriginal-specific services. As the report noted: 'Overall, participants showed considerable scepticism about the expertise, confidentiality and sensitivity of Aboriginal health services towards the needs of injecting drug users.' There was also a greater reluctance to visit pharmacies for clean equipment than was reported in the WA study.

The SA study41 reported that 36% of Indigenous IDUs were reluctant to obtain clean injecting equipment from pharmacies, while 15% said they did not like to use NSP services. That study also showed that it was common for people to obtain supplies in bulk (26% typically collected needles in boxes of 100 or more) and to obtain equipment on behalf of other people as well as themselves; 57% said that they usually collected equipment on behalf of at least one other person.

The 2005 national study42 expanded on the factors underlying Indigenous IDU preferences on where to obtain clean equipment. Cost was clearly one factor, with a number of participants in the research specifying said that they preferred to access free equipment where they could. Judgemental attitudes on the part of staff – whether at a hospital, pharmacy or NSP – also served as a barrier to accessing particular services. People reported that they avoided services where they had had a negative previous experience, regardless of the setting. Hours of operation were also a factor, leading to use of sources such as a late-opening pharmacy, mobile van or hospital as available. The national report also highlighted some people's reluctance to access NSP services via an AMS or other Aboriginal-specific service; respondents spoke of a lack of awareness of the issues facing IDUs and an apparent lack of confidentiality that was sometimes exhibited. It was also noted – consistent with the research previously conducted in WA – that this reluctance was strongest in non-urban locations, where anonymity is a particularly difficult issue.

Virtually all of these earlier studies refer to the important role that 'shame' plays in Indigenous IDU interactions with services. Several instances were reported (for example in the national research) where IDUs had been ostracised in their communities for being known injecting drug users, and it was said that this persisted even if the injecting behaviour had stopped. The extent to which this directly leads to unsafe injecting practices (rather than accessing available services) is unclear. However, it is noteworthy that there is such consistent reporting that services or particular types of service are avoided because of shame.

According to various studies, vending machines were commonly used where there were available – and were called for in places where they were unavailable or difficult to access. Although respondents in the national study noted that vending machines involved a cost, having immediate late night access to clean injecting equipment was seen as an important means of deterring risky injecting practices. As one respondent said, '...there should be vending machines around for the days when there's no fits around...on weekends and that...when I've caught Hep C would have been on a weekend ...I've had no fits'.

The research also confirms that Indigenous IDUs may obtain clean injecting equipment from trusted friends or other members of the IDU community, and are comfortable with obtaining equipment in this way. A number of respondents spoke of how they themselves played a role in distributing equipment (obtained in bulk from an NSP) to their peers43.

In summary, the past research shows that Indigenous IDUs access clean injecting equipment through a variety of settings, tending to make greater use of services that offer after hours access and a non-judgemental, understanding and confidential environment.
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C.6 Unsafe injecting and knowledge of risks

The previous research reports continuing risky injecting practices, with sharing of equipment reported as common. For example, 18% of the respondents to the Queensland study44 said that they had shared a needle in the past week, while a further 21% had shared in the past month (with sharing defined as using a needle before or after someone else). Sharing was much higher among young people - 63% of those aged under 20 reported sharing in the previous month. Virtually all of those who reported sharing said that needles were cleaned between uses, but only about a half of these used the (then) recommended method of bleach and cold water 2X2X2.

The WA study went into some detail about the sharing behaviour of Indigenous IDUs. Some 43% of the sample acknowledged normally sharing needles when they injected. A larger 53% reported sharing bags, spoons, filters and other injecting equipment. Among these people, many said they were part of an 'injecting group' where needles and other equipment were always cleaned between uses. However, few if any of these people described cleaning practices that effectively minimised the risk of viral transmission. For example, most reported using boiling water rather than cold water to clean equipment, many without using bleach. Some reported using alcohol or detergent to clean equipment.

In the SA study45 64% of those surveyed had at some time used a syringe either before of after another person, with 12% having used a syringe after another person in the previous 2-3 months. Among those who had shared a syringe or other equipment, only 22% described a cleaning process regarded as ideal. The SA study also explored the reasons for sharing injecting equipment. Lack of availability of clean equipment was put forward as a reason for sharing in 71% of cases, with 29% specifically saying that the NSP was closed and 15% saying that they had no transport to get to an NSP. Familiarity with members of the injecting group was also a common response, while 15% of those who reported sharing indicated a lack of concern for the implications of this. Only 4% referred to a lack of awareness of the risks of sharing.

The ACT study46 found broadly similar patterns, but also observed that 'accidental' sharing occurred at times, whereby someone else's needle was used by mistake – even though it might have been labelled or marked in some way to signify ownership.

Among other things these results point to resignation among some IDUs to the prospect of contracting a blood-borne infection. This was a theme also explored through the AFAO/AIVL national research47, leading to the report's title of 'Something is Going to Get Us'. That report states that hepatitis C in particular was considered by many in the sample to be 'common', or 'nothing', and it goes on to suggest that people had a perception that premature death from other causes was likely in any event. In the words of one respondent, '...gunna die anyway soon from all those other things like heart and liver'. The study also suggested that a lack of awareness of the routes of hepatitis C transmission, or a belief that transmission could not be effectively prevented, were factors relevant to sharing behaviour.

Information presented in the NCHECRNational Data Report on the Australian NSP Survey 2003-2007 (p1) shows that among NSP clients surveyed over that period 're-use of someone else's needle in the last month ranged between 13%-18%', while 71%-75% reported using sterile needles and syringes for all injections in the past month. Given that different researchers have asked somewhat different questions in this context, comparing survey data on sharing of equipment is not straightforward.
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C.7 Education and other services

Several of these studies sought to explore what demand existed for additional services for Indigenous IDUs. When respondents in the WA study48 were asked what additional services were required, a high percentage said more counselling and/or treatment services. On the question of whether such services should be Aboriginal controlled or mainstream services, respondents were evenly divided. Perhaps the more important point was that services needed to be familiar with and understanding of both drug culture and Aboriginal culture. In the words of one respondent, the service should be '...for everyone and all drugs. Don't care who runs it as long as staff are understanding of where we come from'. Thirty per cent called for enhanced education for IDUs about available services and harm minimisation practices, and some respondents specifically mentioned the need for education in schools about the harms of injecting drug use. Some 25% wanted to see some form of community-based family support for IDUs. Two-thirds called for greater access to clean injecting equipment, preferably free.

The AFAO/AIVL national research49 canvassed issues relating to the nature of any future education approaches for Indigenous IDUs. There was a fairly clear consensus that more education was needed, and a number of suggestions were made as to how this might be made more effective. Firstly, respondents stressed the value of peer education or, as one person put it, 'us mob telling each other'. Past and present IDUs and people living with blood-borne viruses were thought to have the most credibility and ability to communicate with people in an informal and natural way. Older people were singled out as being particularly credible. A respondent to the AFAO/AIVL study claimed to be already playing this kind of role and actively distributing various educational pamphlets and the like to others in the community.

NSPs were seen as an obvious place to distribute information - whether to individual IDUs or to peers or intermediaries who might distribute it more widely. It was suggested that all packs of needles could include some written information or a sticker that provided a short message and/or helped to make Indigenous clients feel welcome at the service.

The research also suggested a role for written information with 'a black face'. It drew attention to the importance of making written information available in a variety of formats, to suit people of different literacy levels, ages, economic circumstances and cultural backgrounds. The use of radio, and in particular music, was also suggested as an effective communication channel for some.

The research also found that some saw merit in organising social events or gatherings for Indigenous IDUs. Putting on a barbeque, for example, with the possibility of social interaction, was thought to provide a good basis for communicating an educational message. More educational activities in schools, gaols and legal centres were also advocated.

The national study also stressed the importance of using education and other approaches to encourage acknowledgement of the fact of drug injecting in Indigenous communities and to attempt to address the stigma associated with injecting drug use. IDUs involved in that study were of the view that Elders, AMSs and other community organisations had potential roles to play, but that this was not happening. There was a strong sense that the issue had been hidden or 'swept under the carpet' to avoid the shame that it might involve for the community. It seemed clear from this research that the development and refinement of services appropriate for Indigenous IDUs was, in part at least, being hampered by a lack of acknowledgement of the problem in the Indigenous communities.

The NSW report published in 2004 places particular emphasis on a need for a holistic approach to addressing blood-borne infections among Aboriginal people – placing hepatitis C issues, for example, in the broader context of other blood-borne infections, general health, and social, cultural and emotional factors.
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Footnotes

1 Coupland H, Ball K, Costello M, Harvey B and Maher L, Something is Going to Get Us: a consultation and development project for a national campaign addressing injecting drug use in Indigenous Communities, 2005. AFAO and AIVL.
2 Larson A, Shannon C and Eldridge C (1999) Indigenous Australians who inject drugs: results from a Brisbane study, Australian Centre for International and Tropical Health and Nutrition, Graduate School of Medicine, University of Queensland, Australia, Drug and Alcohol Review (1999) 18, 53.62
3 Day C and Dolan K, Characteristics of Indigenous Injecting Drug Users in Sydney: gender, prison history and treatment experiences, National Drug and Alcohol Research Centre, University of New South Wales. Paper presented at the Best Practice Interventions in Corrections for Indigenous People Conference convened by the Australian Institute of Criminology and held in Sydney, 8-9 October 2001.
4 Gray D, Saggers S, Atkinson D, Carter M, Loxley W and Hayward D (2001) . The Harm Reduction Needs of Aboriginal People Who Inject Drugs , National Drug Research Institute, Curtin University of Technology, Perth
5 Holly, C Shoobridge J (2003) Responding to the Needs of Indigenous People Who Inject Drugs: using rapid assessment procedures to investigate the impact of injecting drug use amongst Indigenous Australians in metropolitan Adelaide. Aboriginal Drug and Alcohol Council (SA) Inc. Adelaide.
6 Dance, P, Tongs J, Guthrie J, McDonal D, D'Souza R, Cubillo C, Bammer G (2004) "I want to be heard": An analysis of needs of Aboriginal and Torres Strait Islander illegal drug users in the ACT and region for treatment and other services. National Centre for Epidemiology and Population Health, The Australian National University. Canberra.
7 Commonwealth Department of Human Services and Health (1994) National Drug Strategy Household Survey: Urban Aboriginal and Torres Strait Islander Peoples Supplement 1994. Canberra, Australian Government Publishing Services.
8 Commonwealth Department of Human Services and Health, 1994
9 Day et al, 2001
10 National Centre in HIV Epidemiology and Clinical Research (2005) HIV/AIDS, Viral Hepatitis and Sexually Transmissible Infections in Australia, Annual Surveillance Report. NCHECR and Australian Institute of Health and Welfare. Canberra.
11 Gray et al, 2001
12 Gary Meyerhoff 'Injecting Drug Use in Urban Indigenous Communities: a Literature Review with a Particular Focus on the Darwin Area', Danila Dilba Medical Service, 2000.
13 ibid p7
14 Larson et al, 1999
15 Gray et al, 2001
16 Holly et al, 2003
17 See p2
18 Day et al, 2001
19 Holly et al, 2003
20 Coupland et al, 2005
21 Australian NSP Survey: National Data Report 2003-2007, National Centre in HIV Epidemiology and Clinical Research, p2
22 Gray et al
23 Larson et al, 1999
24 ibid
25 Coupland et al, 2005
26 ibid
27 Larson et al, 1999
28 Day et al, 2001
29 Australian NSP Survey: National Data Report 2003-2007, National Centre in HIV Epidemiology and Clinical Research, p9
30 Coupland et al, 2005
31 Larson et al, 1999
32 Holly et al, 2003
33 Gray et al, 2001
34 ibid
35 ibid
36 Larson et al, 1999
37 Coupland et al, 2005
38 Gray et al, 2001
39 ibid
40 Larson et al, 1999
41 Holly et al, 2003
42 Coupland et al, 2005
43 ibid
44 Larson et al, 1999
45 Holly et al, 2003
46 Dance et al, 2004
47 Coupland et al, 2005
48 Gray et al, 2001
49 Coupland et al, 2005