International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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International Journal of Drug Policy 25 (2014) 575–582 Contents lists available at ScienceDirect International Journal of Drug Policy j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o Research paper Safe havens and rough waters: Networks, place, and the navigation of risk among injection drug-using Malaysian fishermen Brooke S. West a,∗ , Martin Choo b , Nabila El-Bassel c , Louisa Gilbert c , Elwin Wu c , Adeeba Kamarulzaman b a Department of Sociomedical Sciences, Columbia University, New York, NY, USA b Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia c Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA a r t i c l e i n f o Article history: Received 16 April 2013 Received in revised form 6 November 2013 Accepted 13 November 2013 Keywords: Injection drug use HIV Social networks Place Risk environment Fishermen Malaysia a b s t r a c t Background: HIV prevalence among Malaysian fishermen is ten times that of the general population. Fishing boats are a key place where drug use occurs, but we know little about how these environments shape HIV risk behaviour. Utilizing Rhodes' 'risk environment' framework, we assessed drug use contexts and how characteristics of place associated with fishing and fishermen's social networks served as key axes along which drug use and HIV risk behaviour occurred. Methods: Data were collected during 2009–2011 in Kuantan, a fishing port on the eastern coast of Malaysia, and include 28 in-depth interviews and 398 surveys collected using RDS. Logistic regres- sion was used to determine the effect of occupational, network and risk environment characteristics on unsafe injection behaviour and access to clean needles/syringes; qualitative data were coded and analyzed thematically. Results: Drug injecting was common and occurred on boats, often with other crewmembers. Captains and crewmembers were aware of drug use. Unsafe injection practices were significantly associated with having a larger proportion of drug injectors in network (OR = 3.510, 95% CI = 1.053–11.700) and having a captain provide drugs for work (OR = 2.777, 95% CI = 1.018–7.576). Size of fishermen network (OR = 0.987, 95% CI = 0.977–0.996), crewmembers' knowledge of drug use (OR = 7.234, 95% CI = 1.430–36.604), and having a captain provide drugs for work (OR = 0.134, 95% CI = 0.025–0.720) predicted access to clean needles/syringes. Qualitative analyses revealed that occupational culture and social relationships on boats drove drug use and HIV risk. Conclusions: While marginalized in broader society, the acceptance of drug use within the fishing com- munity created occupational networks of risk. Fishing boats were spaces of both risk and safety; where drug users participated in the formal economy, but also where HIV risk behaviour occurred. Understand- ing the interplay between social networks and place is essential for developing HIV prevention and harm reduction policies appropriate for the unique needs of this fishing population. © 2013 Elsevier B.V. All rights reserved. Introduction Fishermen are a high-risk group for HIV, having higher HIV rates than other typically at-risk groups, like truck drivers and military personnel (Kissling et al., 2005). Despite this, fishermen and their communities remain under-researched, especially in Southeast Asia. In Malaysia, there is particular cause for con- cern as estimates suggest that fishing communities have an HIV ∗ Corresponding author at: Department of Sociomedical Sciences, Columbia Uni- versity, 722 West 168th Street, New York, NY 10032, USA. Tel.: +1 347 218 3628; fax: +1 917 438 0894. E-mail address: (B.S. West). prevalence rate 10 times that of the general population (Kissling et al., 2005). While only 1.3% of the working population is employed in the fishing industry (Department of Statistics Malaysia, 2005), fishermen constitute 3.8% of the total reported HIV cases in the country (Ministry of Health Malaysia, 2008). The dearth of research on fishing communities underscores the need for a greater under- standing of the social determinants of HIV risk among fishermen. Integral to this understanding is an examination of social networks and how local environments and broader social, economic, and occupational factors shape HIV risk behaviour. Despite the substantial focus in public health on behaviour change models, there is increasing attention to the ways in which health priorities and behaviours are shaped by larger social struc- tures that intersect with biological, psychological and network 0955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved.

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