"Sharing is my only option": An ethnographic analysis of the underlying contexts of needle and syringe sharing via the socio-ecological framework

Mohammad Niaz Morshed Khan^1,2Samira Dishti Irfan¹Md Alamgir Hossain¹Michiko Moriyama²Sharful Islam Khan^1*

• ¹Center for HIV and AIDS, International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Dhaka, Bangladesh
• ²Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan

Results: The findings presented multilayered contexts driving needle and syringe sharing. At the intrapersonal level, PWID possessed myths and misconceptions regarding needle and syringe sharing, which hindered their risk perception of needle and syringe sharing. As many PWID, especially street-based PWID, felt despondence and distress towards their life, they perceived safe injecting as futile as they were already in fatal conditions. Some PWID partook in concurrent substance use, clouding their judgment, increasing their aggression, and perpetuating risky injection. Moreover, findings showed that withdrawal took precedence in needle and syringe sharing behaviors. At the interpersonal level, PWID communities protected fraternal relationships through sharing, inherited community-bred misinformation about safe injecting practices, and were influenced by gendered and community hierarchies and power dynamics within the PWID sub-culture, which all fueled needle and syringe sharing. Shadowing sessions, observations and interviews revealed challenges at the organizational level (i.e., the PWID intervention) such as inconvenient outreach schedules in relation to PWID’s drug-injecting time windows; challenges in the needle and syringe distribution approach; and a predominantly peer-focused outreach approach where peers exhibited work performance and compliance issues, and challenges in capacity building and upholding motivation among OWs. At the structural level, changes in infrastructure and associated inconveniences, criminalization of drug use and harassment of PWID, increased drug prices and financial constraints, and changes in fund allocation policy of the donor engendered risky injection.