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DECRETO DEL DIRETTORE DELL’AGENZIA REGIONALE SANITARIA

N. 1/ARS DEL 26/03/2013

Oggetto: avvio della procedura di acquisizione del servizio di traduzione verso l’italiano di n. 1 testo in lingua inglese relativo alle 3 Sessioni del Workstream n. 8 del Progetto Europeo “REDUCE”

IL DIRETTORE DELL’AGENZIA REGIONALE SANITARIA

- . - . -

(omissis)

- D E C R E T A -

- di avviare la procedura di acquisizione del servizio di traduzione in l’italiano di n. 1 testo in lingua inglese relativo alle 3 Sessioni del Workstream n. 8 del Progetto “REDUCE (Riduzione dei comportamenti a rischio, sia di tipo sessuale, che di assunzione di droghe, di trasmissione di Epatite C tra le donne che fanno uso di droghe in Europa: mettere l’evidenza scientifica nella pratica)”, che si allega in copia al presente provvedimento, di cui costituisce parte integrante e sostanziale (Allegato A);

- di nominare, ai sensi dell’art. 3, comma 1, del Regolamento per l’acquisizione di beni e servizi approvato con Decreto del Direttore dell’ARS n. 8/2012, quale Responsabile del Procedimento il Xxxx. Xxxxxxx Xxxxxxxx, Dirigente amministrativo in utilizzo all’ARS, per l’espletamento delle procedure di acquisizione del servizio mediante il Mercato Elettronico della PA, nel rispetto degli adempimenti previsti dalla vigente normativa in materia di contratti pubblici;

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- di procedere, con successivo atto, all’affidamento del servizio in parola, previo espletamento delle procedure di cui sopra, sulla base della migliore offerta economica e nel limite delle disponibilità di € 1.500,00.

Il Direttore dell’ARS

Xxxx. Xxxxx Xxxxxx

- ALLEGATI -

(Allegato A)

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ALLEGATO A

The REDUCE group intervention manual

Reducing Hepatitis C drug and sexual risk behaviours among female drug users in Europe (REDUCE): translating evidence to practice project

xxxx://xxx.xxxxxxxxxxxxxxxx.xxxx.xx/xxxxx.xxxx is co-funded by the European Union Drug Prevention and Information Programme (Project number: JUST/2010/DPIP/AG/0975 REDUCE) Developed by Xxxx Xxxxxxxxx with the REDUCE group (Spain: Xxxxx Xxxxxxx, Xxxxx Xxxxxx; Italy: Xxxxx Xx Xxxxx, Xxxxxx Xxxxxxxxxx; Austria: Xxxxxxxx Xxxxxxx, Xxxxxx Xxxxx, Xxxxxxxx Xxxx Poland: Xxxxx Xxxxxxxxxxx, Xxxxxxxxx Xxxxxxxxx; Scotland: Xxxxx Xxxxxx, Xxxxx Xxxx)

Version 1. 19 March 2013

Materials: Attendance register,

Name badges, Participant folders, Flipchart and pen, Myths and Facts cards [DUIT], Dye Demo video [DUIT]

Handouts

1. Timetable of sessions

2. Risk pyramids

3. Hepatitis C leaflets

SESSION 1: UNDERSTANDING HEPATITIS C TRANSMISSION RISKS

Goals for Session 1:

1. Introduce the REDUCE project and intervention.

2. Build group cohesion.

3. Establish group rules.

4. Engage participants.

5. Increase knowledge about Hepatitis C and transmission injecting risk behaviours.

6. Motivate participants to change their risk behaviours

Objectives:

Participants will …

   understand what participating in the intervention requires.

   feel a sense of group cohesion.

   increase their knowledge about Hepatitis C and transmission risk behaviours.

• consider changing their risk behaviour

Session 1 outline:

1.1. Introduction and welcome (10 minutes)

1.2. Group rules (10 minutes)

1.3. Myths and facts [game] about Hepatitis C (20 minutes)

1.4. Injecting risks: cross contamination [video] (15 minutes)

Break (15 minutes)

1.5. Transmission risks pyramid [exercise] (15 minutes)

1.6. Strategies for reducing injection risk (10 minutes)

1.7. Deciding whether or not to change your behaviour (15 minutes)

1.8. Distribution of leaflet on Hepatitis C transmission risks and local resources (5 minutes)

1.9. Close (5 minutes)

This column reminds the facilitator of the purpose of each session, the materials required to run the session and the procedures to be followed. Notes to facilitators are also

included.

Facilitators should read verbatim the text below [possible dialogue in italics after each point. These are possible dialogue points and don’t have to be read. However, all other information must be shared verbatim with participants]

Purpose: Introduce participants to each other and outline the brief intervention.

Materials: Name badges, flipchart and pen

1.1 Introduction and welcome (10 minutes)

Thank you for agreeing to participate in the REDUCE intervention. The intervention is taking place simultaneously in five countries in Europe –

Austria, Italy, Poland, Scotland and Spain. The aim of participating in this brief intervention is to provide female drug users with the skills and knowledge to reduce the risk of Hepatitis C transmission and infection. My name is (name of facilitator) and I am going to be the facilitator of the

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Procedure: Invite participants to “sign-in”, introduce themselves, and write their name on their name tag. Outline the intervention and briefly describe the aim and content of the three sessions.

NOTE TO FACILITATORS: See

possible dialogue in italics after each point. These are possible dialogue points and don’t have to be read.

However, all other information must be shared verbatim with participants.

Purpose: Build group cohesion. Increase sense of project ownership.

Materials: Flipchart and pen

Procedure: Invite suggestions for rules and allow group to brainstorm for a short time. Write the ideas that the group comes up with on the flip chart, with similar ideas placed together. Prompt ideas by raising questions or giving examples. After the session, rewrite the rules on a clean piece of paper, and keep

the rules posted during each group

meeting. The brainstorm should result in at least these bulleted rules:

NOTE TO FACILITATORS: See

possible dialogue in italics after each point. These are possible dialogue points and don’t have to be read.

However, all other information must be shared with participants verbatim. This discussion on rules should be framed

in a positive manner (e.g. “Let’s try to work together to make this project

worthwhile for everyone. These are your sessions, let’s make the most of

three sessions of this intervention. My role is to give you information about how Hepatitis C is transmitted and work together to help you develop strategies and skills to reduce transmission risks.

It is great to see you all here today. I want to run through the aims of the group, go over the group rules, and talk about confidentiality. We will meet every (day of week) for a further two weeks from (time) in (location). Each session will last approximately two hours with a break of 15 minutes. To get the most out of this group it is important that you attend all 3 sessions and that you turn up on time. We will send you a text message or reminder call the night before each group session to remind you.

In each of the 3 sessions we will learn about Hepatitis C and transmission risks through discussion and activities. We will spend time talking about injecting and sexual risk behaviours for Hepatitis C, discover when we are most likely to take risks and learn strategies and skills to reduce these risks. As you know, this group is part of a research study that aims to look at whether the intervention increases knowledge about Hepatitis C transmission among females and you will be asked to complete a questionnaire at the end of the third session and again 4 weeks later. At the end of the three sessions we will also ask you what you liked and disliked about the group, what worked and did not work for you. This information will be used to improve the content of the group sessions in the future.

Briefly, the three sessions will cover:

Session 1. Understanding Hepatitis C transmission risks Session 2. Hepatitis C and sexual wellbeing – negotiating safety Session 3. Hepatitis C and emotional wellbeing – reducing negative mood

Before we begin, I would like to ask each of you to introduce yourself and your reasons for participating in the intervention. To help others in the group remember your name, please can you wear your name badge. You will each be given a folder to keep the handouts and exercises from the sessions.

1.2. Group rules (10 minutes) [adapted with permission from DUIT (Xxxxxxx et al., 2007)xxxx://xxxx.xxxx.xxx/]

Since we are going to be spending some time together over the next couple of weeks, it's important to have a few group rules so that everyone can get the most from the programme. We’d like to set up an atmosphere where everyone can learn from each other and feel respected during our discussions. Our time together will be more interesting and valuable if everyone is able to participate without any hesitations. This is our group so we need to come up with some of our own rules that we will all agree to follow. Later, if someone thinks of something that we missed and the group agrees on it, we can add to the rules. What we talk about during the sessions is confidential. That means I will not share what you say with the staff at the clinic. I am required by law however, to tell a member of staff if you tell me that you are planning on harming yourself or another person or if you tell me a child is being harmed or at risk of being harmed. Does anyone have any questions about this? Confidentiality is very important as everyone should feel safe in sharing their thoughts and feelings without worrying about what they say will be talked about outside this room.

   Respect - Everyone’s opinion should be respected. This means that there should be no interrupting, whispering, giving funny looks or making fun, put downs, or judgments, threatening or intimidating other group members.

• Appreciate different stages of use and treatment – People are in different

stages of drug use and treatment. Some of you may have chosen to stop using and some of you are still using drugs. The group needs to accept that different people make different choices. You are not required to stop using to be in this programme. Note that some programme content includes video and/or discussion of syringes and other injection paraphernalia, and any participants who are in recovery or who are concerned with that have the right not to watch/participate in that part of the session.

   Right to choose to participate - You should not feel pressured to participate in a certain activity or answer any questions that make you feel uncomfortable. You should feel comfortable to ask any questions you have.

   Be fit to participate - You can participate better, without disrupting the group, if you manage your drug use. Be well while you’re here.

   The right to ask questions - You should ask questions whenever you feel that you don't understand something or that you want more information.

   Be on time – Be here on time so the group don’t have to wait for you and you won’t miss out.

OK, here’s the list of rules we just came up with. We’ll keep this up during all our sessions to help us keep these in mind. If you think of other things that you want to add to the list later, even if it’s at another session, bring it to the group and we can talk about it.

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them”)

Procedure:

   Correct misinformation, as needed.

   Establish the informational gist of the bonus questions then guide discussion of the bonus questions

to the final point which stresses the importance of prevention.

NOTE TO FACILITATORS:

Discussion prompts are provided to facilitate discussion, and may be covered as time permits.

1.3. Myths and facts about Hepatitis C (Exercise) [adapted with permission from DUIT (Garfien et al., 2007)xxxx://xxxx.xxxx.xxx/] (20 minutes)

There are many misunderstandings, or myths, about Hepatitis C. To make sure that we have the right information, we are going to play a Myths & Facts game.

   I’ll read a statement, and you can decide if the statement is true or false. I will then ask you to explain why you believe the statement is true (or false).

   Each card has a “bonus question” that requires more than just a true or false answer. They’re harder than the true or false questions, so don’t worry if you don’t know the answer.

CARD 1: Hepatitis C is an infection caused by a virus that attacks the liver

TRUE. Around 75 per cent of people exposed to Hepatitis C develop chronic infection, defined as the presence of the Hepatitis C virus in the bloodstream for longer than six months. The remaining 25 per cent will spontaneously clear the infection, but will continue to have detectable antibodies. Clearance of the Hepatitis C virus does not lead to immunity and Hepatitis C re-infection can occur following re-exposure. After 10 to 20 years, chronic Hepatitis C can cause cirrhosis. After 20 to 40 years, it can cause liver cancer.

CARD 2: You can tell if someone is infected with Hepatitis C by how they look? FALSE. Most people don’t show signs of infection with Hepatitis C and most people do not have symptoms. The problem for most people is that they are unaware that they have been infected because of the lack of symptoms.

Bonus question: How do you know if someone has Hepatitis C?

   Only way to know is from test results, but It is possible for someone to test negative and get infected later (Have to remember window period: up to 6 months for HCV)

What’s the message? Don’t assume the person is Hepatitis C negative. Avoid infection by not sharing needles.

CARD 3: Hepatitis C can be transmitted through unprotected sex

TRUE. .Although the Hepatitis C virus is much less likely to enter the body through unprotected sex, it can be passed that way. Avoid infection by using latex condoms.

Bonus question: Why does the HIV virus transmit more easily through sex than the Hepatitis C virus?

   HIV doesn’t need direct blood-to-blood contact. Hepatitis C does.

   The HIV virus can spread through all types of sex (anal, vaginal, oral).

What’s the message? Xxx’t assume that the person you are having sex with is Hepatitis C negative. Avoid infection by using latex condoms.

CARD 4: There is a vaccine to protect people from Hepatitis C.

FALSE. There is no vaccine to prevent someone from getting infected with Hepatitis C.

Bonus question: People can get vaccinated against which 2 types of hepatitis?    Hepatitis A and Hepatitis B

What’s the message? A vaccination is not available to prevent Hepatitis C virus infection. But you can protect yourself in other ways. Use latex condoms and don’t share needles or

works.

CARD 5: There is treatment available for Hepatitis C.

TRUE. There is treatment, but there are some important things to understand about these treatments. Bonus question: Does treatment cure Hepatitis C?

   Effective treatment attacks the virus and prevents it from multiplying but it does not “cure” (or kill off) the virus.

   Effective treatment lowers the amount of virus (viral load) in the body and can slow down the progression of the disease. What’s the message? Currently, treatment for Hepatitis C only cures about 1/3 of the patients.

   The main drug for Hepatitis C is called interferon. Some people with Hepatitis C may receive “combination therapy” (interferon with ribavirin). After 6-12 months of therapy, it cures 30- 40% of the people who complete it. However, it requires 3 injections a week that can make a person feel like they have the flu, and most medical providers require patients to be clean (no injecting or alcohol) for 6 months before they are considered eligible for treatment.

   Even when people are able to get rid of the Hepatitis C virus through treatment, they can become infected again if re-exposed.

CARD 6: Hepatitis C can be transmitted by casual contact such as shaking hands, hugging, or drinking out of the same cup.

FALSE. Hepatitis C virus has to get into a person’s blood stream before they can

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Purpose:

To re-examine principles of transmission and risky behaviours that participants have been introduced to during pre- and post-test counselling sessions.

Respond to questions. If someone

does not want to watch, they can leave the room and return for the group

discussion following the video. The facilitator can later explain the content of the video.

Procedure:

1. View video.

become infected.

Bonus question: Are there other ways besides sharing a needle that can spread Hepatitis C from one person to another?

   Sharing cookers, cotton, or water for preparing drugs.

   Sharing contaminated needles for tattooing or piercing.

   Sharing razors or toothbrushes.

What’s the message? Sharing anything that might have even the smallest amount of blood on it from a person with Hepatitis C could cause you to become infected.

CARD 7: If a person who shares injecting equipment tests negative for Hepatitis C, it means that they can’t get infected.

FALSE. All it means is that they have been lucky so far.

Bonus question: What can a person who tests negative do to stay that way? [must explain answer and hint at one of the following, to receive point]

   Stop injecting drugs.

   Stop sharing needles and any other injection equipment.

   Use condoms consistently and correctly with all sex partners.

What’s the message? As long as a person is injecting drugs or having sex with people who have risk factors for Hepatitis C infection he/she will be at risk of becoming infected.

CARD 8: If a person already has Hepatitis C, they can be re-infected.

TRUE. Even if you already have Hepatitis C, another genotype of the virus can reinfect you. You may be told you have Hepatitis C antibodies, these do not protect you against reinfection.

CARD 9: A single or one time exposure is enough to contract Hepatitis C.

TRUE.

CARD 10: No more than a tiny amount of blood (so small that it can`t be seen) is needed to pass on Hepatitis C.

TRUE.

Bonus question: How long does the Hepatitis C virus “live” on a used syringe?

• The Hepatitis C virus can live in syringes for up to 63 days in high volume tuberculin syringes with detachable needles compared to a little more than seven days survival time in low volume insulin syringes with permanent needles

• Therefore, it is vital to 1) dispose of your used syringes safely, 2) use a new syringe for every injection and 3) never share your injecting equipment with others to avoid becoming infected or infecting others.

CARD 11: You can get infected with Hepatitis C from re-using your own syringe

FALSE. It is not possible to get infected with Hepatitis C from re-using your own syringe, unless you've shared your works with someone and it's been cross contaminated. If you yourself are not infected with Hepatitis C then there is no chance of catching it reusing your own syringe.

1.4. Injecting risks: cross contamination (Video exercise) [reproduced with permission from DUIT (Xxxxxxx et al., 2007)] (15 minutes)

The video we are about to watch includes syringes and other paraphernalia. As we discussed earlier today when we talked about ground rules, if this concerns you, please let one of us know. We support any of your efforts to reduce or stop your drug use and we can find something else for you to do instead if you feel it might be a problem for you to watch this video. Does anyone have any concerns about watching the video or questions at this point?

In order for us to reduce risk behaviours, we first have to make sure that we have our facts straight about how Hepatitis C can be spread. You’ve all heard that people shouldn’t share needles or other injection equipment, now we’re going to view a video that shows why. xxxx://xxxx.xxxx.xxx/xxxxx.xxxx

[View video then ask the following questions]

1. What equipment got contaminated? Were you surprised?

Let’s break down how some of the items became contaminated and how that could have been avoided. How did the rinse water become contaminated?

From the used syringe

How did the dye get into the cooker and cotton?

   From the syringe

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2. After video, lead a discussion based on the questions below. See statements in italics for scripts if participants have trouble answering questions.

Have a volunteer define what backloading is; if no one volunteers, the facilitator should define it:

BACKLOADING is a procedure to divide up drugs after they have been dissolved and cooked. As you saw in the video, Xxxxx xxxx up drugs from the cooker/spoon into a syringe, and then used that same syringe to squirt half of it into someone else's syringe.

That’s backloading. If the backloading syringe or the cooker, cotton or water

has been used before, or if it touches any part of the syringe it backloads into, then virus can be spread from the donor syringe to the receiving syringe or the other way around.

Purpose: To demonstrate

prevalence and incidence of Hepatitis C among injectors as a way of increasing participants’ perception of vulnerability.

   From contaminated rinse water

What could she have done differently to avoid cross-contamination? Possible Answers:

   Split the drugs dry and have each person use their own syringe, water, cooker and cotton to prepare their own drugs (Best Option)

   Used the new needle to prepare the drugs

   Cleaned the contaminated syringe with bleach 2. How did the new syringe get contaminated?

Xxxx backloaded the contaminated solution into it.

Would it have been any safer if her partner drew up their drugs right from the cooker instead?

No, the cooker was already contaminated

3. Was there anything else that got contaminated that could spread Hepatitis C?

Yes, Xxxx’x fingers. If she touched her partner’s needle or skin with traces of blood on her fingers, the virus has a small but real chance of getting into her partner.

Thank you all for sharing your observations of the video and your knowledge of how injection equipment can become contaminated during the drug preparation process. Maybe some of you knew that before, or maybe you didn’t know, but we hope you learned how important it is not to share ANY injection equipment.

Remember, a single or one time exposure is enough to contract Hepatitis C, and no more than a tiny amount of blood (so small that it can`t be seen) is needed to pass on Hepatitis C.

The video we just saw shows how injection equipment can get infected. Which brings up an important question: how likely is it that people you inject with are infected? And how likely is it that you could get infected, that your works could be contaminated just like what happened in the video?

Even if you never share, it’s important to think about how common these viruses are, how many other people are already infected, and how easy it could be for you to get infected. With that in mind, about 7 in every ten injecting drug users in (country) is infected with Hepatitis C.

Break (15 minutes)

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Purpose:

To introduce the concepts

behind injection (and potential sexual) risk and harm reduction, and apply them to understanding what behaviours are more/less risky than others.

Learning Objectives:

Participants will be able to:

• Identify the presence of blood as the key factor in injection risk.

• Explain how actions taken to kill virus in the blood

• Correctly rank various injecting behaviours in terms of their level of risk.

Write “Clues” on whiteboard or flipchart, and below list these two clues:

Procedure: Hand out cards representing the injection behaviours and ask for volunteers to place the cards on the risk pyramid.

NOTE TO FACILITATORS: You want

the participants to be engaged and to learn from this. So don’t put yourself in

the middle of their learning. If someone puts something in the wrong place, don’t move it for them (but if another participant thinks something should be moved, ask them why, see if the group agrees, and if there’s consensus, let them move it.) Once all of the cards are up, then the facilitator should resume “teaching” and review what’s on the pyramid. General points for facilitators to follow:

• Let the participants put the cards

up themselves without interference or guidance from you.

• If they seem confused, remind them of who is at risk. This is about the risk of an Hepatitis C negative person getting Hepatitis C from an infected person. So how risky is it for the negative person?

• Allow the group to self-correct. The facilitator should only build consensus and make sure participants indicate why they put things in the places they do (and always encourage them to relate their reasons to whether there is likely to be blood, and if anything has been done to eliminate blood and/or kill virus). If someone in the group disagrees with where

1.5. Transmission risks pyramid [adapted with permission from DUIT (Xxxxxxx et al., 2007xxxx://xxxx.xxxx.xxx/] (15 minutes)

When we’re talking about injecting, harm reduction means you don’t have to completely stop injecting – if you really cannot stop there are other things you can do, smaller steps that can really reduce your risk of getting Hepatitis C. Some injection behaviours are more risky than others.

We’re going to pass out cards that list some specific injection behaviours that may put you at risk of getting Hepatitis C. You’re going to create a pyramid by ranking injection behaviours according to how risky they are. Your job is to decide where on this pyramid each card should go. Put behaviours with the highest risk at the top of the pyramid, and put behaviours with the lowest risk at the bottom of the pyramid. Risk is all about blood. Here are two hints for things to think about as you’re figuring out if something is higher or lower risk.

1. Is there a chance that there is anyone else’s blood, even the tiniest amount of blood, on any injection equipment or anywhere else?

1. Have you done something to eliminate the blood or kill any virus that might be in it?

Creating this pyramid may be a little confusing at first because you don’t know what all the behaviours are that are going to go on the pyramid. That’s OK, it’ll make more sense as we go, and you can move cards up or down on the pyramid as we go along.

Rank the risk of Hepatitis C transmission to an uninfected injector from an infected injector

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someone else put their card, ask them why they disagree and where they think the card should go. Have the group decide right then if the card should go where the first person suggested, or where the second person suggested.

• If the pyramid is correct, little

further discussion is needed. Have the group tell you why the top and bottom behaviours are most/least risky: “The highest one, why is that one so risky?” (Answer should describe the likelihood of someone else’s blood being present and if anything has been done to

eliminate blood/kill virus.) “The lowest one, why is this not risky?” (Answer should be in terms of blood.)

• If there are mistakes in the pyramid, don’t review their work just by starting at the bottom and working your way to the top. Do start with what they did right, and

give them the opportunity to identify the mistakes themselves. If they still don’t identify their mistakes, point out a card that’s wrong and ask the group to think about what makes something

risky and what that means for where that card should go (in other words, they should figure out why it’s wrong and where to put it that would be right).

• Some spontaneous discussion of

what less risky activity one might do in place of a more risky activity might occur. That’s a good thing. However, we’re not going to initiate a discussion of strategies to successfully negotiate less risky behaviours. That will come in second half of the session. Here we mainly want to make sure they

understand risk.

Facilitator: Make sure these points are covered:

• Hepatitis C is easier to get through injecting than HIV

• The idea is to avoid any contact with another person’s blood.

• Hepatitis C can live longer outside the body than HIV.

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Purpose: Bring the information on

injection risk back to the personal level, so that participants relate it to

themselves. Make them more conscious of their own injection behaviour.

Procedure: Lead a discussion

about strategies to reduce injection risk using the questions as guides.

Learning objective: Participants

will be able to focus on their injection risk through discussion of general strategies they have used to reduce risk. Let participants share their

strategies of using identifying marks, placement, etc. Points to cover: Some people label their needle with tape or a pen. Since syringes can get mixed up

or someone might use your syringe without you knowing it, it is still safest to only use new syringes that come right out of a sterile wrapper.

1.6. Strategies for reducing injection risk [reproduced with permission from DUIT (Xxxxxxx et al., 2007) and

xxxx://xxx.xxxxxxxxxxx.xxx] (5 minutes)

Of course the safest way to avoid getting Hepatitis C would be to stop injecting. For people who inject drugs, the greatest risk of Hepatitis C comes from sharing needles with other people. Some ways to lower risk are to use a new needle for every injection, and to use a new needle for preparing and splitting drugs. Also, not sharing equipment like cottons, cookers, and rinse water lowers your risk. Even if you can’t use a new syringe every time you inject, having your own personal syringe can greatly reduce the

chance that you will come in contact with someone else’s blood.

What are some ways you can tell which syringe is yours and which is someone else’s?

• Labelling your syringe

• Use a clean surface to prepare injection this helps to stop the spread of infection and blood- borne virus. Lay the new equipment out on paper to prevent cross infection. Putting the equipment on paper will mean that you have a cleaner surface to prepare the drugs on and you know who the equipment belongs to.

Bleach is not an effective way to kill the Hepatitis C virus that can live in blood that collects in a syringe. You should always use a new syringe for every injection. The most risky behaviour is injecting with a syringe that someone else just used. Injecting with someone else’s syringe gives Hepatitis C a direct route into your bloodstream.

The bottom line is, it is important to look at the steps of the pyramid as steps we can take to reduce the risk of Hepatitis C transmission. Stopping the spread of these viruses is the ultimate goal.

Learning Objective: Participants will be able to explain the correct way to clean the skin with an alcohol pad prior to injection.

Procedure: Distribute alcohol pads and demonstrate correct use:

Step #1: Wipe back and forth over site until pads no longer appear dirty.

Step #2: With new pad, pressing over site of injection, wipe in circular motion extending continuously outward with larger circles to push dirt and bacteria away from site of injection. (Note:

Wet-wipes can clean dirt off the skin, but do not kill germs.)

Skin cleaning & abscess prevention [reproduced with permission from DUIT (Xxxxxxx et al., 2007) and xxxx://xxx.xxxxxxxxxxx.xxx] (5 minutes)

Wash your hands before you start the injection process as this will help reduce the spread of infection and other health problems. Now, let’s spend a few minutes talking about ways to clean your skin when you inject. Cleaning the skin is important to prevent infection, because if someone’s blood got on your skin and you don’t clean it properly, you could get infected when you inject. Cleaning the skin is also important to prevent abscesses.

First, remember that the skin is your body’s best protection against infections. Every time you make a hole in the skin, e.g. by injecting drugs, you create a place where dirt, bacteria, and viruses can enter your body. That’s why it is so important that the skin where you are preparing to inject and the equipment you use to inject with are as clean as possible. Avoiding abscesses is just one part of a whole set of things that you can do to reduce the harm that can come from injecting.

Use a dry cotton swab for applying pressure to an injection site, not your finger or an alcohol pad. Using alcohol pads on fresh injection sites will cause them to bleed more, not less. Do not use a cotton swab that has previously been used by someone else.

The bottom line is that all your equipment needs to be sterile and free of other people’s blood.

Purpose: Increase motivation among participants to change their injecting behaviour and reduce Hepatitis C transmission risk behaviours.

Procedure: Explain the decisional balance chart and complete the exercise together as a group – weighing up the costs and benefits of changing their injecting behaviour to reduce their risk of transmitting or getting Hepatitis C.

Learning Objective: For someone to change their behaviour,

1.7. Deciding whether or not to change your behaviour (15 minutes)

When we decide whether or not to change a behaviour, we look at the pros (benefits) and cons (costs) of changing this behaviour.

You decided to take part in this intervention as you wanted to learn more about Hepatitis C transmission among injecting drug users in order to be able to protect yourself and others from getting or passing on the virus. Learning more about how to protect yourself and others may result in you changing your behaviour and possibly the behaviour of others you inject with.

I now want you to think about the pros and cons of sharing injecting equipment. Let’s complete the decisional balance chart together, shout out your thoughts as we go around the room.

STOP sharing injecting equipment (change

behaviour)

KEEP sharing injecting equipment (do not change

behaviour)

Pros

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the costs need to outweigh the benefits. The aim of the exercise is that the decisional balance chart will have more pros that cons in the STOP sharing injecting equipment box, and more cons than pros in the KEEP sharing injecting equipment box. Purpose: Distribute country specific leaflet on injecting risk behaviours and Hepatitis C including information on services available. Purpose: Review lessons learned from this session and specify the practice activity for next session. Handout: Local Hepatitis C transmission risks and available services leaflet
		Cons
	Remember only you can decide whether to change your behaviour.
	1.8. Distribution of leaflet on Hepatitis C transmission risks and local resources (5 minutes) Please take one of these leaflets which describes the Hepatitis C transmission risks from the preparation and injecting of drugs. The leaflet also provides details of needle exchanges and other services where you can seek advice or treatment, and where you can get tested for Hepatitis C
	1.9. REVIEW AND CLOSE When it comes to injecting and different injection behaviours, what is the most important thing to think about in rating how risky a behaviour is? Whether or not someone else’s blood may be present. What’s a common problem people run into when they want to be safer with their injecting, and what’s a possible solution for that problem? Any of the equipment and their solutions. Why is it important to clean your injection site correctly before injecting? Prevent abscesses. That was a good review. The bottom line from everything we’ve talked about today is this: wherever there’s another person’s blood, even a tiny amount, there’s risk. You have to avoid the blood to avoid the risk. Does anyone have any further questions? Remember as this is a research project, I would really like to get your feedback on this session so that it can be improved if necessary in the future. What did you like about this session? What did you dislike about this session? What would you change about this session? Thank you all for coming. This is going to be a great group. See you on (day of week).

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Attendance Log

Name	Session 1	Session 2	Session 3

Timetable of sessions

Session 1	Understanding hepatitis C transmission risks	[date]
Session 2	Hepatitis C and sexual wellbeing – negotiating safety	[date]
Session 3	Hepatitis C and emotional wellbeing – reducing negative mood	[date]

Group rules

1. Confidentiality ("privacy")

2. Respect

3. Appreciate different stages of use and recovery

4. Right to choose to participate

5. Be fit to participate

6. The right to ask questions

7. Be on time

Myths and facts cards

CARD 1: Hepatitis C is an infection caused by a virus that attacks the liver

CARD 2: If someone doesn’t look sick, it’s OK to share needles with them

CARD 3: Hepatitis C can both be transmitted through unprotected sex

CARD 4: There is a vaccine to protect people from Hepatitis C

CARD 5: There is treatment available for Hepatitis C

CARD 6: Hepatitis C can be transmitted by casual contact such as shaking hands, hugging, or drinking out of the same cup

CARD 7: If a person who shares needles or has unprotected sex tests negative for Hepatitis C, it means that they can’t get infected

CARD 8: If a person already has Hepatitis C, they can be re-infected.

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CARD 11: You can get infected with Hepatitis C from re-using your own syringe

CARD 10: No more than a tiny amount of blood (so small that it can’t be seen) is needed to pass on Hepatitis C.

CARD 9: A single or one time exposure is enough to contract Hepatitis C.

Agenzia Regionale Sanitaria

Risk of hepatitis C transmission to an uninfected injector from an infected injector

Injecting risk pyramid exercise

Please cut out each of these statements for use during the exercise

HIGHEST RISK	LOWEST RISK
Injecting with someone else’s used syringe (no bleaching)	Preparing and splitting drugs with someone else’s used syringe
Injecting with someone else’s bleached syringe	Sharing water, cotton and unbleached cooker
Using only new or bleached syringes and cookers and new cotton and water to split drugs	Re-use your own syringes and equipment
Use a new syringe and equipment for every injection	Stop injecting
Stop using drugs

• Materials: attendance register, name badges, participant folders, flipchart and pen, group rules, injecting risk pyramid cards, rate the

SESSION 2. HEPATITIS C AND SEXUAL WELLBEING – NEGOTIATING SAFETY

Goals for Session 2:

1. Increase knowledge about hepatitis C transmission and sexual well-being.

2. Identify barriers to reducing sexual and injecting risk behaviours.

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activity cards

• Handouts

1. TALK poster

3. Identify strategies for reducing hepatitis C risk with intimate partners and others.

4. Increase knowledge about hepatitis C transmission during pregnancy and from mother to child.

5. Motivate participants to change their risk behaviours

Objectives:

Participants will …

• increase their knowledge about Hepatitis C and transmission risk behaviours.

• understand why women engage in sexual and injecting risk behaviours.

• be able to identify and negotiate solutions to safer injecting and sexual practices using the TALK model.

• increase their knowledge about how Hepatitis C can be transmitted from mother to child

• consider changing their risk behaviour

Session 2 outline:

2.1. Welcome and feedback on Session 1 (5 minutes)

2.2. Sexual Transmission of Hepatitis C (10 minutes)

2.3. Pregnancy, motherhood and Hepatitis C (5 minutes)

2.4. Rate the risk activity (20 minutes)

2.5. Why do women do risky things that can put them at risk of hepatitis C? (20 minutes)

Break (15 minutes)

2.6. Skills Building: Using TALK to Negotiate Safer Sex and Injection Behaviours (40 minutes)

2.7. Review and close (5 minutes)

This column reminds the facilitator of the purpose of each session, the materials required to run the session and the procedures to be followed. Notes to

facilitators are also included.

Purpose: To welcome participants back to the group; to process participants’ experiences relating to last week’s session.

2.1. Introduction and feedback on Session 1 (5 minutes) [reproduced with permission from DUIT (Xxxxxxx et al., 2007)xxxx://xxxx.xxxx.xxx/]

Hello, I would like to start by saying how great it is to see you here at the second session of the REDUCE intervention. Thank you for coming back.

Before we start today’s session, let’s remind ourselves of the group rules we developed and agreed together last week. Who can remember what these rules were? And why we need them? [read from the rules and redistribute the group rules].

   Confidentiality ("privacy") - We will be talking about very private things and we need to respect each other and not talk about the private lives of other group members to our friends and families. You can talk about what you learn in the group, but don’t tell others who is in the group. You don’t have to tell the group about your own personal stories or information (such as your age). If you prefer, you can talk about the people you know or people like yourselves. If you share a personal story, you don’t have to say it is about yourself. [Note to remind participants about limitations of confidentiality. Confidentiality means I will not share what you say with the staff at the clinic. I am required by law however, to tell a member of staff if you tell me that you are planning on harming yourself or another person or if you tell me a child is being harmed or at risk of being harmed.]

• Appreciate different stages of use and treatment – People are in different

stages of drug use and treatment. Some of you may have chosen to stop using and some of you are still using drugs. The group needs to accept that different people make different choices. You are not required to stop using to be in this programme. [Note that some programme content includes video and/or discussion of syringes and other injection paraphernalia, and any participants who are in recovery or who are concerned with that have the right not to watch/participate in that part of the session].

   Be fit to participate - You can participate better, without disrupting the group, if you manage your drug use. Be well while you’re here.

   The right to ask questions - You should ask questions whenever you feel that you don't understand something or that you want

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Purpose: Make sure all participants understand the basics of sexual

transmission and have information they can apply to determine what behaviours are risky.

Learning objective: Participants will be able to identify sexual risk for Hepatitis C transmission.

more information.

   Be on time – Be here on time so the group don’t have to wait for you and you won’t miss out.

Remember, following these group rules is very important as everyone should feel able and safe in sharing their thoughts and feelings during the session.

Last week we focused on increasing our knowledge about Hepatitis C and injecting risk behaviours surrounding transmission. Does anyone have any questions or anything they would like to say about what they learned last session?

Today we will start off by talking about sexual well-being and Hepatitis C and discuss why some women may engage in sexual and/or injecting risk behaviours. We will also learn about how Hepatitis C could be transmitted from mother to child. Then we will learn strategies to negotiate safer sexual and injecting interactions with our partners and others, and then practice these new negotiation strategies.

Does anyone have any questions before we begin?

2.2. Sexual Transmission of Hepatitis C (10 min) [material used with permission

xxx.xxxxxxxxxxx.xxx/xxxxxxxxx/xxxxxxxxxx_xxx/xxxXXX.xxx]

How does sex put us at risk for Hepatitis C? We learned last time that risk of acquiring Hepatitis C requires that HCV-infected blood must get into someone’s blood directly from another person’s blood that is infected with hepatitis C. Hepatitis C is not passed on by everyday contact such as kissing, hugging, and holding hands. The information that we have on heterosexual or lesbian long-term monogamous partners is that it is uncommon to pass hepatitis C sexually. A monogamous partnership is usually defined as a person in a relationship for 5-10 (or more) years and who doesn’t have sex with anyone else outside of the relationship. In this group the chances of passing on hepatitis C are very low. It is believed that people who have a lot of sexual partners, have a sexually transmitted disease such as herpes, HIV or hepatitis B or any sex that involves blood, are at a higher risk for transmitting or getting hepatitis C through sex. The chances for having blood exposure through anal sex, rough sex, and dry sex are also higher. Sex toys that are shared between partners could also have blood on them. In these cases it is always best to practice safer sex (e.g. using condoms) to prevent giving or getting hepatitis C and other diseases. When a woman is menstruating, it is recommended that (male or female) condoms are used during sex and dental dams during oral sex. Once a male or female condom has been used, it cannot be reused. A new condom should be used each time you have sex. If cuts or bleeding gums are present, there is a risk of Hepatitis C being transmitted during oral sex. Remember, Hepatitis C is present in blood, and therefore, the greatest risk of sexual transmission is through anal sex.Both methadone and Hepatitis C treatments can cause constipation, which may lead to an anal fissure, which is a break or tear in the skin of the anal canal. Anal sex can also cause an anal fissure. As a fissure is a tear in the anal canal, you are at increased risk of acquiring or transmitting Hepatitis C due to direct access to your blood. Making changes to your diet can help prevent

constipation and make your faeces softer. You can do this by eating a balanced diet with lots of fibre, drinking enough fluid so that you don’t become dehydrated and taking regular exercise.

Purpose: Make sure all participants

understand about vertical transmission of Hepatitis C and the dangers of conceiving while receiving HCV treatment.

Learning objective: Participants will be able to determine the risk of vertical transmission of Hepatitis C.

2.3. Pregnancy, motherhood and Hepatitis C (5 minutes) [reprinted with permission from

xxxx://xxx.xxxxxxxxxxx.xxx/xxxxxxxxx/xxxxxxxxxx_xxx/Xx_xxxxxxxxx.xxx]

During this session we will discuss pregnancy and motherhood and the risk of Hepatitis C transmission.

The technical term for an infection passing from mother to unborn offspring is vertical transmission. Vertical transmission is uncommon, but it does occur. Among Hepatitis C positive women, the rate of vertical transmission is 4% to 7%. The rate of vertical transmission increases to 25% for women who are coinfected with HIV and Hepatitis C. Hepatitis C vertical transmission risk appears to be higher for those with high viral loads (a higher amount of virus in their blood).

Approximately ninety-five out of a hundred times, a Hepatitis C positive woman will give birth to a Hepatitis C negative baby. Treatment for hepatitis C lasts between 24-48 weeks depending on the Genotype. Pregnancy should not occur while a patient is being treated for Hepatitis C. This applies both to female patients and female partners of male patients receiving treatment for Hepatitis C. Women should never become pregnant during and for six months after the completion of Hepatitis C treatment. Patients are told to use two reliable forms of birth control during Hepatitis C treatment and for 6 months after treatment has stopped.

Current Hepatitis C treatment may cause birth defects and miscarriage.

All major medical guidelines recommend routine testing of children born to Hepatitis C positive mothers. Infants can begin life with their mother’s Hepatitis C antibodies but this does not mean they are Hepatitis C positive. Since infants’ immune systems take time to develop, testing should not occur until they are at least 18 months old. Hepatitis C positive children usually have little or no

symptoms, and disease progression is minimal for the first 20 years of a child’s life. Children can be treated with antiviral therapy. The

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Procedure: The Rate the Risk Activity involves one set of 9 cards. Each specifies a sexual situation in terms of 3 things: 1) partner type; 2) the specific sexual behaviour; and 3) things that people want out of sex or out of a sexual relationship. The situations are:

NOTE TO FACILITATORS:

The first question (“How risky is this situation?”) is the most important point of the exercise. If participants define risk by the type of relationship or the reason for having sex, remind them to look at the risk pyramids. Encourage them to reach the conclusion that it’s risky fluids and places that define risk. Try not to state this conclusion for them. Give them the chance to figure it out for themselves.

Some important questions/topics that could come up here (especially if participants insist on partner type or

reason for having sex being what defines risk) and how facilitators might address them:

• “But if we’ve been together for this long, s/he’s not a risky partner.” [Response: Does the virus know how long you’ve been together?]

• “But sex is about showing you love each other, that’s not risky.” [Response: Does the virus know why you’re having sex? Does the virus know it’s about love?]

• “But if my partner is negative then it’s not risky because there’s no virus.” [Response: Let’s talk about that, how do you know your partner is negative? Did you get tested together? Did s/he just tell you so? Did you just assume? Can you talk about what you need to do to really be sure your partner is negative.]

Let participants go through several examples. If the

response rate for children is better than the adult rate. Children usually tolerate treatment well, some having little or no side effects. At this point, the long-term effects on adults who underwent treatment during childhood are unknown.

There are no recommendations against breastfeeding for Hepatitis C positive women, including those receiving opiate substitution treatment, unless they are receiving Hepatitis C treatment. There is some risk of Hepatitis C transmission from breastfeeding for Hepatitis C positive women if your nipples are cracked or bleeding. If your nipples are cracked or bleeding, stop breastfeeding until they are healed. Women should not breastfeed during Hepatitis C treatment.

Women who start their family first might want to postpone treatment until their children are older. Current Hepatitis C treatment has

side effects, such as tiredness and depression. It can be hard to take care of young children if you aren’t in good physical and emotional condition. No matter what age your child or children are, get support while you are undergoing treatment.

2.4. “Rate the Risk” Activity (20 minutes) (reproduced with permission from DUIT (Xxxxxxx et al., 2007)

One of the reasons it can be easy to know what to do but hard to do it, is that the things people want out of sex can be so important to them that they ignore the risk. They ignore that what they’re doing is risky and might get them infected with hepatitis C or sexually transmitted infections or become pregnant when they do not wish to. To actually do the things you need to do to be safer, there are two things that are necessary:

You have to be willing to do it, and you have to be able to do it.

What do I mean by “willing” to do it? Maybe a person doesn’t think they need to be safer, maybe they have some reason why they like doing things the way they do, and they just don’t want to change things to reduce their risk. Maybe I’ve been with my partner a while, and I really love and trust him/her. I might say, “Condoms? Why do I need to use condoms, we love and trust each other!” A person who says that is not willing to do the safer thing.

Being able to do it is a little different. You might want to do something but for some reason you can’t. I might want to go to Hawaii, but if I don’t have a plane ticket, I can’t go. It’s the same thing with reducing your sexual risk. Maybe I want to do less risky things, or use condoms, but I’m afraid if I do I’ll get beaten up, or maybe I just don’t know how to talk to my partner about being safer.

The next activity we’re going to do will help us think about sexual risk and what people might be willing and able to do to reduce their risk. You will decide how risky certain sexual situations are, and what the person in that situation could realistically do to reduce their risk.

   How risky is this situation? Why?

   What is a safer alternative?

   Would someone in this situation be willing to do the safer behaviour? Why or why not?

   Would someone in this situation be able to do the safer behaviour? Why or why not?

It’s not always easy to do the safer thing. Later in this session, I’ll teach you a tool to help negotiate safer behaviour.

[Rate the risk activity cards] CARD 1

Regular sex partner wants to stop using condoms with his partner because he prefers the sensation and says he is Hepatitis C negative.

CARD 2

Man wants to have sex after the first date.

CARD 3

Long-term intimate partner, who has been unfaithful and violent towards his girlfriend, wants to have anal sex without a condom.

CARD 4

Client offers to pay sex worker more money for vaginal sex if she has sex with him without a condom.

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group does not reach the conclusion that risk is defined by risky fluids and places by the end of

the activity, facilitators should clearly state it: Risk is defined by risky fluids and places, not by partner type or reason for having sex.

Learning Objectives: Participants will be able to:

• Recognise examples of barriers to reducing risk having to do with equipment, withdrawal, relationships and power.

• Offer further examples of barriers within these categories.

• Recall the content of the dye video as evidence that shows how Hepatitis C can be indirectly transmitted.

Procedure:

• First present the risk behaviours from the injection risk hierarchy – holding up the cards that participants used to build the pyramid and specifying problems that get in the way of risk reduction.

• Take each behaviour on the injection risk pyramid (i.e., “Injecting with someone else’s used syringe (no bleaching)”). Then introduce 3 categories for each behaviour (i.e., equipment, withdrawal, power/ relationships) and have participants specify problems within those categories. Start with an example or two, then ask participants to specify others.

• Write the examples of problems for each behaviour on the flipchart/white board. Use three columns, one for each category.

• The problems identified for “Injecting with someone else’s used syringe (no bleaching)” also apply to the next level down (i.e., “Preparing and splitting drugs with someone else’s used syringe” and “Injecting with someone else’s bleached syringe”) so you can bring up examples of those problems quickly as a review.

• The equipment problems for “Sharing water, cotton, unbleached cooker” are different only in detail –

they have to do with getting new works from a

2.5. Why do women do risky things that can put them at risk of Hepatitis C? (20 minutes) [reproduced with permission from DUIT (Xxxxxxx et al., 2007)]

We now have learned about behaviours that increase the likelihood of Hepatitis C transmission. Much of this information isn’t new to you. But some people have a hard time reducing their risk. Today, let’s try and understand what problems get in the way of reducing risk. Once we identify the problems, we can think about solutions.

[Note to facilitator: Hold up the “Injecting with someone else’s used syringe” card].

Let’s look at the most risky drug behaviour: Using unclean needles. By this time, I’d say just about everyone knows that injecting with used, unclean needles risks getting infected with Hepatitis C. I’d also say that probably everybody would want to keep safe. So why do people keep using unclean needles?

Often the problem has to do with equipment.

If you don’t have a brand new sterile needle and syringe, you can’t inject safely.

Another problem that could make it hard is withdrawal. An example of withdrawal making it harder to be safe could be, for example, if you’re suffering withdrawal you’ll do anything to get a hit.

Another problem has to do with relationships and power. A relationship issue could be if you feel it’s OK to share with your partner – because he/she’s your man/woman, you trust them and sharing with your partner is a way of demonstrating that trust. An example of power could be if you bought the drugs with other people and you have to share – you might feel like you don’t have the power in that situation to demand to be as safe as you’d like. Another example of power is if you are in a relationship with someone who controls the injecting process and you do not feel you are able to negotiate the use of a clean needle and syringe.

[Note to facilitator: Hold up the “Preparing & splitting drugs with someone else’s used syringe” cards.

Let’s move down the risk pyramid. Preparing and splitting drugs with someone else’s used syringe. Not everyone knows that these are risky things to do. We went over why these are risky. Who can remember what we learned about why preparing and splitting drugs, and sharing water, cotton and cookers is risky? (Dye demonstration video – cross-contamination)

Let’s think about preparing and splitting drugs with someone else’s needle. What problems with equipment could stop people from reducing this risky behaviour?

Basically the same problems as for “injecting with someone else’s used syringe.”

What problems with withdrawal could stop people from reducing their risk of getting infected?

Basically the same problems as for “injecting with someone else’s used syringe (no bleaching).”

What problems with relationships and power could stop people from reducing their risk of getting infected? Basically the same problems as for “injecting with someone else’s used syringe”.

[Note to facilitator: Hold up the “Sharing water, cotton, unbleached cooker” card].

There’s another behaviour that’s at that level of risk – sharing water, cotton and an unbleached cooker. Why is that risky? (Remember the dye video)

What problems with equipment get in the way of reducing that risk? No one is carrying brand new cookers or cottons.

[Note to facilitator: Hold up the “Reusing your own syringes and equipment” card]. Let’s move down the risk pyramid. Who can remember why reusing your own syringes and equipment is risky? You don’t know for sure that nobody has used it besides you. All of these are the same problems that can get in the way of reducing the risk from reusing your own syringe and works, right?

Right

[Note to facilitator: Hold up the “Using a new syringe and equipment for every injection” card].

Let’s keep moving down the risk pyramid. If you’re using brand new sterile equipment to measure and inject drugs, that means you no longer have problems with equipment, right?

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needle exchange programme, rather than getting new needles.

NOTE TO FACILITATORS: The “problems” and “solutions” parts of this exercise are presented separately. If your group spontaneously starts suggesting solution strategies as the problems are identified, let it happen. Make sure all the problems are identified, and the solutions are appropriate to the problem. Also make sure that you keep presenting the problems in association with risk levels from the pyramid. If the “problems” and “solutions” sections are

done separately, “problems” should take 20 minutes, and “solutions” should take 10.

Write “Equipment” xx xxxxx board, this will be the top of the column to list equipment-related problems. Write the examples on the white board in the

“equipment” column. Ask if anyone has any other suggestions, and write them down. Additional suggestions may include:

• No one has money to buy new sterile needles

• No one knows where a nearby needle exchange programme is to get new sterile needles

Write “withdrawal” at the top of the second column. Ask if anyone has any other suggestions, and write them on flipchart. An additional suggestion may be: Your friend is “strung out” and you want to help.

Write “relationships/power” at top of third and final column. Write the examples down. Ask if anyone has any other suggestions, and write them on the white board/flip chart. Additional suggestions may include:

• You feel that you have to share because he/she just gave you drugs

• You want your main partner to trust you

• You want to feel that nothing can come between you and your main partner.

Write any newly suggested problems in the “equipment” column.

Again, write newly suggested problems down.

Right

How about problems with withdrawal?

Withdrawal wouldn’t put you at risk of infection if everyone had their own brand new sterile equipment to measure and split drugs and you weren’t in too much of a rush to use them. How about problems with relationships and power? These can still be a problem. Even when you have your equipment under control, you may not want to be standing out from your drug using friends/acquaintances. You might still have problems with power that keep putting you in a position that risks getting infected. But if everyone has their own rig, then you’d be under less pressure.

[Note to facilitator: Hold up the “Stop injecting” card].

Now we’re down to much less risk. If you’re not shooting drugs, do you have any problems with equipment that make it hard to reduce your risk for Hepatitis C?

Problems with withdrawal?

Maybe yes, this is one reason why still using can be risky.

Problems with relationships or power? Not really.

[Note to facilitator: Hold up the “Stop using drugs” card].

Stopping using drugs is the best way to avoid risk of Hepatitis C through injecting. It should be obvious why people keep doing things that put themselves at risk - because there are problems with equipment, withdrawal and relationships that prevent people from changing their behaviour

[Note to facilitator: Hold up the “Have sex without a condom” card].

Why might people have sex without a condom? People may not have access to condoms (“heat of the moment”). How about problems with relationships and power? People in relationships may decide and agree not to use condoms. In other relationships men may refuse to have sex without a condom or pressure women into unsafe sex (power). Some women therefore, may have difficulties negotiating safer sexual interactions.

Solutions Withdrawal

Once you’ve taken care of the equipment problem, there are still other problems. Let’s say you yourself have a clean sterile needle and clean works, but your friend is suffering withdrawal and you really want to help. The only problem is that your friend doesn’t have a needle. Of course if you had a good supply of sterile needles and works to hand to your

friends, you’d be ok. But suppose you didn’t replenish your needles and works early enough. How do you help your friend who’s suffering withdrawal? Without taking the chance of someone getting infected?

• Try to obtain a new syringe. You should not pass your used needle and syringe onto your friend.

• Try to manage your drug use so that you always have some extra left over for yourself or someone else.

Relationships and power

You could still be doing things that risk getting infected with Hepatitis C even if you have plenty of clean sterile needles and works. We looked at problems about relationships and power. Can someone help solve those kinds of problems? Let’s say the problem is your boyfriend or your girlfriend thinks it should be OK to share – but you have clean

sterile needles and clean works and you don’t want to share. What can you say or do to be safer?

- “I know you’re my boy/girlfriend, and I really love you, but this has nothing to do with you. I just don’t want to share, there’s just too much risk.”

Let’s say the problem is that you have clean, sterile needles and clean works, but he just gave you drugs so you think you have to share his works and his needle. But you don’t want to take the risk of getting infected. What can you say?

- “I appreciate that you are sharing these drugs with me, but I want to use my own equipment. It has nothing to do with you, it’s nothing personal. I just don’t want to share because there’s too much risk for both of us.”

Let’s say the problem is that you want to use a condom but your partner doesn´t. But you don’t want to take the risk of getting infected. What can you say?

- “I know you’re my boy/girlfriend, and I want you to understand that although I really love and trust you, I’d rather use a condom to protect both of us from getting infected and to avoid getting pregnant”

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Ask if anyone has any other suggestions, and write them all down in the appropriate column. Additional suggestions may include: No one knows where a nearby needle exchange is to get new supplies

One by one read 4-5 of the problems already mentioned and written down. Then, continuing to gesture to additional problems that have been

written down, but without reading them.

Purpose: To introduce TALK, a negotiation tool, and promote its utility for reducing sex and injection risk.

Learning Objective: Participants will be able to identify each element of the TALK model and give examples of applying them with at least one partner type (sex or drug).

Procedure: First deliver the introduction below, followed by the explanation of what a bottom line is, and the importance of thinking about and knowing what your bottom line is before you get into a conversation.

Then explain each letter on the flip

chart. Solicit examples for how each letter can be used with steady and casual sex partners and with drug using partners.

Procedure: Briefly review the TALK tools and lead discussion using

questions below. Refer to the TALK poster while talking about each tool. Start the discussion of each point with general questions, and follow up with

more specific questions if the participants don’t understand the general question or aren’t getting it.

Let participants come up with examples. Some of their examples will probably highlight the need for better communication with “I” statements.

A: Assert what you want. VERBAL

   I want to start using condoms.

   I’m not gonna do it with you unless you are wearing a condom.

   I want to protect myself and you.

Thanks, this was a great activity. The point of it was to recognize that there are real problems that get in the way of being safer, but also to see that if you think about it and work at it, you can find solutions to those problems. After the break we will find out about how to communicate and negotiate more effectively with your sex or drug partners to reduce risk behaviours.

Break (15 minutes)

2.6. Skills Building: Using TALK to Negotiate Safer Sex and Injection Behaviors (40 minutes) [reproduced with permission from DUIT (Xxxxxxx et al., 2007)]

TALK model (10 minutes)

We have discussed problems that may prevent you from reducing your risk of Hepatitis C infection– problems having to do with equipment, withdrawal, and relationships or power. We just discussed difficulties in reducing risk of infection through sex – the importance of being willing and able to reduce risk. As some of you have shared, talking about risk reduction with an injecting or sex partner may not be easy [repeat good examples that may have come up]. Sometimes it is also hard because sex and drugs often happen together. So we’d like to give you another communication tool, a tool for negotiating with your sex or drug partners about being safer. This poster shows the TALK tools. Each letter stands for a different step that will help you be firm without making the other person get defensive or angry. TALK is very helpful to use when you’re trying to reduce your own risk of infection, and you need someone else’s cooperation. TALK is useful in situations like this:

   When you want to change to a less risky type of sex

   When you want to ask a partner to use a condom

   When you want to tell a drug buddy that you aren’t going to share works

People are social creatures. We all get into situations where we need someone else’s cooperation. Let’s think about what a negotiation is. The difference between discussing and negotiating is that negotiating is all about getting what you want. So you first have to figure out what kind of safer behaviour you want. We think of this as the “bottom line.”“Bottom line” is a phrase that means “After all is said and done, this is what I want.

And I won’t settle for less.” An example of a bottom line having to do with safe sex is “I use condoms or I don’t have sex.” If your bottom line is something different, like “I use

condoms with everyone except my main partner,” just remember that unprotected sex is very risky no matter who your partner is. And realize you’re taking a risk. An example of a bottom line having to do with safe injection behaviour is “I never share my needles or works.” If your bottom line is something less than that, realize that you’re taking a risk.

Here’s the poster showing the TALK tools:

TALK Poster

T: Timing is everything – pick the right time & place. A: Assert what you want.

L: List your reasons for being safe. K: Keep to your bottom line.

Let’s go through each of these tools to understand what each one means. I will explain what it means, and I want you to give me an example of how it can be used during sex with steady partners, and with casual partners, and also for when you are wanting to be safer when injecting.

TALK– emphasizes that you have to choose the right moment when you’re having an important conversation.

“T” stands for Timing is everything – pick the right time & place. Remember this is a conversation, so pick a good time to talk.

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   I’m not going to share my works.

   I only split drugs dry.

   I’m worried about all the stuff that’s out there and I want to be safe.

Again, let them come up with ideas. Let them define it. If they’re right, paraphrase their answer and if they’re wrong, highlight what part they got right and correct what they got wrong.

NON-VERBAL

   Just bring out male condom and put it on him in a sexy way.

   Just bring out a female condom and offer to put it on in a sexy way.

   Move his or her hands away from your genital area/stop foreplay.

Mark your works and keep them away from everyone else’s.

   Move your works away from other people’s.

   Keep a separate set up when injecting don’t let anyone borrow or lend you works.

L: List your reasons for being safe

   I like to use condoms because it makes me feel like I am taking care of myself.

   I am in charge of my health, and I like using condoms / using my own works.

   I just can’t enjoy myself during sex unless I’m using protection.

   I just can’t enjoy my high unless I’m injecting safely.

   I don’t want to get any disease— it’s just not healthy for me.

   I don’t want to get pregnant.

K: Keep to your bottom line examples – in case participants cannot come up with similar ones.

   I use condoms or I don’t have sex.

   If I can’t get my steady to use condoms, then it’s not worth the risk.

   If I don’t even know a date that well, and it’s not worth risking sex with him/her unless we can do it with a condom.

   I don’t share needles. Period.

   I will always carry my own clean cooker and cottons with me in case I score drugs.

   I only split drugs dry.

Procedure: Divide participants into 2 groups. In each group select 2 participants who engage in a roleplay

Don’t wait for the last minute.

What’s a good time to talk to drug buddies?

Bring it up with your drug buddies when you’re not strung out (withdrawal) or too high.

What’s a good time to talk to a partner if it’s someone you’re just starting a relationship with? What about if it’s a long term relationship? What about a casual partner?

Bring it up at the beginning of a relationship, before you start having sex. If you’re already in a relationship, bring it up before either of you are too horny.

“A” stands for Assert what you want. By assert we mean: Let your friend or partner know what you want to do. Can you think of ways you can let a sex partner know what you want? How about a drug buddy?

It is good to use sentences that start with “I” because if you start sentences with “you,” you put your partner on the defensive. For example, listen to the difference between this: “You never do this! And You never do that” compared with “I want to do this… and I want to do that… ” Do you see how the first way puts the listener on the defensive? See how the

second way gets across the same information without turning the conversation into a fight? Can you think of sentences that start with “I” instead of “you” that you could use to tell sex partners what you want? How about drug buddies?

There’s another way to assert what you want, and that’s with non-verbal communication. What does “non-verbal” mean? It’s body language, it’s just doing it instead of saying it. Can you give us an example of asserting what you want non-verbally for safer sex? How about for safer injecting?

L” stands for List your reasons for being safe. What sort of reasons might you give a sex partner or shooting buddy for being safe? “K” stands for Keep to your bottom line. This is because you can’t talk to your partner or friends about what you want and what you’re willing to do unless you know what your limits are. “Keeping to your bottom line” means that you have to think about how much risk you are willing to take when having sex or shooting up, you set a limit and you stick to it. What are some examples of a statement that explains a “bottom line”?

So that’s what the TALK tools are. You might have been doing a lot of this already, and it might seem easy to you. Or maybe it’s new to you, and you feel like you need some practice before you could really do it. This next exercise will give us all some practice using the TALK tools.

TALK role-play exercise & wrap-up (30 minutes)

Now we’re going to practice using “TALK” in some situations that people may have. In this exercise we’re going to split into two groups, and each group is going to practice using 3 different TALK tools (Assert what you want, List your reasons for being safe, and Keep to your bottom line). Two people in each group are going to play the role of the two sex or shooting partners. Each time they use a part of TALK during their role play, the observers will make a note on the checklist. A facilitator will be with each group to help out. Each group will get a chance to practice two different scenarios. You will find that you may need to tailor or change the TALK tools for each situation. As you do the exercise, you should try to come up with your own responses, but you can use the list of examples that we covered before when we were going over the TALK tools. You’ll each get 2 minutes to try to convince your partner to be safer during sex or injecting. Look at TALK tools on the wall to remember what each letter stands for.

Role Play Scenarios Scenario 1.

Partner A: You have been talking to your friend about what you have been learning in our sessions. You usually share cookers and spoons with this person. You’re about to get high and they pull out a spoon from their kit and begins to prepare like usual. You ask if it would be ok to split the drugs while they are dry so you can be safer and not share the cooker.

Partner B: Your friend has been telling you about the stuff they have been learning as part of a research study they have been participating in. You’re about to prepare drugs when your friend all of the sudden wants to split the drugs and prepare it themselves. You begin to think they are scared of catching something from you. You don’t see any reason to change the way you’ve been doing things now.

Scenario 2.

Partner A: You and this person broke up six months ago. Sex was always good even when the relationship wasn’t, and the two of you never used condoms. You know this person has been with other people in your same circle of friends. You recently went from snorting to injecting and have used a needle that may have been used before. You know you could have gotten infected with something from that needle, so you want to be safe when having sex. You don’t want Partner B to know you’re injecting.

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dialogue as if they were sexual partners. One sex partner in each group should use TALK tools to

negotiate for safer sex. The remainder of the participants should observe and listen for the use of 3 of the TALK tools (Assert, Listen, and Know). Briefly describe to the participants each partner type and have participants select the role-play they want to do. Each facilitator monitors the role-plays of one group of participants. At the end of each role-play, you should get feedback from the rest of their group to sum up (and reinforce and praise) the total number of TALK tools used. When number of TALK tools used. When the larger group rejoins, remember to sum up the smaller groups’ roleplays. After the role-play ends, ask observers to say what TALK tools they saw used in the role-plays. If participants have a hard time coming up with TALK examples, add what you yourselves observed. As always, reinforce the points that participants make.

Hand out TALK tool card.

Purpose: Review lessons learned from this session and specify the practice activity for next session.

Partner B: You know that Partner A insists on using condoms when having sex with casual partners so you don’t think he/she is at any more risk now than when you two broke up.

Scenario 3. (adapted from modelling session of WWT turn around what they say)

Partner A: You’re about to have sex with your steady partner. When you ask him to wear a condom he refuses and gets annoyed. You know that he is often unfaithful to you on several occasions recently. You want to have sex with him but you want him to wear a condom as you are concerned that he might have caught a sexually transmitted infection from one of these women.

Partner B: You do not want to use a condom for sex with your steady partner as you don´t like them and can´t feel much during sex when you wear one. You and your steady partner do not usually use condoms.

Scenario 4.

Partner A: You’re about to score some drugs but you’re short on money. Your connection says you can work it out with sex but they don’t want to use condoms. You really need to score but you are mostly concerned about your health and the health of your steady partner.

Partner B: You have wanted to have sex with this person for a while and you think you might finally have a chance. You don’t think this person would normally find themselves in this situation so you don’t think they are at risk to give you anything.

This role-play gave you a chance to practice using TALK tools. Some of you may have noticed that in some situations – usually with steadies— “one liners” are not always going to do the trick. Working through these issues and staying safe with your steady partners may require a lot of communication. TALK tools are a strategy for making sure that conversations go smoothly, without getting overheated. It is important to remind you that

people should know their limits – or their bottom line – in case their alternatives for safer behaviour don't work out. That might mean leaving the situation or getting out. Today you started to think about what YOUR limits might be in certain situations. If you think about your limits first, you’ll be less likely to do something that threatens your limits.

2.7. REVIEW AND CLOSE (5 minutes)

When it comes to sex, what is the most important thing to think about in rating how risky a behaviour is?

Whether or not someone else’s blood may be present.

What kind of sex is increases the risk of being exposed to blood?

The chances for having blood exposure are higher through anal sex, rough sex, and dry sex

How common is vertical (mother to child) transmission of Hepatitis C?

Among Hepatitis C positive women, the rate of vertical transmission is 4% to 7%. The rate of vertical transmission increases to 25% for women who are co-infected with HIV and Hepatitis C. Hepatitis C vertical transmission risk appears to be higher for those with high viral loads (a higher amount of virus in their blood).

Is it safe to get pregnant while you or your partner are being treated for Hepatitis C?

No. Women should never become pregnant during and for six months after the completion of Hepatitis C treatment as current Hepatitis C treatment may cause birth defects and miscarriage.

Why do women do risky things that can put them at risk of Hepatitis C?

Equipment, withdrawal, relationships and power.

What does TALK stand for?

T: Timing is everything – pick the right time & place. A: Assert what you want.

L: List your reasons for being safe. K: Keep to your bottom line.

That was a good review. Today we discussed why women may take risks and how to negotiate with your partner and others to reduce these risks. Does anyone have any further questions?

Remember as this is a research project, I would really like to get your feedback on this session so that it can be improved if necessary in the future.

What did you like about this session? What did you dislike about this session?

What would you change about this session?

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Thank you all for coming. This is a great group. See you on (day of week).

Group rules

1. Confidentiality ("privacy")

2. Respect

3. Appreciate different stages of use and recovery

4. Right to choose to participate

5. Be fit to participate

6. The right to ask questions

7. Be on time

RATE THE RISK ACTIVITY CARDS

CARD 1

Regular sex partner wants to stop using condoms with his partner because he prefers the sensation and says he is Hepatitis C negative.

CARD 2

Man wants to have sex after the first date.

CARD 3

Long-term intimate partner, who has been unfaithful and violent towards his girlfriend, wants to have anal sex without a condom.

CARD 4

Client offers to pay sex worker more money for vaginal sex if she has sex with him without a condom.

Risk of hepatitis C transmission to an uninfected injector from an infected injector Injecting risk pyramid exercise

Please cut out each of these statements for use during the exercise

HIGHEST RISK	LOWEST RISK
Injecting with someone else’s used syringe (no bleaching)	Preparing and splitting drugs with someone else’s used syringe
Injecting with someone else’s bleached syringe	Sharing water, cotton and unbleached cooker
Using only new or bleached syringes and cookers and new cotton and water to split drugs	Re-use your own syringes and equipment
Use a new syringe and equipment for every injection	Stop injecting
Stop using drugs

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TALK Poster

T: Timing is everything – pick the right time & place. A: Assert what you want.

L: List your reasons for being safe. K: Keep to your bottom line.

• Materials: attendance register, name badges, participant folders, flipchart and pen

• Handouts

1. Depression self-help tips

2. Behavioural model of depression

3. Depression spiral

4. Wallet card – 4 key things to remember

SESSION 3. HEPATITIS C AND EMOTIONAL WELLBEING – REDUCING NEGATIVE MOOD

Goals for Session 3:

1. Increase knowledge about the association between Hepatitis C treatment and depression.

2. Increase knowledge about the potential relationship between risk behaviours and negative mood.

3. Identify symptoms of negative mood.

4. Introduce the behavioural model of depression.

5. Identify strategies for managing negative mood.

6. Develop an understanding of self-talk and how to use it.

7. Motivate participants to change their risk behaviours.

Objectives:

Participants will …

• increase their knowledge about negative mood and the potential relationship with risk behaviours and Hepatitis C.

• understand the behavioural model of depression.

• be able to identify strategies for managing negative mood.

• develop an understanding of self-talk and how to use it.

Session 3 outline:

3.1. Welcome and feedback on Session 2 (5 minutes)

3.2. What is depression? (10 minutes)

3.3. Understanding the link between depression and Hepatitis C (5 minutes)

3.4. What can we do to change the way we feel? (15 minutes)

3.5. The depression model (20 minutes)

Break (15 minutes)

3.6. Skills Building: Using Safe-Coping and Self-Talk (35 minutes)

3.7. Review and close (15 minutes)

This column reminds the facilitator of the purpose of each session, the materials required to run the session and the procedures to be followed. Notes to

facilitators are also included.

Purpose: To welcome participants back to the group; to process participants’ experiences relating to

3.1. Introduction and feedback on Session 1 (5 minutes) [adapted with permission from DUIT (Xxxxxxx et al., 2007)]

Hello, I would like to start by saying how great it is to see you here at the third and final session of the REDUCE intervention. Thank you for coming back.

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last week’s session.

• Appreciate different stages of use and treatment – People are in different

stages of drug use and treatment. Some of you may have chosen to stop using and some of you are still using drugs. The group needs to accept that different people make different choices. You are not required to stop using to be in this programme. [Note that some programme content includes video and/or discussion of syringes and other injection paraphernalia, and any participants who are in recovery or who are concerned with that have the right not to watch/participate in that part of the session].

   Be fit to participate - You can participate better, without disrupting the group, if you manage your drug use. Be well while you’re here.

   The right to ask questions - You should ask questions whenever you feel that you don't understand something or that you want more information.

   Be on time – Be here on time so the group don’t have to wait for you and you won’t miss out.

Remember, following these group rules is very important as everyone should feel able and safe in sharing their thoughts and feelings during the session.

Last week we focused on increasing our knowledge about Hepatitis C and sexual risk behaviours and on strategies to negotiate safer sexual and injecting behaviours to protect ourselves and others from Hepatitis C transmission. Does anyone have any questions or anything they would like to say about what they learned last session?

Today we will start off by talking about negative mood or depression and consider how this might be associated with risk taking behaviours and Hepatitis C. Then we will discuss how feelings, thoughts, behaviour and the environment are all related and look at what we can do to change the way we feel. We will learn and practice positive “self-talk” which is a way of talking to yourself to really change your attitude and behaviour.

Does anyone have any questions before we begin?

Purpose: To discuss the concept of “depression” and what makes people depressed

3.2 What is depression? (10 minutes) [adapted from Women’s Wellness Treatment, Xxxxxxx et al., 2006]

Learning objective:

Identify what it feels like to be depressed and some of the causes of depression

Procedure

A. Discuss the concept of “depression” and what makes us depressed.

1. Elicit examples from group members.

2. What is depression, what does it feel like to be depressed?: Write list on flip chart.

Reasons for depression

1. Elicit examples - What causes depression? Why do we get depressed?

2. Write list on flip chart.

3. Elicit a discussion specifically focused that

So as I said we are going to begin by talking more specifically about negative mood or depression. I want you to spend the next few minutes in small groups and discuss the following 3 questions:

What is depression?

What does it feel like to be depressed? Why do you think people get depressed?

[give groups time to discuss, then write responses on flip chart]

Suggested responses What is depression?

• Low mood

• Feeling sad/unhappy

What does it feel like to be depressed?

• Sad/unhappy

• Worthless

• Tearful

• Suicidal

• Irritable

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relates negative mood to drug use, risk taking behaviours and/ or relationship conflict.

Purpose: Make sure all participants understand the links between depression, risk taking behaviours and Hepatitis C.

Learning objective: Participants will be able to identify the links between depression, risk taking behaviours and Hepatitis C.

Procedure:

Didactic session.

Purpose: To identify things that women can do to make themselves feel better when they are depressed.

Learning objective: Participants will be able to identify effective and less effective strategies for enhancing their mood.

Procedure:

Identify ways in which members try to make themselves feel better when they are depressed (what hinders them from being able to do so)

• Part of the goal in this component is to draw a connection between pleasant activities and positive mood.

• The discussion helps members become explicit about the ways in which they

Why do you think people get depressed?

• Loneliness/ Lack of social support

• Recent stressful life experiences

• Marital or relationship problems/ conflict/ intimate partner violence

• Financial strain

• Early childhood trauma or abuse

• Alcohol or drug abuse

• Unemployment or problems at work

• Health problems or chronic pain

From your discussions there is agreement that depression is [summarise discussion] and that people get depressed for a variety of reasons including [summarise]. It is clear from what you have said that depression or negative mood is clearly related to your drug use and also to your relationships with your partners and others.

I am now going to move on to discuss the importance of your mood in relation to risk taking behaviours and also the links between depression and Hepatitis C.

3.3. Understanding the links between depression and Hepatitis C (5 minutes) [adapted from

xxxx://xxx.xxxxxxxxxxx.xxx/xxxxxxxxx/xxxxxxxxxx_xxx/XX_XXX%00xxx%00Xxxxxxxxxx.xxx]

Depression is common among women and among women who use drugs. As we discussed last week some women may be more likely to engage in drug and sexual risk behaviours when they are feeling low, as they may become indifferent to the health risks resulting from these behaviours. Women who are or have been in abusive relationships are also more likely to experience depression and engage in risk taking behaviours potentially due to the negative control of their partner.

The prevalence of depressive symptoms is higher among people with Hepatitis C. This could be due to several reasons. Firstly, living with a chronic disease can be challenging. Some people with Hepatitis C report symptoms such as severe fatigue, body aches, and sleep problems, which can also lead to feeling down or depression. Secondly, depression is a common side effect of Hepatitis C treatment. Therefore, it is important to tell your doctor if you have a current or past history of depression or any other mental health problem if you are considering treatment for Hepatitis C. It is especially important to report severe depression, hospitalisation for any psychiatric illness, or any suicide attempts. If you have thoughts of suicide or hurting yourself or others, seek immediate professional help. Sometimes antidepressant medications are used in conjunction with Hepatitis C treatment and many patients state that antidepressants can make a huge difference in their quality of life while they

are undergoing Hepatitis C treatment. Finally, some people may feel depressed if the outcome of Hepatitis C treatment does not turn out the way you hoped.

3.4. What can we do to change the way we feel? (15 minutes) [adapted from Behavioural Modification for Drug Dependence, (Xxxxxxxxx

et al., 1984; Xxxxxxxxx et al., 2006; 2008)]

Help for depression can come in a variety of ways. Sometimes mild depression can be improved with self-help measures alone. Prolonged or severe depression usually requires professional treatment. There are many ways to cope with negative mood or depression. However, the more difficult the challenge the more likely we are to use coping strategies that are well rehearsed. This may lead to an increase in the urge to use drugs or other strategies that may be harmful.

I’d like us to begin by thinking about What sorts of things do you do when you are feeling down to “self-soothe” or make yourself feel better? Let’s make a list. Think about:

• Activities you really enjoy

• Something you can do frequently.

• Activities you have complete control over. That is, you do not have to always rely on others.

• Activities that are relatively inexpensive.

• Activities that are not upsetting to others, so that they do not result in negative reactions.

• Activities that improve your physical health [make a list on the flip chart]

Possible responses

• Listening to music

• Walking

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manage/ enhance their mood. While women may frequently turn to drugs and alcohol to improve their mood, in addition, they may also have positive strategies they already use; acknowledging this may help women feel more empowered.

• Similarly, this is a good opportunity to distinguish between effective and less effective strategies (How does that work for you?) and constructive versus self destructive (safe vs. unsafe – what are the consequences of the behaviour?)

Purpose:

• To present the depression model and discuss the relationship between their mood and activity level within the behavioural model of depression.

Learning outcome:

By the end of session participants will be able to understand how depression is related to their environment and activity level, and identify the activities that improve their mood.

Handouts:

1. The mood-behaviour triangle

2. The depression spiral

Procedure:

The model and treatment rationale are directed towards building the perception that the participant has control over her emotional state

• Talking to friends/family

• Having a bath

• Reading

OK so now we have identified what sorts of things or activities you can do to enhance your mood or make you feel better [summarise from flipchart]. Let’s think about:

How does that work for you?

What are the consequences of the behaviour?

[elicit group discussion]

So we have identified that there is a connection between doing things that we enjoy or pleasant activities and positive mood or making ourselves feel better.

Now I want us to think about:

What stops us from being able to do these activities when we feel down?

Possible responses

• Ourselves

• Lack of energy/ lethargy

• No motivation

• Low self-esteem

• Problems concentrating

You have all identified positive and successful strategies you already use to improve your mood, and you have identified the reasons that you are not always able to do these activities. I’m going to give you out a leaflet that reminds you of some of the things you can do to try and lift your mood [distribute Depression Self-help Tips].

During today’s session we will examine the relationship between pleasant activities and positive mood in greater detail and what we can do to improve our mood.

3.5. The depression model (20 minutes) [adapted from Behavioural Modification for Drug Dependence, (Xxxxxxxxx et al., 1984; Xxxxxxxxx et al., 2006; 2008)]

To summarise what we discussed earlier, depression is a state of low mood that may make you feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless. When people get depressed they may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, or problems concentrating, remembering details or making decisions; have sleep problems, loss of energy or tiredness, or aches and pains. Depression may also reduce the motivation needed to make important lifestyle changes.

I would like you to take a few minutes to change your feelings. If you are happy try to feel sad, if you are anxious try to feel calm etc. But I want you to try and do this without saying anything to yourself and without thinking about pleasant things, or doing anything like walking around. [wait two minutes then ask] Were you able to do that? [elicit answers from individuals]. So you would agree then that it’s almost impossible to do. Feelings can only be changed by what we do or where we are. Your mood can be changed by your activities and the situations in which you place yourselves.

We discussed earlier how we can lift our mood by doing pleasant things. I am now going to explain that to you in a bit more detail. Let’s look at the

mood-behaviour triangle.

We are going to look at how “feelings”, “behaviour” and “environment” all influence each other. It is usually easier to influence our feelings by changing aspects of the environment or our behaviour rather than trying to change a feeling directly. Here there are three things to remember: [write the following 3 points on the flip chart and ask participants to identify examples]

1. The environment (when and where) can influence how we feel, act, and think.

2. Our behaviours influence the environment and how we feel (Behaviour includes the things we do. This can be the activity we engage in during the day or the way we talk to ourselves – positive or negative. These behaviours can effect how we feel and also change the environment. We may notice we are more likely to do certain things or talk to ourselves in certain ways in certain situations. The environmental context can “set the table” for our actions, self-talk, and feelings

3. Our feelings can influence how we act and think (explain that there are many types of feelings and they can change throughout the day. Our emotions can be pleasant like “I feel happy” or unpleasant such as “I feel sad or I feel angry.” We may be more aware of our feelings than the behaviours we are doing).

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Let’s look at the depression spiral this becomes even clearer. The depression spiral offers a visual example of how a decrease in a person’s activity level can further their depressive feelings and began a cycle that results in further depression and withdrawal. You can see as the positive experiences decrease or negative experiences increase people tend to do less, withdraw, or avoid. This can lead to a downward spiral of feeling depressed, withdrawing, doing less, and feeling more depressed etc. Therefore when you are feeling down you need to break the spiral by changing your behaviour and environment. Low mood affect our energy; our desire to do things, our desire to engage in safer behaviours and our

motivation to engage with the world.

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Thinking about this depression spiral, can you give me some examples of this from your own lives? [Special attention should be paid to the participants’ avoidance and withdrawal responses (sleeping, cancelling going out with friends, ignoring the phone) that removes them from the situations that could possibly stop the spiral].

Think about the pleasant activities you identified earlier that you said lifted your mood. What sort of things could you try to avoid the depression spiral in the future?

Remember, there are many ways to cope with negative feelings. However, the more difficult the challenge the more likely we are to use coping strategies that are well rehearsed. This may lead to an increase in the urge to use drugs or other strategies that may be harmful to you. Earlier in the session you identified activities that made you feel better when you were feeling depressed, such as seeing friends; going for a walk etc. In the exercise we also discovered how difficult it is to change our feelings and that feelings can only be changed by what we do or where we are.

You need to consider how you can develop a plan to increase pleasant activities in order to change your behaviors and your mood. Remember

think about:

⮚ Activities you really enjoy

⮚ Something you can do frequently.

⮚ Activities you have complete control over. That is, you do not have to always rely on others.

⮚ Activities that are relatively inexpensive.

⮚ Activities that are not upsetting to others, so that they do not result in negative reactions.

Let’ take a break. When we come back we will learn about safe-coping strategies and ways to change our behaviour.

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Wellness Promoting

Wellness Inhibiting

- Blocking things out of my mind

- Keeping busy

- Counting to myself

- Going out and enjoying myself

- Going to the movies

- Listening to music

- Yelling and letting it all out

- Eating

- Smoke a cigarette

- Praying

- Reading

- Socialising

- Meditating

- Talking to someone

- Avoiding certain situations

- Exercising

- Taking a time out

- Cool down and be by yourself (e.g. take a bath)

- Positive thinking (glass half full)

- Using drugs and/or alcohol

- Smoke a cigarette

- Getting angry at yourself

- Taking it out on others (e.g. children, family, friends)

- Avoiding, “blowing off” commitments (e.g. not going to treatment, missing appointments, not meeting people you have plans with)

- Negative thinking (glass half empty)

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Purpose:

To identify ways in which participants can soothe themselves in response to distress in their intimate relationships and/or when they feel depressed.

Learning objectives:

• Participants will learn to draw a connection between drugs and alcohol use and healthy relationships.

Procedure:

Facilitator will need to define self-soothing first. The discussion helps participants become explicit about the ways in which they care for themselves. While women may frequently turn to drugs and alcohol to self-soothe, in addition, they may also have positive strategies they already use; acknowledging this may

help women feel more empowered. Similarly, this is a good opportunity to distinguish between effective and less effective strategies (How

does that work for you?) and constructive versus self destructive (safe vs. unsafe – what are the consequences of the behaviour?).

Break (15 minutes)

3.6. Skills Building: Using Safe-Coping and Self-Talk (35 minutes) [adapted with permission from Women’s Wellness Treatment, Xxxxxxx

et al., 2006]

So today we have learned how “feelings”, “behaviour” and “environment” all influence each other, and that it is usually easier to influence our feelings by changing aspects of the environment or our behaviour rather than trying to change a feeling directly. Behaviour includes the things we do. This can be the activity we engage in during the day or the way we talk to ourselves. We may notice we are more likely to talk to ourselves in certain ways in certain situations.

Self soothing is a way to comfort yourself, make yourself feel better when you feel upset, mad, sad, etc. We have already spoken about how some women may use drugs to comfort themselves or “self-soothe”, that is make themselves feel better when they are feeling down or after a fight with their boy/girlfriend. This can also lead to risky injecting and sexual behaviours.

But there also may be other alternatives, alternatives that do more to promote wellness in your life than using drugs. This last session will focus on safe-coping strategies including positive self-talk.

Let’s begin by talking about the things you might do that are safe and healthy and then I’d like for you to talk about the things you might do to make yourself feel better that don’t promote wellness or are less healthy.

Similar to the previous exercise, I’d like you to work in pairs and think about self-soothing behaviours you might use to comfort yourself, make yourself feel better when you feel upset, mad, sad, etc. However, this time I want you to think about which of these behaviours are “wellness promoting” such as keeping busy or talking to a friend, and behaviours that are “wellness inhibiting” such as using drugs and/or alcohol or getting angry with yourself. I also want you to discuss which strategies work best for you, which are effective and which are less effective strategies.

[Write responses in two columns on flip-chart]

Possible Responses:

Looking at these two lists, what behaviours have worked well/ less well for you?

Can you tell us what the consequences of these behaviours were for you when you have used them to self-soothe? [Xxxxxx what worked well/ less well and the consequences of these behaviours]

Let’s now discuss the consequences of these various self–soothing strategies. Some strategies are of the “feel good now, pay later” variety.

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What does it cost you to receive comfort?

List your three most used comfort strategies in increasing order of cost. Something costly can lead to negative consequences. Using drugs can result in legal trouble or can impair a woman’s judgment leaving her vulnerable to violence, injecting and sexual risk behaviours or negative mood. Cost also involves how much energy the strategy exhausts. Denial is a way to deal with stressful events but can use a lot of energy. Finally cost also has to do with missed opportunities. For example, someone may use a less healthy strategy and therefore be blind to healthier options. [discuss responses]

I now want to teach you all a simple yet really powerful safe-coping strategy, positive self-talk. Actually I am sure that a lot of you already do this and might not even know that you are doing it. As we have previously discussed, negative mood, withdrawal and problems with relationships and power may result in risk taking behaviours and unsafe coping behaviours such as risky or unsafe injecting practices. Now I want to talk about what you say to yourself if you are experiencing a trigger to use drugs or to take risks. How you talk to yourself can really change your attitude and behaviour. And, if you are experiencing an urge to use drugs or are being tempted by a trigger, you need to stay in "I can do it" mode. If a person says to herself "Well, that shows I can't stop sharing injecting equipment. So, I might as well forget about it," she will have trouble continuing her plan to inject safely. Or if she says something like "Oh, I feel terrible. How could I do such a thing? I guess I'm just not worth all the effort," she will have trouble continuing. People are only human and temptation often hits when they are feeling low or vulnerable. You never know when temptation will hit you, so you need to protect yourself - and your partner. But you have to remember all the reasons you wanted to reduce risk taking behaviours: your family, friends, your future goals, and most of all your commitment to your own and others’ health and well- being.

Self-talk is identifying the “voice” in your head and having it say positive, supportive statements instead of self-defeating ones. Self-talk should be in the form of “I” statements: for example, “I can go back to not using drugs, I want to”

Some self-talk can be aimed at reminding you what to do:

- I can develop a plan to deal with this.

- I will think about what I have to do.

- I will think about what I can do about this situation/stress.

- I will think before I act.

- I have a lot of different positive coping strategies to call on to help me through this.

Other self-talk that may work for you is telling yourself kind and comforting statements that you would tell a friend in your situation like:

• You are going through a rough time, but I know you have the power and strength inside of you to stick to your plan.

• You need to put yourself and your goals first, you can tell your partner that you want to use a condom

Last week we discussed how women may engage in risky injecting practices due to lack of equipment, withdrawal and/or relationships and power. Imagine if you did not have a clean needle and syringe and your partner suggested that you use theirs. You are feeling tempted to share injecting equipment with your partner as you are experiencing withdrawal. How would you use self-talk or think about what they would tell a friend to tell herself if she was tempted to share?

[Elicit examples of self-talk from participants that they can use. Write down responses on flipchart. Summarise and praise range of responses]. Let’s go back to some of the situations when you might be more likely to engage in sexual or drug risk behaviours that we mentioned in the first and second sessions.

Let’s role play in pairs. What I would like you to do is to practice self-talking yourself through the following situations. [Have participants practice and ask group members for their suggestions for self-talk. Give specific praise].

For example:

1. You are feeling really down and as a result are not bothered about the potential risks involved with sharing injecting equipment with other drug users, how can you use self-talk to make sure you do not put yourself at risk?

2. You are really mad/ angry, how can you use self-talk to calm down?

3. Your new boyfriend wants to have sex without a condom and you don’t want to, but you are worried that if you don’t he won’t continue with the relationship, how can you use self-talk to make sure you do not have sex without a condom?

4. You had a big fight with your boy/girlfriend where he/she got nasty, how can you use self-talk to comfort yourself?

[Elicit examples of self-talk from participants that they can use. Write down responses on flipchart. Summarise and praise range of responses]. That’s great. I hope that during today’s session we have identified how “feelings”, “behaviour” and “environment” all influence each other, and that to change our feelings and behaviours we need to enhance the pleasant activities we engage in or the way we talk to ourselves. You have

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Purpose: Review lessons learned from this session and identify participants’ experience of attending the intervention.

identified coping strategies that work for you and can be used to help you avoid risk behaviours in the future.

3.7. REVIEW AND CLOSE (15 minutes)

Can you list the three components of the mood-behaviour triangle? “feelings”, “behaviour” and “environment” all influence each other. Can you explain the depression spiral?

The depression spiral offers a visual example of how a decrease in a person’s activity level can further their depressive feelings and began a cycle that results in further depression and withdrawal. You can see as the positive experiences decrease or negative experiences increase people tend to do less, withdraw, or avoid. This can lead to a downward spiral of feeling depressed, withdrawing, doing less, and feeling more depressed etc. Therefore when you are feeling down you need to break the spiral by changing your behaviour and environment. Low mood affect our energy; our desire to do things, our desire to engage in safer behaviours and our motivation to engage with the world.

What sort of things can you do to try break the depression spiral?

[Any response from the list of “tips” or participant identified pleasant activities].

That was a good review. Today we discussed negative mood and depression and how we can use strategies such asa self-talk to reduce risk taking behaviours. Does anyone have any further questions?

Remember as this is a research project, I would really like to get your feedback on this session so that it can be improved if necessary in the future. [Facilitator to take detailed notes for the evaluation]

What did you like about this session? What did you dislike about this session?

What would you change about this session?

Have your attitudes changed about risk reduction?

Have you changed any of your behaviours following the intervention?

You have all agreed to complete a further questionnaire with the researcher in 4 weeks time, to see how you are getting on. They will contact you to arrange a convenient time to talk to you.

Thank you all again for coming. This has been a great group. Today is the last session, I hope you all found it useful. I really enjoyed working with you these last few weeks. I want to leave you with just 4 more things to remember [distribute wallet card – 4 key things to remember], these are:

1. You can do it – maintain your motivation in touch situations

2. You matter

3. Protect yourself – avoid risk and negotiate safer solutions

4. There are services that can help you

Thanks again for your participation, stay safe!

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4 KEY THINGS TO REMEMBER!

1. You can do it - maintain your motivation in tough situations

2. You matter

3. Protect yourself – avoid risk and negotiate safer solutions

4. There are services that can help you

References

Xxxxxxxxx, K.M., Xxxxxxxxxxx, X., Xxxxx, J.L., Xxxxxx, M.Y. & Xxxxx, E.V. (2006). Behavioral Therapy for Depression in Drug Dependence (BTDD): Results of a stage 1a therapy development trial.

American Journal of Drug and Alcohol Abuse, 32:541–548.

Xxxxxxxxx, K.M., Xxxxx, X.X., Xxxxxxxxxxx, X. & Xxxxx, E.V. (2008). Developing therapies for depression in drug dependence: results of a stage 1 therapy study. American Journal of Drug and Alcohol Abuse, 34:642-652.

Xxxxxxx, R.S., Xxxxx, E.T., Xxxxxxxxx, A.E., Xxxxx, X., Xxxxxx, D.L., Xxxxxx, S.M., Xxxxxxx, X., Xxxxx, M.H., Xxxxxxx, X.X., Xxxxxxx, D.W., Xxxxxxxxx, S.A. & Xxxxxx, X. for the DUIT Study Team (2007). A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users. AIDS, 21:1923–1932.

Xxxxxxx, X., Xx-Xxxxxx, N., Xxxxxx, X., Xx, X., Xx, H., Golder, S., Xxxxxxx, X. & Xxxxxxx, X. (2006). An integrated relapse prevention and relationship safety intervention for women on methadone: Testing short-term effects on intimate partner violence and substance use. Violence and Victims, 21:657-672.

Xxxxxxxxx, P.M., Xxxxxxxxxx, D.O., Breckenridge, J.S. & Xxxx, X. (1984). The Coping with Depression Course. Xxxxxx OR: Castalia Publishing Company.

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