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

:在较低的收入和过渡环境中实现对抗逆转录病毒HIV治疗(ART)的“普遍获得”是全球目标。然而,获得抗逆转录病毒药物的途径取决于当地的社会状况,绝不是普遍的。定性研究非常适合描述获得抗逆转录病毒疗法在社会上的位置。我们探索了在俄罗斯城市(叶卡捷琳堡)注射艾滋病毒(HIV)需求量很大的注射毒品者(PWID)中获取ART的系统性障碍。我们对具有当前或最近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。对帐目进行了主题分析,并在此处补充了说明性的案例研究。确定了三个核心主题:控制获取抗逆转录病毒药物的“迷宫式官僚主义”;期望在有限的药物治疗机会的情况下获得抗病毒药物的条件是要获得抗逆转录病毒药物而创建的“系统捕​​获22”;以及“系统垂直化”,即艾滋病毒,结核病和药物治疗之间缺乏整合,影响了抗逆转录病毒疗法的获取。综上所述,我们发现系统性因素在影响获得ART的过程中起着关键作用,并具有再生治疗起始延迟和脱离治疗的潜在不利影响。我们认为影响PWID获得抗逆转录病毒疗法的中观系统性因素与更广泛的宏观结构性因素相互作用,包括那些与毒品治疗政策和PWID的社会边缘化有关的因素。我们注意到迫切需要进行系统和结构上的改革,以改善在这种情况下PWID获得抗病毒治疗的途径,包括简化官僚程序,促进艾滋病毒,结核病和药物治疗的综合服务,以及倡导药物治疗政策的改革。

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