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1.
Lancet ; 402 Suppl 1: S11, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37997050

RESUMEN

BACKGROUND: Stigma and discrimination are widely recognised as core social determinants of health. There is a gap in understanding how to intervene at societal and systems level to address stigma. This study aims to theorise how particular care and support systems shape experiences of stigma as it relates to homelessness, and to then develop systems-level interventions. METHODS: We present findings from an ongoing longitudinal ethnographic study, which started June 2022, in south London. Data collection included interviews with people managing, delivering, and using homelessness services (n=41 interviews, two focus groups); participant observation across a range of service settings (>70 h, principally in five sites), and documentary analysis. Participants and research sites gave informed consent. The study was framed by Bourdieu's social practice theory, which structures data collection and analysis around the power and resources individuals have within particular social contexts. We did the analyses using thematic and grounded approaches to qualitative data. FINDINGS: We found that across homeless and health services there was in-depth awareness of stigma and discrimination, but that, collectively, we are "stuck in a rut" in responding to stigma. A proximate challenge was limited clarity and agreement across systems on the nature of the issues involved. A deeper analysis also suggested specific organisational structures and ways of thinking within homelessness and health systems that limit collective discussion and agreement on social and systemic responses to stigma. We also collected data on how stigma was experienced, delineating different forms of stigma and discrimination and where and how they take shape, focusing on enacted, anticipated, and internalised stigma. We also explored how stigma was actively managed and overcome, and how different intersections of systems of inequality produce varying forms of stigma and discrimination. INTERPRETATION: Our study provides insight into how stigma and discrimination could potentially be addressed systemically within homelessness and health systems. The existing collective awareness of stigma and discrimination offers specific opportunities for generating systemic change. Study limitations include the focus on one geographic area of the UK, although we reflect on how our findings could be generalised to other settings. FUNDING: UK Research and Innovation.


Asunto(s)
Personas con Mala Vivienda , Estigma Social , Humanos , Londres , Investigación Cualitativa , Grupos Focales
2.
Harm Reduct J ; 18(1): 15, 2021 02 03.
Artículo en Inglés | MEDLINE | ID: mdl-33536033

RESUMEN

INTRODUCTION: Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic. METHODS: Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts. RESULTS: Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as 'bridge' and 'role model' processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and 'bridge' mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O). CONCLUSION: Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.


Asunto(s)
Infecciones por VIH , Preparaciones Farmacéuticas , Países en Desarrollo , Infecciones por VIH/prevención & control , Reducción del Daño , Humanos , Grupo Paritario
3.
Subst Use Misuse ; 56(9): 1312-1319, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34027819

RESUMEN

BACKGROUND: Methadone, as part of Medically Assisted Therapy (MAT) for treatment of opioid dependence and supporting HIV prevention and treatment, has been recently introduced in Kenya. Few low income settings have implemented methadone, so there is little evidence to guide ongoing scale-up across the region. We specifically consider the role of community level access barriers and support. OBJECTIVES: To inform ongoing MAT implementation we implemented a qualitative study to understand access barriers and enablers at a community level. METHODS: We conducted 30 semi-structured interviews with people who use drugs accessing MAT, supplemented by interviews with 2 stakeholders, linked to participant observation in a community drop in center within one urban area in Kenya. We used thematic analysis. RESULTS: We developed five themes to express experiences of factors enabling and disabling MAT access and how community support can address these: 1) time, travel and economic hardship; 2) managing methadone and contingencies of life, 3) peer support among MAT clients as treatment ambassadors, 4) family relations, and 5)outreach project contributions. Crosscutting themes address managing socioeconomic constraints and gender inequities. CONCLUSIONS: People who use drugs experience and manage socio-economic constraints and gender inequities in accessing MAT with the support of local communities. We discuss how these access barriers could be addressed through strengthening the participation of networks of people who use drugs in drug treatment and supporting community projects working with people who use drugs. We also explore potential for how socio-economic constraints could be managed within an integrated health and social care response.


Asunto(s)
Metadona , Trastornos Relacionados con Opioides , Consejo , Humanos , Kenia , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Investigación Cualitativa
4.
Cult Health Sex ; 22(9): 1080-1095, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-31625809

RESUMEN

Women's initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation; sub-themes were identified drawing on three concepts within the theory of gender and power. With reference to sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. With regard to structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in understanding the intersection of risk, gender and harm reduction within injection initiation events across socio-cultural contexts.


Asunto(s)
Rol de Género , Relaciones Interpersonales , Parejas Sexuales , Normas Sociales , Abuso de Sustancias por Vía Intravenosa/psicología , Adulto , California , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Estudios Prospectivos , Asunción de Riesgos , Factores Sexuales
5.
BMC Infect Dis ; 18(1): 281, 2018 06 19.
Artículo en Inglés | MEDLINE | ID: mdl-29914381

RESUMEN

BACKGROUND: Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK. METHODS: A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants' responses. RESULTS: We report an overarching theme of 'tension' in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation. CONCLUSIONS: The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.


Asunto(s)
Hepatitis C/diagnóstico , Manejo de Especímenes/métodos , Manejo de Especímenes/psicología , Trastornos Relacionados con Sustancias/virología , Adulto , Grupos Focales , Homosexualidad Masculina , Humanos , Londres , Masculino , Autocuidado , Minorías Sexuales y de Género , Trastornos Relacionados con Sustancias/psicología
6.
AIDS Care ; 29(9): 1119-1128, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28281354

RESUMEN

People who use drugs in many contexts have limited access to opioid substitution therapy and HIV care. Service integration is one strategy identified to support increased access. We reviewed and synthesized literature exploring client and provider experiences of integrated opioid substitution therapy and HIV care to identify acceptable approaches to care delivery. We systematically reviewed qualitative literature. We searched nine bibliographic databases, supplemented by manual searches of reference lists of articles from the database search, relevant journals, conferences, key organizations and consultation with experts. Thematic synthesis was used to develop descriptive themes in client and provider experiences. The search yielded 11 articles for inclusion, along with 8 expert and policy reports. We identify five descriptive themes: the convenience and comprehensive nature of co-located care, contrasting care philosophies and their role in shaping integration, the limits to disclosure and communication between clients and providers, opioid substitution therapy enabling HIV care access and engagement, and health system challenges to delivering integrated services. The discussion explores how integrated opioid substitution therapy and HIV care needs to adapt to specific social conditions, rather than following universal approaches. We identify priorities for future research. Acceptable integrated opioid substitution therapy and HIV care for people who use drugs and providers is most likely through co-located care and relies upon attention to stigma, supportive relationships and client centred cultures of delivery. Further research is needed to understand experiences of integrated care, particularly delivery in low and middle income settings and models of care focused on community and non-clinic based delivery.


Asunto(s)
Antirretrovirales/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Tratamiento de Sustitución de Opiáceos , Servicios Preventivos de Salud/organización & administración , Atención Primaria de Salud/métodos , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Atención a la Salud/organización & administración , Infecciones por VIH/prevención & control , Infecciones por VIH/psicología , Humanos , Estigma Social , Trastornos Relacionados con Sustancias/psicología
7.
Clin Infect Dis ; 63(8): 1094-1104, 2016 10 15.
Artículo en Inglés | MEDLINE | ID: mdl-27343545

RESUMEN

BACKGROUND: Human immunodeficiency virus (HIV)-infected people who inject drugs (PWID) frequently encounter barriers accessing and remaining on antiretroviral therapy (ART). Some studies have suggested that opioid substitution therapy (OST) could facilitate PWID's engagement with HIV services. We conducted a systematic review and meta-analysis to evaluate the impact of concurrent OST use on ART-related outcomes among HIV-infected PWID. METHODS: We searched Medline, PsycInfo, Embase, Global Health, Cochrane, Web of Science, and Social Policy and Practice databases for studies between 1996 to November 2014 documenting the impact of OST, compared to no OST, on ART outcomes. Outcomes considered were coverage and recruitment onto ART, adherence, viral suppression, attrition from ART, and mortality. Meta-analyses were conducted using random-effects modeling, and heterogeneity assessed using Cochran Q test and I(2) statistic. RESULTS: We identified 4685 articles, and 32 studies conducted in North America, Europe, Indonesia, and China were included. OST was associated with a 69% increase in recruitment onto ART (hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.32-2.15), a 54% increase in ART coverage (odds ratio [OR], 1.54; 95% CI, 1.17-2.03), a 2-fold increase in adherence (OR, 2.14; 95% CI, 1.41-3.26), and a 23% decrease in the odds of attrition (OR, 0.77; 95% CI, .63-.95). OST was associated with a 45% increase in odds of viral suppression (OR, 1.45; 95% CI, 1.21-1.73), but there was limited evidence from 6 studies for OST decreasing mortality for PWID on ART (HR, 0.91; 95% CI, .65-1.25). CONCLUSIONS: These findings support the use of OST, and its integration with HIV services, to improve the HIV treatment and care continuum among HIV-infected PWID.


Asunto(s)
Antirretrovirales/uso terapéutico , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Sustancias/complicaciones , Terapia Antirretroviral Altamente Activa , Buprenorfina/uso terapéutico , Recuento de Linfocito CD4 , Infecciones por VIH/mortalidad , Infecciones por VIH/virología , Humanos , Cumplimiento de la Medicación , Metadona/uso terapéutico , Oportunidad Relativa , Sesgo de Publicación , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Resultado del Tratamiento , Carga Viral
8.
AIDS Care ; 28(12): 1595-1599, 2016 12.
Artículo en Inglés | MEDLINE | ID: mdl-27267309

RESUMEN

People who inject drugs (PWID) experience a range of barriers to HIV treatment and care access. The Kenyan government and community-based organisations have sought to develop HIV care for PWID. A principal approach to delivery in Kenya is to provide care from clinics serving the general population and for this to be linked to support from community-based organisations providing harm reduction outreach. This study explores accounts of PWID accessing care in Kenya to identify care barriers and facilitators. PWID accounts were collected within a qualitative longitudinal study. In-depth interviews with PWID living with HIV (n = 44) are combined with interviews with other PWID, care providers and community observation. Results show that some PWID are able to access care successfully, whilst other PWID report challenges. The results focus on three principal themes to give insights into these experiences: the hardship of addiction and the costs of care, the silencing of HIV in the community and then discrimination and support in the clinic. Some PWID are able to overcome, often with social and outreach support, barriers to clinic access; for others, the challenges of addiction, hardship, stigma and discrimination are too constraining. We discuss how clinics serving the general population could be further adapted to increase access. Clinic-based care, even with community links, may, however, be fundamentally challenging for some PWID to access. Additional strategies to develop stand-alone care for PWID and also decentralise HIV treatment and care to community settings and involve peers in delivery should be considered.


Asunto(s)
Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Accesibilidad a los Servicios de Salud , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adulto , Atención Ambulatoria/organización & administración , Actitud del Personal de Salud , Servicios de Salud Comunitaria/organización & administración , Femenino , Reducción del Daño , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Entrevistas como Asunto , Kenia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Prejuicio , Investigación Cualitativa , Estigma Social , Apoyo Social , Abuso de Sustancias por Vía Intravenosa/terapia , Adulto Joven
9.
Lancet ; 393(10182): 1695-1696, 2019 04 27.
Artículo en Inglés | MEDLINE | ID: mdl-31034373
10.
Harm Reduct J ; 12: 27, 2015 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-26337729

RESUMEN

BACKGROUND: Heroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes. METHODS: We combine data from two separate studies conducted in Kenya: an in-depth qualitative study of HIV care access for people who inject drugs (study 1) and an ethnographic study of the political economy of the heroin trade in Kenya (study 2). In-depth interviews with PWID and community observation from study 1 are triangulated with accounts from stakeholders involved in the heroin trade and documentary data from study 2. RESULTS: People who inject drugs link transitions to injecting from smoking to a range of social and behavioural factors, as well as particular aspects of the local drug supply and economy. We present these results in the form of two narratives that account for factors shaping transitions. A dominant narrative of 'managing markets and maintaining a high' results from a process of trying to manage poverty and a shifting heroin supply, in the context of deepening addiction to heroin. A secondary narrative focuses on people's curiosity for the 'feeling' of injecting, and the potential pleasure from it, with less emphasis on structural circumstances. CONCLUSIONS: The narratives we describe represent pathways through which structural and social factors interact with individual experiences of addiction to increase the risk of transitions to injecting. In response, HIV and harm reduction programmes need combinations of different strategies to respond to varied experiences of transitions. These strategies should include, alongside behaviour-oriented interventions, structural interventions to address economic vulnerability and the policing of the drug supply.


Asunto(s)
Consumidores de Drogas/estadística & datos numéricos , Infecciones por VIH/prevención & control , Reducción del Daño , Dependencia de Heroína/epidemiología , Investigación Cualitativa , Abuso de Sustancias por Vía Intravenosa/prevención & control , Adulto , Comorbilidad , Femenino , Infecciones por VIH/epidemiología , Heroína/administración & dosificación , Humanos , Entrevistas como Asunto , Kenia/epidemiología , Masculino , Persona de Mediana Edad , Abuso de Sustancias por Vía Intravenosa/epidemiología , Adulto Joven
11.
Soc Sci Med ; 347: 116774, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38537331

RESUMEN

Stigma and discrimination are increasingly understood as shaping health, and in turn conceptualised as social processes shaped by power and structural inequities. A challenge to analysis and implementing interventions is developing theory that can integrate analysis of structure, agency and power. One theoretical framework already promoted by prominent scholars as supporting this need is Bourdieu's social practice theory. This paper explores the application to date of Bourdieu's theory on stigma, discrimination and health. The paper describes how existing health literature has used concepts of symbolic violence, fields, capitals and habitus to develop insight into stigma power. The discussion explores how this theoretical framework is though underutilised and there has been little consideration of new programmatic approaches based on this theory. Directions for future research include the need for integrated approaches to analysis, especially using habitus to explore stigma power, and addressing processes of change. Directions for conceptualising interventions address how a mismatch of field and habitus could foster change and then the role for prophets in fostering symbolic revolutions. All these potential directions must in turn be integrated within the vast scholarship on stigma. In conclusion, further application and development of Bourdieu's social practice theory could help address the theoretical challenges facing the field of stigma, discrimination and health research.

12.
BMC Health Serv Res ; 13: 171, 2013 May 07.
Artículo en Inglés | MEDLINE | ID: mdl-23647922

RESUMEN

BACKGROUND: The integration of HIV care into primary care services is one of the strategies proposed to increase access to treatment for people living with HIV/AIDS in high HIV burden countries. However, how best to do this is poorly understood. This study documents different factors influencing models of integration within clinics. METHODS: Using methods based on the meta-ethnographic approach, we synthesised the findings from three qualitative studies of the factors that influenced integration of HIV care into all consultations in primary care. The studies were conducted amongst staff and patients in South Africa during a randomised trial of nurse initiation of antiretroviral therapy (ART) and integration of HIV care into primary care services - the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial. Themes from each study were identified and translated into each other to develop categories and sub-categories and then to inform higher level interpretations of the synthesised data. RESULTS: Clinics varied as to how HIV care was integrated. Existing administration systems, workload and support staff shortages tended to hinder integration. Nurses' wanted to be involved in providing HIV care and yet also expressed preferences for developing expertise in certain areas and for establishing good nurse patient relationships by specialising in certain services. Patients, in turn, were concerned about the stigma of separate HIV services and yet preferred to be seen by nurses with expertise in HIV care. These factors had conflicting effects on efforts to integrate HIV care. CONCLUSION: Local clinic factors and nurse and patient preferences in relation to care delivery should be taken into account in programmes to integrate HIV care into primary care services. The integration of medical records, monitoring and reporting systems would support clinic based efforts to integrate HIV care into primary care services.


Asunto(s)
Prestación Integrada de Atención de Salud , Infecciones por VIH/enfermería , Infecciones por VIH/terapia , Pautas de la Práctica en Enfermería , Atención Primaria de Salud/métodos , Humanos , Investigación Cualitativa , Sudáfrica
13.
Lancet ; 387(10036): 2377-8, 2016 Jun 11.
Artículo en Inglés | MEDLINE | ID: mdl-27312300
14.
Health Soc Care Community ; 30(6): e6622-e6630, 2022 11.
Artículo en Inglés | MEDLINE | ID: mdl-36471491

RESUMEN

Legal problems can be cause and consequence of ill-health and homelessness, necessitating efforts to integrate responses to these challenges. How to respond to legal issues within the context of health services for people who are homeless is though unclear. Groundswell piloted providing legal support to peer advocates (who have current or past experience of homelessness) and clients currently homeless in addition to their health-focused work. A participatory action-research design evaluated the emerging programme. Groundswell staff, both researchers and those involved in service delivery, co-led the research alongside an external researcher. Qualitative methods were used to understand the experiences of legal support. We interviewed peer advocates and volunteers (n = 8), Groundswell clients (n = 3) and sector stakeholders (n = 3). Interviews were linked to regular reflective recorded meetings (n = 7) where Groundswell staff and researchers discussed the programme and the evaluation. Data were analysed thematically. The findings focus on three themes. First, peer advocates' and clients' legal needs involve an experience of being overwhelmed by system complexity. Second, the legal support to peer advocates aided in brokering and signposting to other legal support, in the context of a supportive organisational culture. Third, support to clients can be effective, although the complexity of legal need undermines potential for sustainable responses. In conclusion, legal support for peer advocates should be developed by Groundswell and considered by other similar agencies. Legal support to people who are currently street homeless requires significant resources and so health-focused third-sector organisations maybe unable to offer effective support. Other modes of integration should be pursued. Findings also have implications for how the third sector relates to the government agencies implicated in the legal challenges facing people who are homeless.


Asunto(s)
Personas con Mala Vivienda , Humanos , Londres , Grupo Paritario , Problemas Sociales , Investigación sobre Servicios de Salud
15.
SSM Qual Res Health ; 2: 100038, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-35036989

RESUMEN

High rates of COVID-19 infections and deaths amongst people who are homeless in London, UK were feared. Rates however stayed much lower than expected throughout 2020; an experience that compares to other settings globally. This study sought a community level perspective to explore this rate of infections, and through this explore relationships between COVID-19 and existing health inequalities. Analyses are reported from ongoing qualitative studies on COVID-19 and homeless health service evaluation in London, UK. Repeated in-depth telephone interviews were implemented with people experiencing homelessness in London (n=17; 32 interviews in total) as well as street outreach workers, nurses and hostel staff (n=10) from September 2020 to early 2021. Thematic analysis generated three themes to explore peoples' experiences of, and perspectives on, low infections: people experiencing homelessness following, creating and breaking social distancing and hygiene measures; social distancing in the form of social exclusion as a long-running feature of life; and a narrative of 'street immunity' resulting from harsh living conditions. Further study is needed to understand how these factors combine to prevent COVID-19 and how they relate to different experiences of homelessness. This community perspective can ensure that emerging narratives of COVID-19 prevention success don't ignore longer running causes of homelessness and reinforce stigmatising notions of people who are homeless as lacking agency. Our findings aid theorisation of how health inequalities shape pandemic progression: severe exclusion may substantially delay epidemics in some communities, although with considerable other non-COVID-19 impacts.

17.
Int J Drug Policy ; 69: 24-33, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31029914

RESUMEN

Despite the proliferation of fentanyl and fentanyl-adulterated opioids in North America, the impacts of this drug market change on injection initiation processes have not been examined. With the aim of informing structural interventions to address injection initiation and related harms, we explore how people who inject drugs (PWID) in Vancouver, Canada understand and navigate social norms of initiating others into injecting within the context of an overdose crisis. In-depth qualitative interviews were conducted with 19 PWID who reported helping someone inject for the first time. Participants were recruited from two cohort studies of PWID. Participants articulated moral dilemmas about assisting others with injecting. While participants described a 'moral code' prohibiting assisting injection-naïve individuals, this code was not the sole consideration shaping social action around injection initiation. Rather, PWID exercised agency about whether and how to assist novice injectors within the context of constraining and enabling social norms around practicing interpersonal responsibility. Changes to the drug market heightened feelings of moral culpability and criminal liability among PWID who assisted others into injection, given that injecting heightened initiates' risk of overdose. These concerns operated in tension with the aim of protecting novice injectors from harms associated with an increasingly potent and unpredictable drug supply by providing them with injection assistance, education and supervision. Our analysis of how PWID practice interpersonal responsibility helps conceptualise how 'moral codes' prohibiting initiation assistance are managed and negotiated amidst structural vulnerability. Structural interventions reducing the vulnerability of novice injectors should be prioritized, including the implementation of supervised injection sites allowing for assisted injection, Good Samaritan laws, and policy changes conducive to a safer drug supply.


Asunto(s)
Consumidores de Drogas/psicología , Abuso de Sustancias por Vía Intravenosa/epidemiología , Abuso de Sustancias por Vía Intravenosa/prevención & control , Adulto , Canadá , Estudios de Cohortes , Femenino , Fentanilo , Humanos , Inyecciones , Relaciones Interpersonales , Entrevista Psicológica , Masculino , Persona de Mediana Edad , Principios Morales , Conducta de Reducción del Riesgo , Normas Sociales , Abuso de Sustancias por Vía Intravenosa/psicología
18.
Health Policy Plan ; 34(2): 110-119, 2019 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-30789208

RESUMEN

Integrating methadone and HIV care is a priority in many low- and middle-income settings experiencing a growing challenge of HIV epidemics linked to injecting drug use. There is as yet little understanding of how to integrate methadone and HIV care in these settings and how such services can be implemented; such a gap reflects, in part, limitations in theorizing an implementation science of integrated care. In response, we qualitatively explored the delivery of methadone after its introduction in Kenya to understand integration with HIV care. Semi-structured interviews with people using methadone (n = 30) were supplemented by stakeholder interviews (n = 2) and participant observation in one city. Thematic analysis was used, that also drew on Mol's logic of care as an analytical framework. Respondents described methadone clinic-based care embedded in community support systems. Daily observed clinic care was challenging for methadone and stigmatizing for HIV treatment. In response to these challenges, integration evolved and HIV care differentiated to other sites. The resulting care system was acceptable to respondents and allowed for choice over locations and approaches to HIV care. Using Mol's logic of care as an analytical framework, we explore what led to this differentiation in integrated care. We explore co-production and experimentation around HIV care that compares with more limited experimentation for methadone. This experimentation is bounded by available discourses and materials. The study supports continued integration of services whilst allowing for differentiation of these models to adapt to client preferences. Co-location of integrated services must prioritize clinic organization that prevents HIV status disclosure. Our analysis fosters a material perspective for theory of implementation science and integration of services that focuses attention on local experimentation shaped by context.


Asunto(s)
Antirretrovirales/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , Metadona/administración & dosificación , Tratamiento de Sustitución de Opiáceos , Adulto , Actitud del Personal de Salud , Prestación Integrada de Atención de Salud/métodos , Femenino , Humanos , Ciencia de la Implementación , Kenia , Masculino , Persona de Mediana Edad , Investigación Cualitativa , Estigma Social , Abuso de Sustancias por Vía Intravenosa/tratamiento farmacológico
20.
Int J Drug Policy ; 55: 51-60, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29524733

RESUMEN

BACKGROUND: Injection drug use initiation is shaped by social networks and structural contexts, with people who inject drugs often assisting in this process. We sought to explore the norms and contexts linked to assisting others to initiate injection drug use in San Diego, USA, to inform the development of structural interventions to prevent this phenomenon. METHODS: We undertook qualitative interviews with a purposive sample of people who inject drugs and had reported assisting others to initiate injection (n = 17) and a sub-sample of people who inject drugs (n = 4) who had not reported initiating others to triangulate accounts. We analyzed data thematically and abductively. RESULTS: Respondents' accounts of providing initiation assistance were consistent with themes and motives reported in other contexts: of seeking to reduce harm to the 'initiate', responding to requests for help, fostering pleasure, accessing resources, and claims that initiation assistance was unintentional. We developed analysis of these themes to explore initiation assistance as governed by a 'moral code'. We delineate a fragmented moral code which includes a range of meanings and social contexts that shape initiation assistance. We also show how assistance is happening within a structural context that limits discussion of injection drug use, reflecting a prevailing silence on drug use linked to stigma and criminalization. CONCLUSIONS: In San Diego, the assistance of others to initiate injection drug use is governed by a fragmented moral code situated within particular social norms and contexts. Interventions that address the social and structural conditions shaped by and shaping this code may be beneficial, in tandem with efforts to support safe injection and the reduction of injection-related harms.


Asunto(s)
Conducta de Ayuda , Principios Morales , Normas Sociales , Abuso de Sustancias por Vía Intravenosa/psicología , Adulto , California , Femenino , Humanos , Masculino , Persona de Mediana Edad , Investigación Cualitativa
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