Elsevier

Social Science & Medicine

Volume 61, Issue 5, September 2005, Pages 1026-1044
Social Science & Medicine

The social structural production of HIV risk among injecting drug users

https://doi.org/10.1016/j.socscimed.2004.12.024Get rights and content

Abstract

There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. Drawing on a review of recently published literature, we seek to describe the social structural production of HIV risk associated with injecting drug use. We adopt an inclusive definition of the HIV ‘risk environment’ as the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to HIV. We identify the following factors as critical in the social structural production of HIV risk associated with drug injecting: cross-border trade and transport links; population movement and mixing; urban or neighbourhood deprivation and disadvantage; specific injecting environments (including shooting galleries and prisons); the role of peer groups and social networks; the relevance of ‘social capital’ at the level of networks, communities and neighbourhoods; the role of macro-social change and political or economic transition; political, social and economic inequities in relation to ethnicity, gender and sexuality; the role of social stigma and discrimination in reproducing inequity and vulnerability; the role of policies, laws and policing; and the role of complex emergencies such as armed conflict and natural disasters. We argue that the HIV risk environment is a product of interplay in which social and structural factors intermingle but where political–economic factors may play a predominant role. We therefore emphasise that much of the most needed ‘structural HIV prevention’ is unavoidably political in that it calls for community actions and structural changes within a broad framework concerned to alleviate inequity in health, welfare and human rights.

Introduction

There is now over two decades of global experience in researching HIV risk among injecting drug users (IDUs). This has led to a recent acknowledgement that among the most important determinants influencing HIV transmission and HIV prevention are the ‘risk environments’ in which risk is produced (Barnett & Whiteside, 1999; Rhodes, 2002; Burris et al., 2005; Friedman & Reid, 2002; Singer, Jia, Schensul, Weeks, & Page, 1992). HIV infection is a behavioural disease subject to environmental influence. HIV associated with IDU does not progress within IDU networks or communities in uniform or random ways, but is subject to the relativity of risk and to variations in population behaviour in different social, cultural, economic, policy and political environments (Rhodes et al., 1999a; Singer, 2001).

A synthesis of global evidence over the past decade emphasises that HIV prevention interventions among IDUs which focus solely on individual behaviour change are likely to result in only a partial reduction of HIV transmission risk, perhaps in the order of 25% to a maximum of 40% (Heimer, Bray, Burris, Khoshnood, & Blankenship, 2002; Coyle, Needle, & Normand, 1998). A combination of individually oriented interventions may reduce HIV incidence among IDUs but not to zero (Van Ameijden & Coutinho, 1998). HIV testing and counselling, for example, does not necessarily eliminate continued HIV transmission behaviour among IDUs, including among those newly diagnosed HIV positive (Strathdee et al. (1997a), Strathdee et al. (1997b); Avants, Warburton, Hawkins, & Margolin, 2000). Effective HIV prevention not only comprises targeted interventions fostering changes in individual behaviour, but also interventions creating local environments conducive to, and supportive of, individual and community-level behaviour change. This inevitably necessitates a focus in bringing about changes in the physical, social, economic, legal and policy environments influencing HIV risk and HIV prevention (Rhodes, 2002; Singer & Clair, 2003). Such an approach has been variously termed an ‘enabling environment’ approach to HIV prevention (Tawil, Verster, & O’Reilly, 1997) and ‘structural HIV prevention’ (Des Jarlais, 2000; Blankenship, Bray, & Merson, 2000; Sumartojo, 2000).

There have been few attempts to synthesise evidence on how the environment influences the risk of HIV transmission, whether among IDUs or among other populations at risk (Parker, Easton, & Klein, 2000; Singer, 2001; Aral, 2002; Galea & Vlahov, 2002; Friedman & Reid, 2002; Poundstrone, Strathdee, & Celetano, 2004; Burris et al., 2005). There remains a dearth of evidence which in part reflects the historical immediacy of international interest in the role of environmental interventions in HIV prevention, but also reflects the predominance of ‘individualistic’ models of research and intervention, both in HIV prevention specifically and public health approaches generally (Susser & Susser, 1996; Rhodes, 1997; Fee & Krieger, 1993; Friedman, Des Jarlais, & Ward, 1994; Poundstrone et al., 2004).

In its broadest sense, the ‘risk environment’ comprises all risk factors exogenous to the individual. An orientation towards an understanding of risk environment encourages a focus on the social situations, structures and places in which risk is produced rather than a reliance on a conception of risk as endogenous to individuals’ cognitive decision-making and immediacy of interpersonal relations. For our purposes here, we define the risk environment as the space—whether social or physical—in which a variety of factors exogenous to the individual interact to increase the chances of HIV transmission (Rhodes, 2002; Singer, 1994; Barnett & Whiteside, 1999).

At its most rudimentary level, a model of the risk environment may comprise two key dimensions: the type and level of environmental influence. HIV prevention research among IDUs emphasises four ideal types of environmental influence—physical; social; economic; and policy—in the context of three ideal levels of environmental influence—micro, meso and macro. This usage of ‘environment’ does not narrowly define the term as denoting physical space as is the case in some interpretations of ‘environmental intervention’ in HIV prevention (Wohlfeiler, 2000). Moreover, we make no assumptions that the physical environment is natural or given, since it is almost always socially constructed in two senses: human actions shape the physical environment, and human conceptions filter the experience of it.

Environmental factors are direct or indirect barriers to, as well as facilitators of, an individual's HIV risk and prevention behaviours. These environmental factors operate at the micro-level of interpersonal relationships among IDUs—such as negotiations about the use of injecting equipment between IDUs, and at the meso-level of social and group interactions—such as when perceived group ‘norms’ influence what is considered acceptable injecting behaviour (Latkin, Forman, Knowlton, & Sherman, 2003), and institutional or organisational responses—such as when local policing initiatives disrupt patterns of syringe exchange use and syringe accessibility (Rhodes, Judd, & Mikhailova, 2003a; Blumenthal, Kral, Lorvick, & Watters, 1997; Burris et al., 2005; Wood et al., 2004):

At the intermediate or more proximal level, barriers [to risk reduction] are more closely linked to specific behaviours, such as when they influence the availability of legal and accessible prevention services or products to reduce the likelihood of infection. (Sumartojo, 2000, p. S6)

In addition, environmental factors operate at the macro-level wherein structural factors, such as laws, military actions, policies, economic conditions, social inequalities, and wider cultural beliefs, interplay with micro-level environmental factors (Burris, 1999; Singer (1997), Singer (2001); Parker, Easton, & Klein, 2000; Bourgois, 1998). Also operative at this level are illicit operations, such as the international drug trade or commercial sex trafficking, structures that intertwine at many points with but are also partially outside of formal state processes. The macro-risk environment can therefore be viewed as comprising large-scale social, physical, economic, organisational and policy systems which combine with micro-level factors to ‘structure’ the risk environments in which HIV risk and harm is produced and reproduced:

At the macro-level, the vulnerability of persons to HIV is influenced by broad social structural characteristics. These ‘core’ or distal causes may be far removed from individuals’ control, but impact their lives through economic inequalities, racism, sexism, discrimination and stigmatisation directed towards groups at high risk. (Sumartojo, 2000, p. S6)

Evidence, especially from ethnographic and qualitative research, highlights the inseparability of micro-, meso- and macro-level factors (Singer, 1997; Bourgois, Lettiere, & Quesada, 1997). The risk environment is a product of interplay. We emphasise that the simple model of risk environment outlined above cannot serve to capture the numerous permutations in how various environmental factors interconnect in a given context. The inseparability of environmental factors cautions against an over-determinacy of approach emphasising structural change in HIV prevention. We cannot expect structural factors to be associated with HIV infection in a linear fashion. HIV risk due to structural factors is often an unintended outcome emerging out of larger social forces which operate on multiple levels and which often have contradictory or synergistic effects on infection rates (Bastos & Strathdee, 2000). An environmental approach thus emphasises that effective HIV prevention is locally produced. By this we indicate that environmental approaches to change cannot necessarily be generalised from one local neighbourhood, community or environment to another. Even policy interventions—which have the potential for bringing about social change at the community-level—can differ on account of the local, regional and national settings in which they are produced.

Section snippets

Social and structural factors in risk production

Evidence from HIV epidemics occurring among IDUs in parts of south and south-east Asia over the last two decades, and in the former Soviet Union countries of eastern Europe more recently, points to an interplay of factors which may generally ‘condition’ an environment which seeds and facilitates an epidemic (Rhodes et al., 1999a). These factors cut across the macro-, meso- and micro-dimensions of physical, social, economic and policy environment outlined above. Considering these factors roughly

Discussion

If HIV risk is socially produced then so too are public health solutions. An increased interest in depicting the ‘risk environments’ of HIV risk has led to calls for the creation of ‘enabling environments’ for individual and community change brought about by ‘structural HIV prevention’ (Tawil et al., 1997; Blankenship et al., 2000; Sumartojo, 2000; Des Jarlais, 2000). Additionally, shifts towards understanding the social determinants of HIV connect with wider calls for a paradigm shift in

Conclusion

There is growing appreciation and evidence of community action and public policy interventions as a means of HIV prevention (Sumartojo, 2000; Blankenship et al., 2000; Poundstrone et al., 2004). The cities or countries with most success in controlling, averting or reversing HIV epidemics among IDUs have adopted interventions in keeping with World Health Organization (WHO) endorsed principles of effective public health (Ball, 1998). These intervention approaches are well-established and include

Acknowledgements

The authors are grateful to the World Health Organization who supported Dr. Rhodes in the preparation of this paper as part of a project reviewing evidence for action in HIV prevention for injecting drug users. Professor Bourgois is supported in part by National Institutes of Health grants NIDA DA101164, NINR NR08324, NIMH 54907 and Russell Sage Foundation 87-03-04; Dr. Singer by Centres for Disease Control and Prevention Grants R06-CCR121652 and U558-CCU123064; Dr. Friedman by National

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