Achieving 'universal access' to antiretroviral HIV treatment (ART) in lower income and transitional settings is a global target. Yet, access to ART is shaped by local social condition and is by no means universal. Qualitative studies are ideally suited to describing how access to ART is socially situated. We explored systemic barriers to accessing ART among people who inject drugs (PWID) in a Russian city (Ekaterinburg) with a large burden of HIV treatment demand. We undertook 42 in-depth qualitative interviews with people living with HIV with current or recent experience of injecting drug use. Accounts were analysed thematically, and supplemented here with an illustrative case study. Three core themes were identified: 'labyrinthine bureaucracy' governing access to ART; a 'system Catch 22' created by an expectation that access to ART was conditional upon treated drug use in a setting of limited drug treatment opportunity; and 'system verticalization', where a lack of integration across HIV, tuberculosis (TB) and drug treatment compromised access to ART. Taken together, we find that systemic factors play a key role in shaping access to ART with the potential adverse effects of reproducing treatment initiation delay and disengagement from treatment. We argue that meso-level systemic factors affecting access to ART for PWID interact with wider macro-level structural forces, including those related to drug treatment policy and the social marginalization of PWID. We note the urgent need for systemic and structural changes to improve access to ART for PWID in this setting, including to simplify bureaucratic procedures, foster integrated HIV, TB and drug treatment services, and advocate for drug treatment policy reform.

译文

在低收入和过渡环境中实现抗逆转录病毒艾滋病毒治疗的 “普遍获得” 是一个全球目标。然而,获得艺术的途径是受当地社会条件的影响,绝不是普遍的。定性研究非常适合描述获得艺术的社会地位。我们探讨了在俄罗斯城市 (叶卡捷琳堡) 中注射毒品 (PWID) 的人获得ART的系统性障碍,该城市的HIV治疗需求负担很大。我们对目前或最近有注射吸毒经验的艾滋病毒感染者进行了42次深入的定性访谈。对帐户进行了主题分析,并在此处进行了说明性案例研究。确定了三个核心主题: “迷宫式官僚” 管理获得ART的机会; 由于期望在有限的药物治疗机会中获得ART的条件下以治疗药物的使用为条件而创建的 “系统Catch 22”; 和 “系统垂直化”,其中缺乏艾滋病毒之间的融合,结核病 (TB) 和药物治疗损害了获得ART的机会。综上所述,我们发现系统性因素在塑造获得ART的途径方面起着关键作用,并具有重现治疗开始延迟和脱离治疗的潜在不利影响。我们认为,影响PWID获得ART的中观系统因素与更广泛的宏观结构力量相互作用,包括与药物治疗政策和PWID的社会边缘化有关的力量。我们注意到,在这种情况下,迫切需要进行系统性和结构性改革,以改善PWID获得抗逆转录病毒疗法的机会,包括简化官僚程序,促进艾滋病毒,结核病和药物治疗综合服务,并倡导药物治疗政策改革。

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