Publications by authors named "Tim Rhodes"

152 Publications

Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research.

Int J Drug Policy 2021 Jul 11:103320. Epub 2021 Jul 11.

Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain; Faculty of Medicine, University of Barcelona, Barcelona, Spain. Electronic address:

Background: Stigma is an important element in the experience of living with chronic viral hepatitis B (HBV) and C (HCV), impacting healthcare access and uptake as well as health outcomes. Conceptualisations of stigma in research are, however, often assumed and implicit. This study aimed to synthesise and critically engage with the qualitative literature to provide an overarching conceptualisation of stigma as it pertains to viral hepatitis.

Methods: We critically reviewed qualitative literature that mobilised concepts or theories of stigma in relation to viral hepatitis. We searched seven electronic databases for peer-reviewed literature from 2000 to 2019. Given a dearth of conceptual literature on HBV stigma, we conducted a thematic analysis of concepts deployed to theorise stigma in relation to HCV.

Results: We found 13 studies that conceptualised stigma in relation to HCV, yet none for HBV. We synthesise the analytical findings of these studies and explore how HCV is theorised in relation to four themes: 'identity', 'embodiment', 'institutionalisation', and 'structuration'. Taken together, these themes illustrate the way in which HCV stigma manifests as the confluence of normative assumptions of socially unacceptable practices relating to HCV, such as injecting drug use and sexual behaviours; attitudes towards socially excluded populations; and fears of contracting a contagious and chronic illness. As such, operating within political, social, and economic systems, HCV stigma can act to silence the needs of those with HCV through misrecognising the multifaceted identities of individuals with HCV and structural determinants of health. Stigma, which is built and perpetuated by institutional arrangements, as well as in social processes and policies, shapes deservedness to, as well as engagements with, health and social care.

Conclusion: While commonly employed as a framing concept, much research lacks explicit theoretical or critical engagement on how stigma is conceptualised. There is a tendency for qualitative, empirical research to focus on risk factors shaping individual behaviour change, rather than on risk contexts and socio-structural change. Approaches to address stigma in relation to HCV must consider how stigma operates throughout social processes and is embedded in systems of power and normalised in institutional operating systems.
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http://dx.doi.org/10.1016/j.drugpo.2021.103320DOI Listing
July 2021

Futures-oriented drugs policy research: Events, trends, and speculating on what might become.

Int J Drug Policy 2021 Jun 17:103332. Epub 2021 Jun 17.

University of New South Wales, Australia.

One concern in the field of drugs policy is how to make research more futures-oriented. Tracing trends and events with the potential to alter drug futures are seen as ways of becoming more prepared. This challenge is made complex in fast evolving drug markets which entangle with shifting social and material relations at global scale. In this analysis, we argue that drugs policy research orientates to detection and discovery based on the recent past. This narrows future-oriented analyses to the predictable and probable, imagined as extensions of the immediate and local present. We call for a more speculative approach; one which extends beyond the proximal, and one which orientates to possibilities rather than probabilities. Drawing on ideas on speculation from science and technology and futures studies, we argue that speculative research holds potential for more radical alterations in drugs policy. We encourage research approaches which not only valorise knowing in relation to what might happen but which conduct experiments on what could be. Accordingly, we trace how speculative research makes a difference by altering the present through making deliberative interventions on alternative policy options, including policy scenarios which make a radical break with the present. We look specifically at the 'Big Event' and 'Mega Trend' as devices of speculative intervention in futures-oriented drugs policy research. We illustrate how the device of Mega Trend helps to trace as well as to speculate on some of the entangling elements affecting drug futures, including in relation to climate, environment, development, population, drug production, digitalisation, biotechnology, policy and discourse. [255].
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http://dx.doi.org/10.1016/j.drugpo.2021.103332DOI Listing
June 2021

Qualitative Analysis of Community Support to Methadone Access in Kenya.

Subst Use Misuse 2021 24;56(9):1312-1319. Epub 2021 May 24.

Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.

Background: Methadone, as part of Medically Assisted Therapy (MAT) for treatment of opioid dependence and supporting HIV prevention and treatment, has been recently introduced in Kenya. Few low income settings have implemented methadone, so there is little evidence to guide ongoing scale-up across the region. We specifically consider the role of community level access barriers and support.

Objectives: To inform ongoing MAT implementation we implemented a qualitative study to understand access barriers and enablers at a community level.

Methods: We conducted 30 semi-structured interviews with people who use drugs accessing MAT, supplemented by interviews with 2 stakeholders, linked to participant observation in a community drop in center within one urban area in Kenya. We used thematic analysis.

Results: We developed five themes to express experiences of factors enabling and disabling MAT access and how community support can address these: 1) time, travel and economic hardship; 2) managing methadone and contingencies of life, 3) peer support among MAT clients as treatment ambassadors, 4) family relations, and 5)outreach project contributions. Crosscutting themes address managing socioeconomic constraints and gender inequities.

Conclusions: People who use drugs experience and manage socio-economic constraints and gender inequities in accessing MAT with the support of local communities. We discuss how these access barriers could be addressed through strengthening the participation of networks of people who use drugs in drug treatment and supporting community projects working with people who use drugs. We also explore potential for how socio-economic constraints could be managed within an integrated health and social care response.
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http://dx.doi.org/10.1080/10826084.2021.1922450DOI Listing
May 2021

Excitable models: Projections, targets, and the making of futures without disease.

Sociol Health Illn 2021 May 4;43(4):859-880. Epub 2021 May 4.

University of New South Wales, Sydney, NSW, Australia.

In efforts to control disease, mathematical models and numerical targets play a key role. We take the elimination of a viral infection as a case for exploring mathematical models as 'evidence-making interventions'. Using interviews with mathematical modellers and implementation scientists, and focusing on the emergence of models of 'treatment-as-prevention' in hepatitis C control, we trace how projections detach from their calculative origins as social and policy practices. Drawing on the work of Michel Callon and others, we show that modelled projections of viral elimination circulate as 'qualculations', taking flight via their affects, including as anticipation. Modelled numerical targets do not need 'actual numbers' or precise measurements to perform their authority as evidence of viral elimination or as situated matters-of-concern. Modellers grapple with the ways that their models transform in policy and social practices, apparently beyond reasonable calculus. We highlight how practices of 'holding-on' to projections in relation to imaginaries of 'evidence-based' science entangle with the 'letting-go' of models beyond calculus. We conclude that the 'virtual precision' of models affords them fluid evidence-making potential. We imagine a different mode of modelling science in health, one more attuned to treating projections as qualculative, affective and relational, as excitable matter.
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http://dx.doi.org/10.1111/1467-9566.13263DOI Listing
May 2021

Situating adherence to medicines: The embodied practices and hinterlands of HIV antiretrovirals.

Sociol Health Illn 2021 Jun 28;43(5):1085-1099. Epub 2021 Mar 28.

Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.

Adherence to medicines tends to be envisaged as a matter of actors' reasoned actions, though there is increasing emphasis on situating adherence as a practice materialised in everyday routines. Drawing on the qualitative interview accounts of Black African women living with HIV in London, UK, we treat adherence to HIV medicines as not only situated in the practices of the immediate and everyday but also relating to a hinterland of historical and social relations. We move from accounts which situate adherence as an embodied matter of affect in the present, to accounts which locate adherence as a condition of precarity, which also trace to enactments of time and place in the past. Adherence is therefore envisaged as a multiple and fluid effect which is made-up in-the-now and in relation to a hinterland of practices which locate elsewhere.
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http://dx.doi.org/10.1111/1467-9566.13270DOI Listing
June 2021

Pharmaceutical citizenship in an era of universal access to hepatitis C treatment: Situated potentials and limits.

Health (London) 2021 Jan 28:1363459320988887. Epub 2021 Jan 28.

UNSW Sydney, Australia.

Until recently, the only medical treatment available for the hepatitis C virus (HCV) was interferon-based therapy, a notoriously long and arduous treatment with limited success. However, in December 2015, the Australian Government announced a scheme of 'universal access' to new, highly effective direct-acting antiviral therapies (DAAs). This article draws on in-depth interviews with community actors engaged in national and state-based drug user and viral hepatitis advocacy to trace how universal access to curative medicines affords revised notions of citizenship and social inclusion among people who inject drugs and others affected by HCV. To inform our analysis, we draw on and combine critical perspectives from the biological citizenship literature, particularly pharmaceutical citizenship, along with work on the concepts of 'publics and counterpublics'. We ask: what kinds of emergent HCV communities or are being enacted through our participant accounts in response to the new DAA-era of universal access, and what forms of citizenship and inclusion (or non-citizenship and exclusion) do they postulate? Some accounts indeed enacted treatment as an individual, sometimes collective, 'good': a citizenship potential. However, a number of accounts enacted situated limits to a straightforward actualisation of this potential, performing a model of public health governance that prioritised viral cure whilst rendering injecting drug use and its attendant social disadvantages an absent presence. Reconceptualising HCV treatment within a counterpublic health sensibility would, by engaging with the everyday health needs and aspirations of people living with HCV in conditions of social disadvantage, create space for new social inclusions and citizenships.
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http://dx.doi.org/10.1177/1363459320988887DOI Listing
January 2021

Mathematical models as public troubles in COVID-19 infection control: following the numbers.

Health Sociol Rev 2020 07 13;29(2):177-194. Epub 2020 May 13.

University of New South Wales, Sydney, Australia.

Mathematical models are key actors in policy and public responses to the COVID-19 pandemic. The projections from COVID-19 models travel beyond science into policy decisions and social life. Treating models as 'boundary objects', and focusing on media and public communications, we 'follow the numbers' to trace the social life of key projections from prominent mathematical models of COVID-19. Public deliberations and controversies about models and their projections are illuminating. These help trace how projections are 'made multiple' in their enactments as 'public troubles'. We need an approach to evidence-making for policy which is emergent and adaptive, and which treats science as an entangled effect of public concern made in social practices. We offer a rapid sociological response on the social life of science in the emerging COVID-19 pandemic to speculate on how evidence-making might be done differently going forwards.
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http://dx.doi.org/10.1080/14461242.2020.1764376DOI Listing
July 2020

Ecologies of drug war and more-than-human health: The case of a chemical at war with a plant.

Int J Drug Policy 2021 Mar 13;89:103067. Epub 2020 Dec 13.

University of New South Wales, Australia.

Drawing on an ecological approach, we trace how the political-economy of drug wars are locally materialised in relation to health. We take the case of coca cultivation and eradication as our example. To make our analysis, we trace the different ways that the chemical glyphosate is materialised in a war with the coca plant in Colombia. Glyphosate has been used for decades in aerial fumigation campaigns to eradicate illicit coca cultivation. Our analysis traces the more-than-human effects of glyphosate in relation to health. This leads us to outline a more-than-human approach to harm reduction; a harm reduction which positions health as a matter of ecology, paying attention not only to the nonhuman actors affecting human health but also to the health of environments which are themselves always in-the-making. We envisage harm reduction as a collaboration in which humans 'become-with' their environments.
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http://dx.doi.org/10.1016/j.drugpo.2020.103067DOI Listing
March 2021

COVID-19 and the health of people who use drugs: What is and what could be?

Int J Drug Policy 2020 09;83:102958

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia; London School of Hygiene and Tropical Medicine, London, UK.

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting 'complex adaptive systems': that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.
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http://dx.doi.org/10.1016/j.drugpo.2020.102958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837052PMC
September 2020

A qualitative study of diphenhydramine injection in Kyrgyz prisons and implications for harm reduction.

Harm Reduct J 2020 10 31;17(1):86. Epub 2020 Oct 31.

Yale School of Medicine, AIDS Program, 135 College Street, Suite 323, New Haven, CT, 06510, USA.

Background: To reduce opioid dependence and HIV transmission, Kyrgyzstan has introduced methadone maintenance therapy and needle/syringe programs into prisons. Illicit injection of diphenhydramine, an antihistamine branded as Dimedrol, has been anecdotally reported as a potential challenge to harm reduction efforts in prisons but has not been studied systematically.

Methods: We conducted qualitative interviews in Kyrgyz or Russian with prisoners (n = 49), former prisoners (n = 19), and stakeholders (n = 18), including prison administrators and prisoner advocates near Bishkek, Kyrgyzstan from October 2016 to September 2018. Interviews explored social-contextual factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. Dimedrol injection emerged as an important topic, prompting a dedicated analysis.

Results: After drinking methadone, some people in prison inject crushed Dimedrol tablets, a non-prescription antihistamine that is banned but obtainable in prison, to achieve a state of euphoria. From the perspectives of the study participants, Dimedrol injection was associated with devastating physical and mental health consequences, including psychosis and skin infections. Moreover, the visible wounds of Dimedrol injecting contributed to the perception of methadone as a harmful drug and supporting preference for heroin over methadone.

Conclusion: Dimedrol injecting is a potentially serious threat to harm reduction and HIV prevention efforts in Kyrgyzstan and elsewhere in the Eastern European and Central Asian region and requires further investigation.
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http://dx.doi.org/10.1186/s12954-020-00435-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603760PMC
October 2020

Towards an ontological politics of drug policy: Intervening through policy, evidence and method.

Int J Drug Policy 2020 Sep 8:102932. Epub 2020 Sep 8.

University of New South Wales, Sydney, Australia; London School of Hygiene and Tropical Medicine, UK.

Increasing attention has been paid to matters of ontology, and its accompanying politics, in the drug policy field. In this commentary, we consider what an 'ontological politics' might mean for how we think about what drug policy is and what it might become, as well as for how we think about (and do) research in drug policy. Thinking ontopolitically questions the tacitly accepted status of 'drug problems', calls into question the realist presumptions which underpin much drug policy analysis, and provokes thinking about what counts as 'evidence' and the 'evidence-based policy' paradigm itself. We call attention to the inventive possibilities of method when grappling with the challenges thrown forth by the ontological turn, with a renewed focus on practice and relations. An ontological politics disrupts consensual claims and draws critical attention to objects that might otherwise appear 'finished' or 'ready-made', not least the things we call 'drugs' and 'drug policy'. Working with 'drug policy multiples' invites new thinking and dialogue to provoke an ethico-political mode of intervention in the field of drug policy and drugs research.
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http://dx.doi.org/10.1016/j.drugpo.2020.102932DOI Listing
September 2020

What prevents health policy being 'evidence-based'? New ways to think about evidence, policy and interventions in health.

Br Med Bull 2020 10;135(1):38-49

Centre for Social Research in Health, University of New South Wales, NSW 2052, Sydney, Australia.

Background: Evidence-based policy decision-making is a dominant paradigm in health but realizing this ideal has proven challenging.

Sources Of Data: This paper conceptually maps health policy, policy studies and social science literature critically engaged with evidence and decision-making. No new data were generated or analysed in support of this review.

Areas Of Agreement: Barriers to evidence-based policy have been documented, with efforts made to increase the uptake of evidence.

Areas Of Controversy: Evident complexities have been regarded as a problem of translation. However, this assumes that policy-making is a process of authoritative choice, and that 'evidence' is inherently valuable policy knowledge, which has been critiqued.

Growing Points: Alternative accounts urge consideration of how evidence comes to bear on decisions made within complex systems, and what counts as evidence.

Areas Timely For Developing Research: An 'evidence-making intervention' approach offers a framework for conceptualizing how evidence and interventions are made relationally in practices, thus working with the politics and contingencies of implementation and policy-making.
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http://dx.doi.org/10.1093/bmb/ldaa026DOI Listing
October 2020

Modelling the pandemic: attuning models to their contexts.

BMJ Glob Health 2020 06;5(6)

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.

The evidence produced in mathematical models plays a key role in shaping policy decisions in pandemics. A key question is therefore how well pandemic models relate to their implementation contexts. Drawing on the cases of Ebola and influenza, we map how sociological and anthropological research contributes in the modelling of pandemics to consider lessons for COVID-19. We show how models detach from their implementation contexts through their connections with global narratives of pandemic response, and how sociological and anthropological research can help to locate models differently. This potentiates multiple models of pandemic response attuned to their emerging situations in an iterative and adaptive science. We propose a more open approach to the modelling of pandemics which envisages the model as an intervention of deliberation in situations of evolving uncertainty. This challenges the 'business-as-usual' of evidence-based approaches in global health by accentuating all science, within and beyond pandemics, as 'emergent' and 'adaptive'.
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http://dx.doi.org/10.1136/bmjgh-2020-002914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307539PMC
June 2020

Wastewater monitoring of SARS-CoV-2: lessons from illicit drug policy.

Lancet Gastroenterol Hepatol 2020 07;5(7):641-642

Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia; London School of Hygiene and Tropical Medicine, London, UK.

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http://dx.doi.org/10.1016/S2468-1253(20)30158-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295476PMC
July 2020

More-than-harm reduction: Engaging with alternative ontologies of 'movement' in UK drug services.

Int J Drug Policy 2020 08 6;82:102771. Epub 2020 Jun 6.

London School of Hygiene & Tropical Medicine, London, United Kingdom.

Over the last ten years, UK drug policy has moved towards making abstinence-based recovery rather than harm reduction its primary focus. Drawing on ethnographic fieldwork involving participant observations and interviews at two London drug services, we explore how this shift towards recovery materialises through the practices of drug service delivery as an 'evidence-making intervention'. We understand recovery's making in terms of 'movement'. Where previous policies performed harm reduction through 'getting people into treatment' and 'keeping them safe in treatment', new policies were said to be about 'moving people through treatment'. Approaching movement as a sociomaterial process, we observe how movement is enacted in both narrow ways, towards abstinence from drugs, and more open ways, in what we call 'more-than-harm reduction'. We think of the latter as a speculative practice of doing or 'tinkering with' recovery to afford a care for clients not bound to abstinence-based outcomes. This is important given the limits associated with a recovery-orientated policy impetus. By engaging with these alternative ontologies of movement, we highlight an approach to intervening that both subverts and adheres to perceptions of recovery, embracing its movement, while remaining critical to its vision of abstinence.
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http://dx.doi.org/10.1016/j.drugpo.2020.102771DOI Listing
August 2020

How to think with models and targets: Hepatitis C elimination as a numbering performance.

Int J Drug Policy 2021 Feb 1;88:102694. Epub 2020 Apr 1.

London School of Hygiene and Tropical Medicine, London, United Kingdom; University of New South Wales, Sydney, Australia.

The field of public health is replete with mathematical models and numerical targets. In the case of disease eliminations, modelled projections and targets play a key role in evidencing elimination futures and in shaping actions in relation to these. Drawing on ideas within science and technology studies, we take hepatitis C elimination as a case for reflecting on how to think with mathematical models and numerical targets as 'performative actors' in evidence-making. We focus specifically on the emergence of 'treatment-as-prevention' as a means to trace the social and material effects that models and targets make, including beyond science. We also focus on how enumerations are made locally in their methods and events of production. We trace the work that models and targets do in relation to three analytical themes: governing; affecting; and enacting. This allows us to situate models and targets as technologies of governance in the constitution of health, which affect and are affected by their material relations, including in relation to matters-of-concern which extend beyond calculus. By emphasising models and targets as enactments, we draw attention to how these devices give life to new enumerated entities, which detach from their calculative origins and take flight in new ways. We make this analysis for two reasons: first, as a call to bring the social and enumeration sciences closer together to speculate on how we might think with models and targets differently and more carefully; and second, to encourage an approach to science which treats evidencing-making interventions, such as models and targets, as performative and political.
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http://dx.doi.org/10.1016/j.drugpo.2020.102694DOI Listing
February 2021

Editing the International Journal of Drug Policy.

Int J Drug Policy 2020 02 14;76:102664. Epub 2020 Jan 14.

University of New South Wales, Australia.

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http://dx.doi.org/10.1016/j.drugpo.2020.102664DOI Listing
February 2020

Evidence-making interventions in health: A conceptual framing.

Soc Sci Med 2019 10 10;238:112488. Epub 2019 Aug 10.

Centre for Social Research in Health, University of New South Wales, Sydney, Australia.

We outline a framework for conceptualising interventions in health as 'evidence-making interventions'. An evidence-making intervention (EMI) approach is distinct from a mainstream evidence-based intervention (EBI) approach in that it attends to health, evidence and intervention as matters of local knowledge-making practice. An EMI approach emphasises relational materiality and performativity, engaging with interventions, and their knowing, as matters-of-practice. Rather than concentrating on how 'evidenced interventions' are implemented 'into' given 'contexts' - as if evidence, intervention and context were stable and separate - an EMI approach focuses on the processes and practices through which 'evidence', 'intervention' and 'context' come to be. There are two strands to our analysis. First, we identify concepts to think-with in an EMI approach; and second, we illustrate their implications through case examples. We first reflect on developments in 'implementation science' to distinguish how an EMI approach thinks differently. We note a 'within-limits contingency' of implementation science in contrast to the 'open contingency' of an EMI approach. This helps notice the performativity of science and intervention as evidencing-making practices. We next conceptualise an EMI approach in relation to: 'objects and practices'; 'effects and events'; and 'concerns and care'. We position an EMI approach in relation to theories of 'relational materialism', arguing that this affords a more critical, as well as more careful, way of knowing and doing health intervention.
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http://dx.doi.org/10.1016/j.socscimed.2019.112488DOI Listing
October 2019

The becoming-methadone-body: on the onto-politics of health intervention translations.

Sociol Health Illn 2019 11 16;41(8):1618-1636. Epub 2019 Jul 16.

Yale School of Medicine, Yale University, Connecticut, USA.

In this paper, we reflect on health intervention translations as matters of their implementation practices. Our case is methadone treatment, an intervention promoted globally for treating opioid dependence and preventing HIV among people who inject drugs. Tracing methadone's translations in high-security prisons in the Kyrgyz Republic, we notice the multiple methadones made possible, what these afford, and the onto-political effects they make. We work with the idea of the 'becoming-methadone-body' to trace the making-up of methadone treatment and its effects as an intra-action of human and nonhuman substances and bodies. Methadone's embodied effects flow beyond the mere psycho-activity of substances incorporating individual bodies, to material highs and lows incorporating the governing practices of prisoner society. The methadone-in-practice of prisoner society is altogether different to that imagined as being in translation as an intervention of HIV prevention and opioid treatment, and has material agency as a practice of societal governance. Heroin also emerges as an actor in these relations. Our analysis troubles practices of 'evidence-based' intervention and 'implementation science' in the health field, by arguing for a move towards 'evidence-making' intervention approaches. Noticing the onto-politics of health intervention translations invites speculation on how intervening might be done differently.
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http://dx.doi.org/10.1111/1467-9566.12978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700701PMC
November 2019

Evidence-making hepatitis C cure: Towards a science that knows more carefully.

Int J Drug Policy 2019 10 12;72:40-46. Epub 2019 Jul 12.

Centre for Social Research in Health, University of New South Wales, Australia.

There has been some controversy concerning the curative potential of new treatments for hepatitis C. This follows a systematic review of the Cochrane Collaboration questioning the clinical benefits of direct-acting antivirals (DAAs). This controversy has been debated as a matter of methods regarding how best to evidence treatment in an evidence-based medicine (EBM) approach. Drawing from science and technology studies (STS), we offer an alternative perspective. We propose a different way of thinking with evidence; one which treats 'evidencing as performative'. Using the Cochrane review and its linked published responses as a resource for this analysis, we consider how hepatitis C cure is differently made-up through the knowledge-making practices performing it. We show how matters of apparent fact in evidence-based science are enacted as matters of clinical, social and ethico-political concern. We notice hepatitis C cure as a fluid object in negotiation. We highlight the limits of current debate to advocate a more critical and careful practice-based approach to knowing hepatitis C cure. This calls upon public health researchers to reflect on the performative work of their evidencing. We propose a 'more-than' EBM approach which treats 'evidence-based' science as an 'evidence-making intervention'. We consider the implications of such an approach for the evidencing of public health interventions and for treating hepatitis C in the DAA era of 'viral elimination'.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.023DOI Listing
October 2019

'Just another vial…': a qualitative study to explore the acceptability and feasibility of routine blood-borne virus testing in an emergency department setting in the UK.

BMJ Open 2019 05 1;9(4):e024085. Epub 2019 May 1.

Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.

Objectives: Increased test uptake for HIV and viral hepatitis is fast becoming a health priority at both national and global levels. Late diagnosis of these infections remains a critical public health concern in the UK. Recommendations have been issued to expand blood-borne virus (BBV) testing in alternative settings. Emergency departments (EDs) offer a potentially important point of testing. This paper presents findings from a qualitative study which aimed to explore the acceptability and feasibility of a routine opt-out combined BBV testing intervention implemented at an inner London ED.

Methods: We conducted 22 semistructured interviews with patients and service providers in the ED over a 4-month period during the intervention pilot. A grounded analytical approach was employed to conduct thematic analysis of qualitative study data.

Results: Core interrelating thematic areas, identified and analytically developed in relation to test intervention implementation and experience, included the following: the remaking of routine test procedure; notions of responsibility in relation to status knowledge and test engagement; the opportunity and constraints of the ED as a site for testing; and the renegotiation of testing cultures within and beyond the clinic space.

Conclusion: Study findings demonstrate how relational and spatial dynamics specific to the ED setting shape test meaning and engagement. We found acceptability of the test practice was articulated through narratives of situated responsibility, with the value of the test offset by perceptions of health need and justification of the test expense. Participant accounts indicate that the nontargeted approach of the test affords a productive disruption to 'at-risk' identities, yet they also reveal limits to the test intervention's 'normalising' effect. Evaluation of the intervention must attend to the situated dynamics of the test practice if opportunities of an opt-out BBV test procedure are to be fully realised. Findings also highlight the critical need to further evaluate post-test intervention practices and experiences.
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http://dx.doi.org/10.1136/bmjopen-2018-024085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501954PMC
May 2019

"Towards eliminating viral hepatitis": Examining the productive capacity and constitutive effects of global policy on hepatitis C elimination.

Int J Drug Policy 2020 06 8;80:102419. Epub 2019 Apr 8.

Centre for Social Research in Health, UNSW Sydney, Australia.

In 2016 the World Health Organization published the first global health strategy to address viral hepatitis, setting a goal of eliminating viral hepatitis as a major public health threat by 2030. While the field has been motivated by this goal, to date there has been little critical attention paid to the productive capacity and constitutive effects of this policy. How is governing taking place through the mechanism of this global strategy, and how are its goals and targets shaping what is made thinkable (indeed, what is made as the real) about hepatitis C and its elimination? And with what effects? Taking the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 as a text for analysis, we draw on poststructural thinking on problematisation and governmental technologies to examine how 'elimination' - as a proposal - constitutes the problem of hepatitis C. We critically consider the conceptual logics underpinning the elimination goal and targets, and the multiple material-discursive effects of this policy. We examine how governing takes place through numbers, by analysing 'target-setting' (and its accompanying practices of management, quantification and surveillance) as governmental technologies. We consider how the goal of elimination makes viral hepatitis visible and amenable to structuring, action and global management. Central to making viral hepatitis visible and manageable is quantification. Viral hepatitis is made as a problem requiring urgent global health management not through the representation of its effects on bodies or situated communities but rather through centralising inscription practices and comparison of estimated rates. It is important to remain alert to the multiple makings of hepatitis C and draw attention to effects which might be obscured due to a primary focus on quantification and management. To do so is to recognise the ontopolitical effects of governmental technologies, especially for communities 'targeted' by these strategies (including people who inject drugs).
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http://dx.doi.org/10.1016/j.drugpo.2019.02.008DOI Listing
June 2020

Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review.

BMC Health Serv Res 2019 Mar 8;19(1):152. Epub 2019 Mar 8.

The National Institute for Health Research: Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, UK.

Background: Prisons represent a unique opportunity to diagnose blood-borne viruses. Opt-out testing is receiving increasing interest, as a result of mounting evidence to suggest that the manner in which a test offer is delivered, affects test uptake. Although the effectiveness of opt-out testing within the prison setting has been established, robust explanations are required for the variation in outcomes reported.

Methods: Rapid-realist review methodology was used to synthesise the literature on prison-based opt-out testing. The review was carried out in three phases. Phase one: An expert panel provided literature relevant to the implementation of opt-out testing within the English prison estate. Unstructured searches were also conducted to identify other social programmes where "opt-out" had been used to increase uptake. Phase two: a systematic search of six peer-review and five grey literature databases was carried out to identify empirical data on opt-out testing within the prison setting. Phase three: Additional non-exhaustive searches were carried out to identify literature that reinforced emergent concepts. The development of programme theory took place with each iteration and was validated in consultation with stakeholders.

Results: Programme theory was constructed for two outcomes: the proportion of intake offered a test and the proportion offered that accepted testing. The proportion of intake offered testing was influenced by the timing of the test offer, which was often delayed due to barriers to prisoner access. The decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner's personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer.

Conclusions: This review identified important implementation considerations that moderate the effectiveness of opt-out testing programmes. It also highlighted a lack of appreciation for the theoretical underpinnings of opt-out programmes and tension around how to implement testing in a manner that adheres to both default theory and informed consent. It is anticipated that results will be used to inform the design and implementation of subsequent versions of these programmes, as well as catalyse further in-depth analysis into their operation within the unique context of prison.

Review Registration: CRD42017068342 .
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http://dx.doi.org/10.1186/s12913-019-3970-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408812PMC
March 2019

Integrated and differentiated methadone and HIV care for people who use drugs: a qualitative study in Kenya with implications for implementation science.

Health Policy Plan 2019 Mar;34(2):110-119

Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK.

Integrating methadone and HIV care is a priority in many low- and middle-income settings experiencing a growing challenge of HIV epidemics linked to injecting drug use. There is as yet little understanding of how to integrate methadone and HIV care in these settings and how such services can be implemented; such a gap reflects, in part, limitations in theorizing an implementation science of integrated care. In response, we qualitatively explored the delivery of methadone after its introduction in Kenya to understand integration with HIV care. Semi-structured interviews with people using methadone (n = 30) were supplemented by stakeholder interviews (n = 2) and participant observation in one city. Thematic analysis was used, that also drew on Mol's logic of care as an analytical framework. Respondents described methadone clinic-based care embedded in community support systems. Daily observed clinic care was challenging for methadone and stigmatizing for HIV treatment. In response to these challenges, integration evolved and HIV care differentiated to other sites. The resulting care system was acceptable to respondents and allowed for choice over locations and approaches to HIV care. Using Mol's logic of care as an analytical framework, we explore what led to this differentiation in integrated care. We explore co-production and experimentation around HIV care that compares with more limited experimentation for methadone. This experimentation is bounded by available discourses and materials. The study supports continued integration of services whilst allowing for differentiation of these models to adapt to client preferences. Co-location of integrated services must prioritize clinic organization that prevents HIV status disclosure. Our analysis fosters a material perspective for theory of implementation science and integration of services that focuses attention on local experimentation shaped by context.
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http://dx.doi.org/10.1093/heapol/czz002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481284PMC
March 2019

"A more accurate understanding of drug use": A critical analysis of wastewater analysis technology for drug policy.

Int J Drug Policy 2019 01 26;63:47-55. Epub 2018 Nov 26.

Centre for Social Research in Health, UNSW Sydney, Australia; London School of Hygiene and Tropical Medicine, UK.

The idea of identifying and monitoring urinary excretion of illicit drugs and their metabolites in wastewater has been seen by governments and international organisations as 'promising'. It is claimed that such approaches will enable governments to effectively direct resources to priority areas, monitor the progress of demand and supply reduction strategies, as well as identify emerging trends. Drawing on poststructural approaches to policy analysis and insights from science and technology studies, we consider how the technology of wastewater analysis may be seen as a kind of proposal with productive capacity and constitutive effects. Through this analysis, we seek to raise ontopolitical questions about the production of data by interrogating the claims to 'accuracy' promoted in wastewater analysis, and illuminating the assumptions underpinning such pursuits. By taking an approach which sees method as performative rather than as descriptive of a pre-existing reality, we consider how wastewater analysis enacts realities into being in the drugs field. Taking Australia's National Wastewater Drug Monitoring Program as a case example, we argue that wastewater analysis constitutes drug use as measurable, countable and comparable and, in doing so, enacts a homogenous drug using population in a bounded geographical space, with implications for drug policy. Furthermore, the claim to 'accuracy' constitutes people who use drugs as lacking in knowledge and unaware, and relates to a range of practices which work to continually re-produce people who use drugs as criminal, untrustworthy and in need of surveillance. Through this analysis, we seek to generate critical discussion about practices of 'evidence-making', the privileging of 'scientific data' in drug policy processes (especially as it relates to population prevalence of drug use), and the hitherto unexamined effects of wastewater analysis for drug policy.
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http://dx.doi.org/10.1016/j.drugpo.2018.10.011DOI Listing
January 2019

DIY HIV prevention: Formative qualitative research with men who have sex with men who source PrEP outside of clinical trials.

PLoS One 2018 23;13(8):e0202830. Epub 2018 Aug 23.

Homerton University Hospital NHS Foundation Trust, London, United Kingdom.

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to 'DIY PrEP', purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202830PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107262PMC
February 2019

Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes.

Int J Drug Policy 2018 10 6;60:24-32. Epub 2018 Aug 6.

London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, United Kingdom.

Background: The development of simplified and effective hepatitis C (HCV) pharmaceuticals enables treatment scale up among the most marginalised. This potentiates a promise of viral elimination at the population level but also individual level clinical and non-clinical benefits. Reports of transformative non-clinical outcomes, such as changes in self-worth and substance use, are primarily associated with arduous interferon-based treatments that necessitate intensive care relationships. We consider the implications of simplified treatment provision in the era of direct acting antivirals (DAAs) for the realisation of non-clinical benefits.

Methods: We draw on qualitative data from ethnographic observations and longitudinal interviews with people receiving (n = 22) and providing (n = 10) HCV treatment in London during a transition in HCV biomedicine. First generation DAAs in conjunction with interferon were standard of care for most of this time, with the promise of simplified treatment provision on the horizon.

Findings: Patient accounts of care accentuate the transformative value of interferon-based HCV treatment derived through non-clinical benefits linked to identity and lifestyle change. Such care is constituted as extending beyond the virus and its biomedical effects, with nurse specialists positioned as vital to this care being realised. Provider accounts emphasise the increased pharmaceuticalisation of HCV treatment; whereby care shifts from the facilitation of therapeutic relationships to pharmaceutical access.

Conclusion: HCV care in the interferon-era affords identity transformations for those receiving and providing treatment. Biomedical promise linked to the increasing pharmaceuticalisation of HCV treatment has disruptive potential, shifting how care is practised and potentially the realisation of non-clinical treatment outcomes.
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http://dx.doi.org/10.1016/j.drugpo.2018.07.015DOI Listing
October 2018

A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK.

BMC Infect Dis 2018 06 19;18(1):281. Epub 2018 Jun 19.

London School of Hygiene and Tropical Medicine, London, UK.

Background: Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK.

Methods: A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants' responses.

Results: We report an overarching theme of 'tension' in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation.

Conclusions: The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.
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http://dx.doi.org/10.1186/s12879-018-3185-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006927PMC
June 2018

Fentanyl self-testing outside supervised injection settings to prevent opioid overdose: Do we know enough to promote it?

Int J Drug Policy 2018 08 12;58:31-36. Epub 2018 May 12.

Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre for Social Research in Health, University of New South Wales, Australia.

Since 2013, North America has experienced a sharp increase in unintentional fatal overdoses: fentanyl, and its analogues, are believed to be primarily responsible. Currently, the most practical means for people who use drugs (PWUD) to avoid or mitigate risk of fentanyl-related overdose is to use drugs in the presence of someone who is in possession of, and experienced using, naloxone. Self-test strips which detect fentanyl, and some of its analogues, have been developed for off-label use allowing PWUD to test their drugs prior to consumption. We review the evidence on the off-label sensitivity and specificity of fentanyl test strips, and query whether the accuracy of fentanyl test strips might be mediated according to situated practices of use. We draw attention to the weak research evidence informing the use of fentanyl self-testing strips.
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http://dx.doi.org/10.1016/j.drugpo.2018.04.017DOI Listing
August 2018
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