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‘Care & Prevent’ is a five-phase mixed-methods study that explores skin and soft tissue infection (SSTI) risk, sequelae, care and prevention with people who inject drugs (PWID) in London. In the absence of structural supports such as safe injecting facilities or the prescribing of pharmaceutical diamorphine, there is an urgent need to revisit injecting paraphernalia design and distribution in order to alleviate health harms and distress among the most marginalised. Overuse of acidifier is a modifiable risk factor. To reduce injecting-related injury and associated consequences, it is crucial to understand the interplay of environmental and practice-based risks underpinning venous damage among PWID. Painful injections and damage to peripheral veins were common and often attributed to the use of citric acid. Qualitative accounts highlight the role of poor heroin quality, crack cocaine use, information and manufacturing constraints in acidifier overuse. We found associations between acidifier overuse, femoral injecting and DVT, but not SSTI. Overuse of acidifier was common: of the 418 who provided an estimate, 36% ( n = 150) used more than ½ a sachet, with 30% ( n = 127) using a whole sachet or more. Of the 455 participants, most (92%) injected heroin and/or crack cocaine, with 84% using citric as their primary acid for drug preparation.
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Mixed-methods triangulation was iterative with results comparison informing the direction and questions asked of further analyses. Grounded theory principles informed inductive qualitative analysis. Bivariate and multivariate analyses were conducted using a logistic regression for binary outcomes to explore associations between outcomes and excessive acidifier use. Participants provided life history data and detail on injecting environments and drug preparation practices, including the use of acidifiers. We present a structured survey ( n = 455) and in-depth qualitative interview ( n = 31) data generated with PWID in London for the Care & Prevent study. In this paper, we present mixed-methods data to explore our hypothesis of a link between overly acidic injection solutions, venous damage and SSTI risk. Brown heroin available in Europe requires acidification for injection preparation. Damage and scarring of peripheral veins can exacerbate health harms, such as skin and soft tissue infections (SSTI), and promote transitions to femoral and subcutaneous injecting. Venous access is a priority for people who inject drugs (PWID).