Precarious Lives, Precarious Treatments: Making Drug Treatment Work in Northern Myanmar

The effect of location in mining or borderland areas on HIV incidence among people who use drugs attending a harm reduction programme in Myanmar, 2014-2021: A retrospective cohort study

BACKGROUND

High HIV prevalence has been documented among people who inject drugs in Myanmar particularly in mining and borderland areas. We estimated incidence of HIV among people using drugs (via injecting and other routes) and examine associations between location in mining or borderland areas and risk of infection.

METHODS AND FINDINGS

Analysis of data among clients registered at harm reduction programmes across Sagaing region, Kachin, and Northern Shan States between 2014-2021. Data on sociodemographic, drug use characteristics and clinic-level data on borderland or mining locations were collected at time of registration. Characteristics, repeat HIV testing and HIV seroconversion were analysed using a cohort approach. We use Poisson regression models to examine associations between location in a borderland or mining area and incidence of HIV, adjusting for confounders. Data were available for 85,093 clients, 52,526 reported HIV tests and 20.0% were seropositive. 38,670 clients had no or only one recorded HIV result. The median time between HIV tests was 1.1 years. Among 13,359 clients with 2 or more HIV tests the HIV seroconversion rate was 3.8 per 100 person years (pyrs) (95% CI 3.6-4.0). Incidence among those who injected drugs was 6.8 per 100/pyrs, 8.9 among those aged  ≤  25 years, 2.3 among women, 2.3 among those who had migrated, 5.6 among those located in border areas, and 3.7 among those in mining areas. After adjusting for confounders, HIV incidence remained higher for people located in borderland areas (Incidence Rate Ratio 1.67 95% CI 1.13-2.45) but there was no evidence of association between location in a mining area and HIV seroconversion.

CONCLUSIONS

Findings highlight the need to intensify harm reduction interventions with a focus on cross-border interventions. Increasing uptake of HIV testing alongside the scale up of evidenced based interventions is urgently needed to curb the high rates of HIV transmission associated with drug use, particularly among young people.

Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.

Caring for coca, living with chemicals: Towards ecological harm reduction

In this paper, we show how the materialisation of chemical harms linked to the cultivation of coca and its processing into coca paste reside in a wider politics of structural violence which is also situated ecologically. Drawing on the qualitative interview accounts of coca farmers in Putumayo, Colombia, we attend to practices of care in the field and in the laboratory. We look first at chemicals used in coca's cultivation (herbicides, fertilizers, pesticides), and second at chemicals (such as sulphuric acid, sodium carbonate, magnesium permanganate) used in the processing of coca leaf into paste (before the paste is sold on for refinement into cocaine). Our analysis highlights the tensions which inevitably arise in the balance and multiplicities of care - for crops, livelihood, and environment. We trace how farmers' narratives of the neutralisation of chemical risks habituate chemical harms as mundane, even uneventful, in an economic imperative to 'carry on as normal' in the coca economy. We emphasise health and harm as matters of care which not only affect humans but living environments. Accounts of 'risk environment' can give insufficient attention to Nature, and this leads us to consider 'ecological harm reduction'.

The effect of different types of migration on symptoms of anxiety or depression and experience of violence among people who use or inject drugs in Kachin State, Myanmar

BACKGROUND

Evidence on the social determinants of mental health conditions and violence among people who inject or use drugs (PWUD) is limited, particularly in conflict-affected countries. We estimated the prevalence of symptoms of anxiety or depression and experience of emotional or physical violence among PWUD in Kachin State in Myanmar and examined their association with structural determinants, focusing on types of past migration (migration for any reason, economic or forced displacement).

MATERIALS

A cross-sectional survey was conducted among PWUD attending a harm reduction centre between July and November 2021 in Kachin State, Myanmar. We used logistic regression models to measure associations between past migration, economic migration and forced displacement on two outcomes (1) symptoms of anxiety or depression (Patient Health Questionnaire-4) and (2) physical or emotional violence (last 12 months), adjusted for key confounders.

RESULTS

A total of 406, predominantly male (96.8%), PWUD were recruited. The median age (IQR) was 30 (25, 37) years, most injected drugs (81.5%) and more commonly opioid substances such as heroin or opium (85%). Symptoms of anxiety or depression (PHQ4 ≥ 6) were high (32.8%) as was physical or emotional violence in the last 12 months (61.8%). Almost one-third (28.3%) had not lived in Waingmaw for their whole life (migration for any reason), 77.9% had left home for work at some point (economic migration) and 19.5% had been forced to leave home due to war or armed conflict (forced displacement). A third were in unstable housing in the last 3 months (30.1%) and reported going hungry in the last 12 months (27.7%). Only forced displacement was associated with symptoms of anxiety or depression [adjusted odds ratio, aOR 2.33 (95% confidence interval, CI 1.32-4.11)] and recent experience of violence [aOR 2.18 (95% CI 1.15-4.15)].

CONCLUSION

Findings highlight the importance of mental health services integrated into existing harm reduction services to address high levels of anxiety or depression among PWUD, particularly among those who have been displaced through armed conflict or war. Findings reinforce the need to address broader social determinants, in the form of food poverty, unstable housing and stigma, in order to reduce mental health and violence.