Social and structural determinants of injection drug use-associated bacterial and fungal infections: a qualitative systematic review and thematic synthesis

Abstract

Background: Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections. Methods: We searched PubMed, EMBASE, Scopus, CINAHL, and PsycINFO from January 1, 2000, to February 18, 2021. Informed by Rhodes' "risk environment" framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; (3) consolidating descriptive themes into conceptual categories to identify higher-order analytic themes. Results: We screened 4,841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytic themes. The first analytic theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health care policies and practices, leading to negative experiences that discourage access to care; and (4) harm reduction programs, including structural barriers to effective service provision. The second analytic theme, practices of care among people who inject drugs, addresses protective strategies that people who inject drugs employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g., HIV transmission). Conclusions: Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including unregulated drug quality, criminalization, insufficient housing, limited harm reduction services, and harmful health care practices. Enabling environment interventions that address these factors could further empower people who inject drugs to protect themselves and their community.

Commentary on Brothers et al.: The role of safer environment interventions in addressing injecting‐related bacterial and fungal infections

“…The examination of social‐structural forces influencing incidence and treatment of bacterial and fungal injecting‐related infections by Brothers et al . [1] illustrates how particular modifiable environments shape risk for injecting‐related infections along a pathway from drug acquisition and injection to health outcomes following infections. This suggests adopting a more social‐structural approach to managing bacterial and fungal injecting‐related infections is promising, with prioritization of Safer Environment Interventions (SEIs) to reshape environmental drivers.…”

“…Decriminalization is discussed as a promising macro‐level structural SEI to reform prohibitionist frameworks criminalizing people who inject drugs (PWID) [1], which are implicated in the proliferation of injecting‐related harm [2, 3]. Potential public health benefits of decriminalization (resulting from prioritizing public health over criminal justice system responses) include reductions in drug‐related harm and increased access to risk‐reduction programs and healthcare among PWID [4], partially through reduced stigma and discrimination within healthcare [5].…”

“…Potential public health benefits of decriminalization (resulting from prioritizing public health over criminal justice system responses) include reductions in drug‐related harm and increased access to risk‐reduction programs and healthcare among PWID [4], partially through reduced stigma and discrimination within healthcare [5]. Healthcare access barriers critically shape suboptimal management of injecting‐related infections [1], and this would facilitate improved treatment and reduce reluctance to seek care, which negatively impacts the progression of infections [6]. SEIs are constrained in their operation and coverage by regulatory barriers and prohibition [7], therefore, decriminalization could also support the scale‐up of interventions with potential to reduce incidence and improve management of injecting‐related infections, like syringe services programs and SCS [8, 9].…”

Brothers, Thomas; Lewer, Dan; Colledge-Frisby, Samantha; Jones, Nicola; Bonn, Matthew; Wheeler, Alice; Grebely, Jason; Farrell, Michael; Hayward, Andrew; Hickman, Matthew; Degenhardt, Louisa; (2022) Time periods of altered risk for severe injection drug use-associated skin and soft-tissue infections: protocol for a self-controlled case series in New South Wales, Australia, 2001-2018

“…Better understanding of the social and environmental factors that shape individual injecting practices and risk for injecting-related infections is urgently needed. 16,17 Qualitative research has explored several social and structural factors contributing to risk for injecting-related infections through shaping individual injecting experiences and access to health care. 16,17 For example, people who are incarcerated often need to hide their injection drug use and reuse contaminated or blunted (dull) needles when they do not have access to harm reduction services like a needle and syringe program.…”

“…16,17 Qualitative research has explored several social and structural factors contributing to risk for injecting-related infections through shaping individual injecting experiences and access to health care. 16,17 For example, people who are incarcerated often need to hide their injection drug use and reuse contaminated or blunted (dull) needles when they do not have access to harm reduction services like a needle and syringe program. [18][19][20] People without housing are less likely to have hygienic, well-lit, and safe spaces to prepare and inject their drugs using clean touch techniques, especially if they do not have access to a supervised consumption site.…”