Social and Structural Determinants of Injecting-Related Bacterial and Fungal Infections Among People who Inject Drugs: Qualitative Systematic Review and Thematic Synthesis

Author: Thomas Brothers Matthew Bonn Dan Lewer Inhwa Kim Emilie Comeau Duncan Webster Andrew Hayward Magdalena Harris

Theme: Social Science & Policy Research Year: 2022

Injecting-related bacterial and fungal infections are common among people who inject drugs.
Learning from efforts to prevent other drug-related harms (including HIV and overdose), we sought
to identify social and structural factors contributing to injecting-related infections.
We searched five databases (PubMed, EMBASE, Scopus, CINAHL, PsycINFO) from January 1, 2000 to
February 18, 2021 to identify studies on injecting-related infections that present qualitative data
among people who inject drugs. We performed thematic synthesis in a two-stage analytic process.
First, we identified descriptive themes across included studies. We then consolidated descriptive
themes into conceptual categories to identify (higher order) analytic themes. We used an iterative,
deductive-inductive approach informed by Rhodes’ “risk environment” framework.
After screening 4,841 abstracts and 631 full-text reports, we identified 25 studies with qualitative
data (18 qualitative-only and seven mixed-methods) on injecting-related infections. Studies were
conducted in USA, Canada, UK, Mexico, and Kyrgyzstan. We identified nine descriptive themes
organized into three analytic themes. The first analytic theme, “1. structural production of risk”,
focused on macro-environmental influences including discrimination, criminalization, mandated
abstinence, and austerity politics. Associated descriptive themes were: “1a. local drug supply”; “1b.
(un)safe spaces”; “1c. health care policies and practices”; and “1d. harm reduction services”. The
second analytic theme, “2. intersectional risk environment”, explored heterogeneous effects of the
risk environment among people at the intersections of multiple social locations: “2a. gender and
substance use”; “2b. race and substance use”; and “2c. physical ability and substance use”. The third
analytic theme, “3. practices of care among people who use drugs”, focused on agency and
individual-environment interactions promoting health: “3a. mutual care” and “3b. self-care”.
Injecting-related bacterial and fungal infections are shaped by social and structural factors, including
discrimination and prohibition. Interventions to reduce suffering and death from injecting-related
infections should prioritize modifying these factors.
Disclosure of Interest Statement:
MB reports personal fees from AbbVie, a pharmaceutical research and development company, and
grants and personal fees from Gilead Sciences, a research-based biopharmaceutical company,
outside of the submitted work. The other authors have no disclosures.

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