This thesis analyses the construction of the risk environment with the emergence of a harm reduction policy in Macao, which, I propose acts as a regulatory regime to address the HIV/AIDS epidemic among injecting drug users (IDUs). On the one hand, the policy has endeavoured to address the various levels of the risk environment on the IDUs; on the other hand, it is also portrayed as a bio-political project situated in the history of drug control and public health surveillance in Macao. With harm reduction imperatives such as the methadone maintenance treatment (MMT) and needle and syringe programme (NSP), addict citizens are refashioned and made up to be a particular form of drug using subject – health conscious citizens who rationally and calculatingly perform in the use of drugs in a controlled manner in order to minimise drug-related harm to themselves as well as the general society. With the conferral of neoliberal subjectivity, they are offered political benefits in symbolic and material resources, such as recognition, trust and legitimate status, to obtain welfare. However, the tradeoffs are their freedom and mobility in being constrained by the methadone treatment, which is metaphorically represented as “liquid handcuffs”. The study utilises ethnographic research methods, such as video-recording, photo-taking, field observations and in-depth interviews, as its data sources. The data analysis is informed by a thematic approach, especially discourse and content analyses. Inspired by risk governmentality, IDUs are not passively subjugated to the surveillance of the treatment regime. Contrarily, they actively display modest amounts of agency, which they assert themselves by developing various streetwise risk strategies to handle overdosing. A code of ethics with regards to moral economy and responsibility are cultivated in the drug user community under the impacts of harm reduction (expert) discourses. In the face of entrenched double stigma around drug addiction and HIV/AIDS which shape their risk environment and spoiled identity as junkies, the drug users in this study endeavour to innovate strategies of resistance with the use of harm reduction measures to properly manage their spoiled identity and reclaim their citizenship. This gives them more freedom, autonomy and pleasure in their life experiences through the negotiation process that is embedded in the risk environment. The theoretical implications of this study include: the integration of risk governmentality with risk environment, and an assessment of harm reduction imperatives, including their effect as a newer form of governance on IDUs, which might conceal the material constraints that they face. In short, harm reduction requires a critical focus on the benevolence of biopolitical projects, such as the MMT and NSP, which, while not intentional, might legitimise the repressive measures directed at drug users – who ultimately are not willing to trade their freedom to take part in ―healthy self-care‖ projects under a neoliberal drug policy. / published_or_final_version / Sociology / Doctoral / Doctor of Philosophy

No description available.

published_or_final_version / Public Administration / Master / Master of Public Administration

published_or_final_version / Politics and Public Administration / Master / Master of Public Administration

Background: Despite substantial global progress against the HIV/AIDS epidemic, the Eastern Europe and Central Asian region has experienced a 43% increase in HIV incidence. The HIV epidemic in Kazakhstan has outpaced that of the region, with the incidence of new infections growing by 73% since 2010. Key populations of people who inject drugs (PWID), female sex workers (FSW) and their sexual partners account for the majority of new infections, where drug policies continue to undermine HIV prevention and control efforts. Kazakhstan has made insufficient progress towards 95-95-95 HIV epidemic control targets, with 78% of people living with HIV (PLWH) knowing their HIV status, of which 57% receive ART, and 48% of those receiving ART achieve viral suppression. Laws, policies and their enforcement can shape social and structural determinants of health, and it is fundamental to understand how punitive legal environments shape the HIV epidemic in Kazakhstan. This dissertation seeks to identify patterns of police violence victimization among FSW who use drugs and examine how police violence is associated with the HIV risk environment. Given the insufficient progress towards 95-95-95 HIV epidemic control targets, this dissertation also seeks to identify how patterns of injection and sexual HIV transmission risk behaviors vary among men and women who inject drugs and examine how criminal-legal involvement is associated with patterns of HIV transmission risk behaviors. Methods: Data on police violence victimization among FSW who use drugs were drawn from Project Nova, a cluster-randomized control trial that evaluated the efficacy of a combination HIV risk reduction and microfinance intervention. A community-based sample of 255 FSW who use drugs were recruited and enrolled between February 2015 and May 2017 in Almaty, Kazakhstan. Latent class analysis (LCA) was used to characterize women into distinct subgroups (i.e., classes) of police violence victimization. Next, multinomial logistic regression was used to examine how police violence victimization subgroups are associated with the physical, social, economic and policy HIV risk environment. Data on injection and sexual HIV transmission risk behaviors were drawn from Bridge, an implementation science study that evaluated the effectiveness of HIV service integration into needle/syringe programs on retention in care and viral suppression for PWID living with HIV in Kazakhstan. A random sample of 450 men and 166 women who inject drugs were recruited and enrolled in Almaty, Shymkent, and Temirtau/ Karaganda between February 2017 and June 2019. Similarly, LCA was used to characterize distinct subgroups of HIV transmission risk behaviors among men and women who inject drugs. Multinomial logistic regression was then used to identify associations between criminal-legal involvement and patterns of HIV transmission risk. Results: Three subgroups of police violence victimization among FSW who use drugs emerged. Just over half were characterized as experiencing low violence victimization (“Low Violence;” 51%); over one-third were characterized as experiencing all forms of police violence victimization (Poly-Victimization; 34%), and 15% were characterized as experiencing primarily discrimination and extortion from the police. Relative to Low Violence, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR= 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (aOR= 2.73 (1.15, 6.50)), injection drug use (IDU) (aOR= 2.00 (1.12, 3.58)), greater number of unsafe injection behaviors (aOR= 1.21 (1.08, 1.35)), homelessness (aOR= 1.92 (1.06, 3.48)), greater drug use stigma (aOR= 1.22 (1.07, 1.39)) and sex work stigma (aOR= 1.23 (1.06, 1.43)), greater number of sex work clients (aOR= 2.40 (1.33, 4.31)), working for a boss/pimp (aOR= 2.74 (1.16, 6.50)), client violence (aOR= 2.99 (1.65, 5.42)), economic incentives for condomless sex (aOR= 2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (aOR= 3.47 (1.42, 8.50)), recent arrest (aOR= 2.99 (1.36, 6.55)) and detention (aOR= 2.93 (1.62, 5.30)), and negative police perceptions (aOR= 8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics. Distinct patterns of HIV transmission risk behaviors emerged among men and women, in which men were characterized as having Low Sexual Risk (41.8%), Injection & Sexual Risk (36.4%), and High Injection Risk (21.8%) behaviors. Class membership in the Injection & Sexual Risk and High Injection Risk class was associated with greater criminal-legal involvement, compared to the Low Sexual Risk class. This is demonstrated by higher odds of multiple detentions ((aORInjection & Sexual Risk = 1.28 (1.10, 1.49); aORHigh Injection Risk = 1.25 (1.06, 1.46)) and drug court participation (aORHigh Injection Risk = 5.29 (1.03, 27.20) in the past six months, committing crimes while under the influence of alcohol or drugs (aORInjection & Sexual Risk = 2.79 (1.53, 5.11); aORHigh Injection Risk = 2.76 (1.34, 5.65), and perceived police discrimination (aORHigh Injection Risk = 1.79 (1.01, 3.19). Women who inject drugs were characterized as having Low Injection & Sexual Risk (60.7%), Sex Work Behaviors (8.4%), High Injection Risk (30.7%) behaviors. Class membership in the Sex Work Behaviors and High Injection Risk class was associated with greater odds of being detained (aORSex Work Behaviors= 4.59 (1.27, 16.53) and experiencing verbal police harassment (aORSex Work Behaviors= 3.31 (1.20, 9.15); aORHigh Injection Risk = 2.91 (1.32, 6.40), compared to the Low Injection & Sexual Risk class. Conclusion: Results from this dissertation show that police violence against FSW who use drugs is pervasive in Kazakhstan. Patterns of police violence victimization among FSW who use drugs vary, with multiple forms of police violence victimization being associated with greater HIV susceptibility. This dissertation also demonstrates that men and women who inject drugs and are living with HIV have a high prevalence of injection and sexual HIV transmission risk behaviors, despite low viral suppression, and that patterns of HIV transmission risk behaviors vary by gender. Moreover, criminal-legal involvement is associated with injection and sexual HIV transmission risk, particularly among men who inject drugs. Collectively, these results support drug policy reforms and suggest that decriminalization of drug use and possession may promote enabling environments that support harm reduction, and subsequently reduce HIV transmission through injection and sexual networks of PWID in Kazakhstan.

The history of heroin use disorder intervention has been characterised by fads and fashions. Some of the treatments that have been used have been, at best ineffective, and at worst harmful, and occasionally even dangerous. It is a sad reflection upon the field that practices and procedures for the treatment of heroin use disorders can so easily be introduced and applied without (or even contrary to) evidence. In South Africa, the field of heroin use disorder intervention has been `in transition' since the outbreak of the heroin epidemic. Yet despite growing evidence of an association between heroin dependents use of supplementary intervention services (such as psychosocial and pharmacological/medical care) and intervention outcomes, and the fact that international emerging standards for substance use disorder intervention have called upon treatment intervention providers to enhance traditional substance use disorder services with services that address clients' psychological and social needs, heroin use disorder intervention programmes in South Africa generally fail to meet these research-based intervention standards. Much of what is currently delivered as intervention is based upon current best guesses of how to combine some science-based (for example, cognitive-behavioural therapy and pharmacotherapies) and self-help (12-step programmes) approaches into optimal intervention protocols. As progression is made in the twenty-first century, scientific information is now beginning to be used to guide the evolution and delivery of heroin use disorder care internationally. Regrettably, a scarcity of heroin use disorder intervention research is noted in South Africa. The present study delved into the insights of ten heroin use disorder specialists, and synthesised the findings with the results of a previous study undertaken by the author relating to forty long-term voluntarily abstinent heroin dependents. In terms of theory and practice, findings of the study suggest that the field is less in transition now than it was in 1995. It is an imperative that law-enforcement action be followed by an integrated programme of psychological, social and pharmacological outreach. These programmes will have to be expanded to address new demands and will need to include specialised skills training. Many interventions and procedures have begun to be integrated routinely into clinical practice. / Psychology / (D. Phil. (Psychology))

Heroin dependence, which is escalating within South Africa, has become a symbol of the social disorder of the times - associated with materialism, poverty, crime, the problems of a society in transition, the disadvantaged, and the inner cities. However, that is not to say that all those who misuse heroin develop a problem or become dependent. In reality, only a small minority of heroin users develop a dependence, but for those who do it can result in unpleasant and potentially terrifying experiences/consequences, that can often be extremely difficult to escape from. That is not to say that recovery from dependence to heroin is not possible. Indeed, contrary to the beliefs of many people, the reality is that many people do eventually recover. Despite the vast sums of money devoted to treatment intervention of heroin dependants in the South Africa and worldwide, the processes by which recovery occur remain fairly unclear. Moreover, relatively little is known about the contribution of interventions and processes in facilitating such recovery. The statistical and content analysis of the data revealed that one of the most important factors identified in allowing successful behaviour modification and promoting recovery was psychosocial and pharmacological intervention, which seemed to produce a range of positive effects that facilitated natural healing processes. However, a range of other factors alongside intervention were also important in promoting behaviour modification. This study has provided important information, from forty recovering heroin dependants themselves, on the many factors that are important in achieving abstinence, in allowing recovery to be maintained in the longer term, and in potentially allowing an eventual exit from heroin dependence. A number of difficulties encountered in intervention were also identified. The statistical findings of the study support the `maturing out' hypothesis of heroin dependence (c² = 16.841; r = 0.001; df = 3). Ethnicity, highest level of education, employment status, marital status, biological parents' marital status or whether biological parents were deceased or not did not relate to any of the identified behavioural indices associated with heroin dependence recovery. A framework for the development of a contextual heroin dependence recovery model is also discussed. / Psychology / (M.A.(Psychology))

The history of heroin use disorder intervention has been characterised by fads and fashions. Some of the treatments that have been used have been, at best ineffective, and at worst harmful, and occasionally even dangerous. It is a sad reflection upon the field that practices and procedures for the treatment of heroin use disorders can so easily be introduced and applied without (or even contrary to) evidence. In South Africa, the field of heroin use disorder intervention has been `in transition' since the outbreak of the heroin epidemic. Yet despite growing evidence of an association between heroin dependents use of supplementary intervention services (such as psychosocial and pharmacological/medical care) and intervention outcomes, and the fact that international emerging standards for substance use disorder intervention have called upon treatment intervention providers to enhance traditional substance use disorder services with services that address clients' psychological and social needs, heroin use disorder intervention programmes in South Africa generally fail to meet these research-based intervention standards. Much of what is currently delivered as intervention is based upon current best guesses of how to combine some science-based (for example, cognitive-behavioural therapy and pharmacotherapies) and self-help (12-step programmes) approaches into optimal intervention protocols. As progression is made in the twenty-first century, scientific information is now beginning to be used to guide the evolution and delivery of heroin use disorder care internationally. Regrettably, a scarcity of heroin use disorder intervention research is noted in South Africa. The present study delved into the insights of ten heroin use disorder specialists, and synthesised the findings with the results of a previous study undertaken by the author relating to forty long-term voluntarily abstinent heroin dependents. In terms of theory and practice, findings of the study suggest that the field is less in transition now than it was in 1995. It is an imperative that law-enforcement action be followed by an integrated programme of psychological, social and pharmacological outreach. These programmes will have to be expanded to address new demands and will need to include specialised skills training. Many interventions and procedures have begun to be integrated routinely into clinical practice. / Psychology / (D. Phil. (Psychology))

Heroin dependence, which is escalating within South Africa, has become a symbol of the social disorder of the times - associated with materialism, poverty, crime, the problems of a society in transition, the disadvantaged, and the inner cities. However, that is not to say that all those who misuse heroin develop a problem or become dependent. In reality, only a small minority of heroin users develop a dependence, but for those who do it can result in unpleasant and potentially terrifying experiences/consequences, that can often be extremely difficult to escape from. That is not to say that recovery from dependence to heroin is not possible. Indeed, contrary to the beliefs of many people, the reality is that many people do eventually recover. Despite the vast sums of money devoted to treatment intervention of heroin dependants in the South Africa and worldwide, the processes by which recovery occur remain fairly unclear. Moreover, relatively little is known about the contribution of interventions and processes in facilitating such recovery. The statistical and content analysis of the data revealed that one of the most important factors identified in allowing successful behaviour modification and promoting recovery was psychosocial and pharmacological intervention, which seemed to produce a range of positive effects that facilitated natural healing processes. However, a range of other factors alongside intervention were also important in promoting behaviour modification. This study has provided important information, from forty recovering heroin dependants themselves, on the many factors that are important in achieving abstinence, in allowing recovery to be maintained in the longer term, and in potentially allowing an eventual exit from heroin dependence. A number of difficulties encountered in intervention were also identified. The statistical findings of the study support the `maturing out' hypothesis of heroin dependence (c² = 16.841; r = 0.001; df = 3). Ethnicity, highest level of education, employment status, marital status, biological parents' marital status or whether biological parents were deceased or not did not relate to any of the identified behavioural indices associated with heroin dependence recovery. A framework for the development of a contextual heroin dependence recovery model is also discussed. / Psychology / (M.A.(Psychology))