Surviving in two worlds: Social and structural violence of Thai female injecting drug users

Transition from nonmedical prescribed opioids to non-injection heroin use among young integrated Thai male users in Bangkok

Opioid use and misuse are understudied in Thailand despite evidence suggesting that a portion of young Thai male integrated drug users are initiating use of non-medical prescribed opioids with some transitioning to heroin. This study aims to capture and analyze the individual and social factors influencing these transitions. Twenty in-depth semi-structured interviews were conducted between December 2019 and January 2020 in the Bangkok metropolitan area with young male opioid users who transitioned to heroin. Sixteen respondents initiated opioid through a Tramadol cocktail named "YaPro" and tended to transition to heroin use within 21 months. The interaction of specific social and individual factors such as joining recreational activities, curiosity or experimentation gradually modified the opioid-related meanings, attitude and practices of Thai users, who ultimately transition to heroin use. These results indicate that drug prevention programs in Thailand should encompass young opioid users in their intervention and further research need to focus on nonmedical use of prescription opioids in Thailand.

Stigma as a barrier to integrated substance use and HIV care in Vietnam: A qualitative examination of patient and provider perspectives

Integration of substance use disorder (SUD) treatment and HIV care can increase antiretroviral therapy coverage among people with opioid use disorder (OUD). However, implementation of integrated treatment models remains limited. Stigma towards people with OUD poses a barrier to initiation of, and adherence to, HIV treatment. We sought to understand the extent of stigma towards SUD and HIV among people with OUD in Vietnam, and the effect of stigma on integrated OUD and HIV treatment services utilization. Between 2013 and 2015, we conducted in-depth interviews with 43 patients and 43 providers at 7 methadone clinics and 8 HIV clinics across 4 provinces in Vietnam. We used thematic analysis with a mixed deductive and inductive approach at the semantic level to analyze key topics. Two main themes were identified: (1) Confidentiality concerns about HIV status make patients reluctant to receive integrated care at HIV clinics, given the requirements for daily buprenorphine dosing at HIV clinics. (2) Provider stigma existed mostly toward people with OUD and seemed to center on the belief that substance use causes a deterioration in one's morals, and was most frequently manifested in the form of providers' apprehensive approach towards patients. Concerns regarding stigmatization may cause patients to feel reluctant to receive treatment for both OUD and HIV at a single integrated clinic. Interventions to reduce stigma at the clinic and policy levels may thus serve to improve initiation of and adherence to integrated care.

How has the COVID-19 epidemic affected the risk behaviors of people who inject drugs in a city with high harm reduction service coverage in Vietnam? A qualitative investigation

Introduction

The COVID-19 outbreak disproportionally affects vulnerable populations including people who inject drugs (PWID). Social distancing and stay-at-home orders might result in a lack of access to medical and social services, poorer mental health, and financial precariousness, and thus, increases in HIV and HCV risk behaviors. This article explores how the HIV/HCV risk behaviors of PWID in Haiphong, a city with high harm reduction service coverage in Vietnam, changed during the early phase of the COVID-19 pandemic, and what shaped such changes, using the risk environment framework.

Method

We conducted three focus group discussions with peer outreach workers in May 2020 at the very end of the first lockdown, and 30 in-depth interviews with PWID between September and October 2020, after the second wave of infection in Vietnam. Discussions and interviews centered on the impact of the COVID-19 pandemic on their lives, and how their drug use and sexual behaviors changed as a result of the pandemic.

Results

The national shutdown of nonessential businesses due to the COVID-19 epidemic caused substantial economic challenges to participants, who mostly were in a precarious financial situation before the start of the epidemic. Unsafe injection is no longer an issue among our sample of PWID in Haiphong thanks to a combination of different factors, including high awareness of injection-related HIV/HCV risk and the availability of methadone treatment. However, group methamphetamine use as a means to cope with the boredom and stress related to COVID-19 was common during the lockdown. Sharing of smoking equipment was a standard practice. Female sex workers, especially those who were active heroin users, suffered most from COVID-related financial pressure and may have engaged in unsafe sex.

Conclusion

While unsafe drug injection might no longer be an issue, group methamphetamine use and unsafe sex were the two most worrisome HIV/HCV risk behaviors of PWID in Haiphong during the social distancing and lockdown periods. These elevated risks could continue beyond the enforced lockdown periods, given PWID in general, and PWID who are also sex workers in particular, have been disproportionately affected during the global crisis.

Intersectional analysis of cannabis use, stigma and health among marginalized Nigerian women

Cannabis use by women has been under-researched, particularly use by marginalized women in developing societies. This article draws on qualitative research in Uyo, Nigeria, to explore how intersecting stigmas around social identity categories (e.g. gender, sex work) shapes cannabis use and contributes to health harms for marginalized women. Qualitative data were collected via in-depth interviews with street-involved female cannabis users, and transcribed, coded and analysed thematically. Initiation of cannabis use was influenced by social networks and sexual relationships. Heavy cannabis use enabled some women to perform alternative femininity thereby challenging the boundaries of appropriate gendered behaviour, while others were pressured by normative expectations to enact moderation according to traditional femininity. Recreational cannabis use overlapped with marginalized forms of use, including using heavily to cope with the mental health sequalae of gender-based discriminations and structural inequities. Cannabis use attracted heightened stigma, operating as part of intersecting stigmatizing identities that adversely impacted mental health and wellbeing. Cannabis stigma does not exist in isolation from other social identity categories that shape women's lives. There exists a need to combat stigma through interventions that seek to mediate changes in gender relations, improve living conditions and access to health-care services for marginalized women.

Tales of gender-based oppression and violence: Risks and vulnerabilities of women who inject drugs (WWID) in Dhaka, Bangladesh

BACKGROUND

Women who inject drugs (WWID) experience various complexities, risks and vulnerabilities attributed to unequal gendered power differentials. This article has aimed to explore the unequal gendered power dynamics that influence HIV risks and vulnerabilities among WWID in Dhaka, Bangladesh.

METHODS

This paper is based on an ethnographic study conducted from April 2018 to December 2019 in Dhaka, Bangladesh. This component of the study constituted 2500 h of extensive field observations, 15 in-depth interviews and five focus groups exclusively with WWID. We also interviewed 15 key-informants including programme managers, an academician and harm reduction service providers. Data were thematically analysed in relation to the four bases of gendered power theorised by gender scholars Pratto and Walker which include force, resource control, asymmetrical obligations and consensual ideologies.

RESULTS

The first base, "force", highlighted situations where WWID were compelled into risky injecting and sexual behaviours to avoid violent ramifications or losing their safety nets with intimate partners. The second base, "resource control", depicted unequal access to commodities where men exercised their dominance over money and drugs. The third base, "social obligations", depicted the propensity of WWID to obey their partners and clients, thus precipitating their risky behaviours. The fourth base, consensual ideologies, were linked to weakened negotiation powers of WWID, thus increasing their propensity to risky injecting and sexual behaviours alongside poly-drug use. Despite several instances of gender-based violence and oppression, WWID have fallen victim to gender-blind interventions, as demonstrated by study observations and anecdotes.

CONCLUSION

Gender-based violence and oppression were depicted as prominent driving forces exacerbating WWID's HIV risks and vulnerabilities. If these issues are overlooked, the HIV burden will continue permeating among WWID. Thus, stakeholders need to look beyond the lens of conventional harm reduction modalities and synergize evidence-based gendered dynamics to formulate a gender-responsive comprehensive service package for WWID.

The Experience of Violence Against Women Who Use Injection Drugs: An Exploratory Qualitative Study

BACKGROUND

While literature exists about persons who use injection drugs, few studies explore the experience of women who use these substances. Furthermore, even less research specifically focuses on the lives and experiences of homeless women who use injection drugs. What literature does exist, moreover, is often dated and primarily addresses concerns about infectious disease transmission among these women; and some highlight that these women have lives fraught with violence.

PURPOSE

To update this knowledge and better understand the lives of women who use injection drugs in the Canadian context.

METHODS

We undertook an exploratory qualitative study and we engaged in semi-structured interviews with 31 homeless women who use injection drugs in downtown Ottawa, Canada. We analyzed the data using the principles of applied thematic analysis.

RESULTS

Our data identified that violence pervaded the lives of our participants and that these experiences of violence could be categorized into three main areas: early and lifelong experiences of violence; violence with authority figures (e.g., police, healthcare); and societal violence toward women who use injection drugs.

CONCLUSIONS

We take these findings to mean that, violence toward women is rampant in Canada (not just internationally) and that healthcare workers play a role in propagating and addressing this violence.

Trends of the incidence of drug use disorders from 1990 to 2017: an analysis based on the Global Burden of Disease 2017 data

AIM

Drug use disorders are an important issue worldwide. Systematic attempts to estimate the global incidence of drug use disorders are rare. We aimed to determine the incidence of drug use disorders and their trends.

METHODS

We obtained the annual incident cases and age-standardised incidence rate (ASR) of drug use disorders from 1990 to 2017 using the Global Health Data Exchange query tool. The estimated annual percentage changes of the ASR were used to quantify and evaluate the trends in the incidence rate. Gaussian process regression and the Pearson's correlation coefficient were used to assess the relationship between the ASR and socio-demographic index (SDI).

RESULTS

The number of drug use disorders' cases increased by 33.5% from 1990 to 2017 globally, whereas the ASR exhibited a stable trend. The ASR was higher in men than in women. Most cases (53.1%) of drug use disorders involved opioid. A positive association (ρ=0.35, p < 0.001) was found between ASR and SDI. Teenagers aged 15-19 years had the highest incidence rate.

CONCLUSIONS

The incident cases of drug use disorders were increasing, but the incidence rate did not change significantly from 1990 to 2017. Current preventive measures and policies for drug use disorders might have little effect. The present results suggest that future strategies should focus on men, teenagers and high-risk regions in order to improve the current status of drug use disorders.

The invisible intersectionality of female gender in Thailand's response to the HIV epidemic

This article uses feminist perspectives to analyse Thailand's response to the HIV epidemic from its inception in 1984 until today. In particular, it applies the WHO Gender Responsiveness Assessment Scale to explain how and to what degree gender considerations have been integrated into successive HIV policies and programmes. Findings show that, from 1984 to 1996, HIV prevention policies were generally insensitive to gender and only started to pay limited attention to women's needs between 1997 and 2011. Gender sensitivity increased in the 2012-2019 period, but the focus then was more on 'men who have sex with men' and the transgender communities than on women. In general, Thailand's HIV responses has overlooked gender power relations and the adverse effects of the intersection between women's gender and their other disadvantaged social statuses.

"Not human, dead already": Perceptions and experiences of drug-related stigma among opioid-using young adults from the former Soviet Union living in the U.S

BACKGROUND

Young people from the former Soviet Union (FSU) in the U.S. are engaging in opioid and injection drug use (IDU) in substantial numbers, paralleling nationwide trends. Yet opioid-using FSU immigrants face distinctive acculturation challenges, including perceived stigmatisation as drug users within their immigrant communities, which may exacerbate the negative health and psychosocial consequences of such use.

METHODS

This qualitative study draws on semi-structured interviews with 26 FSU immigrant young adults (ages 18-29) living in New York City who reported opioid use in the past month and/or were currently in treatment for opioid use disorder. Interviews probed youths' drug use histories, immigration/acculturation experiences, family and peer relationships, and service utilisation. Interviews or focus groups were also conducted with 12 FSU mothers of opioid-using youth and 20 service providers familiar with the FSU population. In a content-based thematic analysis, verbatim transcripts were coded for salient themes.

RESULTS

All three participant groups emphasized that stigma towards drug users within the FSU community is pervasive and acute, in contrast to the cultural acceptance of heavy drinking, and is rooted in punitive Soviet-era drug policies, fostering widespread ignorance about drugs and addiction. Young adults and service providers reported instances in which anticipation of community stigmatisation deterred youth from accessing drug treatment and harm reduction services. Similarly, stigma contributed to parents' failure to recognize early signs of their children's opioid problems and their reluctance to seek drug treatment for their children until opioid use had become severe. Young adults described how drug-use stigma is frequently internalized, leading to shame and loss of self-esteem.

CONCLUSION

Findings indicate an urgent need for community-wide education about drugs within FSU immigrant communities, and suggest specific service modalities that may be less stigmatizing for youth, such as peer-delivered syringe exchange and harm reduction education, and technology-based interventions that can be accessed privately and discreetly.

I am just a 'maae' (mother): experiences of mothers injecting drugs in Thailand

Mothers who use drugs face much discriminatory action as society in general finds female drug users' modes of caring for their children unacceptable. In this article, I explore the ways in which Thai women's injecting practices revolve around the role of mother 'maae' and the ways they employ tactics to challenge the motherhood discourse. This article draws on in-depth interviews with 30 Thai mothers injecting drugs. Thai mothers injecting drugs struggled with stigma and self-blame. They internalise the values of the mother 'maae', that is, what the mother is supposed to be; attempting to combine their drug use with their parental responsibilities. Having a child is treated as a means for many women to manage the hostile social impacts of being an addict mother as well as anxieties about the future of their children. To maintain identity as a mother, as gender norms dictates, the mothers employ several tactics to defend that identity from the threats. In conclusion, the findings have implications for harm reduction and reproductive services for women using drugs in Thailand; health care providers need to appreciate the ramifications of the lived experiences of the women who take drugs.

Declining trends in the rates of assisted injecting: a prospective cohort study

Background

Assisted injecting has been associated with increased risk of blood-borne infections, overdose, and other harms among people who inject drugs (PWID), particularly women. Given the changing availability of relevant harm reduction interventions in Vancouver, Canada, in recent years, we conducted a gender-based analysis to examine changes in rates and correlates of assisted injecting over time among active PWID.

Methods

Using data from a prospective cohort of PWID in Vancouver, we employed gender-stratified multivariable generalized estimating equations to examine trends in assisted injecting and identify the correlates during two periods: June 2006–November 2009 and December 2009–May 2014.

Results

Among 1119 participants, 376 (33.6 %) were females. Rates of assisted injecting declined between 2006 and 2014 among males (21.9 to 13.8 %) and females (37.0 to 25.6 %). In multivariable analyses, calendar year of interview also remained independently and negatively associated with assisted injecting among males (adjusted odds ratio [AOR] 0.95, 95 % confidence interval [CI] 0.92–0.99) and females (AOR 0.93, 95 % CI 0.89–0.97). Syringe borrowing remained independently associated with assisted injecting throughout the study period among females (AOR 1.53, 95 % CI 1.10–2.11 during 2006–2009; AOR 2.15, 95 % CI 1.24–3.74 during 2009–2014) and during 2009–2014 among males (AOR 1.88, 95 % CI 1.02–3.48).

Conclusions

Our findings demonstrate assisted injecting has significantly decreased for both males and females over the past decade. Nevertheless, rates of assisted injecting remain high, especially among women, and are associated with high-risk behavior, indicating a need to provide safer assisted injecting services to these vulnerable sub-populations of PWID.