Master of Arts in Sociology (MA)
The Impact of Income Assistance Design on Health and Social Service Utilization
Background: Although optimal access and adherence to modern antiretroviral therapy (ART) reduces rates of HIV-related morbidity and mortality, HIV-positive people who use illicit drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. This thesis sought to apply institutional perspectives to explore individual and organizational interactions in achieving person-centered care (PCC). This aim was met by first, systematically reviewing literature on medical and social service components linked to methadone maintenance therapy (MMT) in improving HIV care cascade outcomes, and second, in a series of empirical studies, assessing institutional-related structures associated with optimal adherence to ART among HIV-positive PWUD. These studies examined: 1) prescription of complex ART regimens, within a single domain of healthcare provision; 2) MMT-ART co-dispensation practices, within multiple domains of healthcare provision; and 3) the production of material insecurity through healthcare, social care and other institutional relationships. Methods: First, a specific search strategy was used to conduct the systematic review. Second, data from an ongoing prospective observational cohort study linked with comprehensive HIV clinical monitoring records in Vancouver, Canada was used to assess institutional-related structures. Multivariable models were built to estimate the relationships between institutional-related variables and adherence to ART, using longitudinal analytic techniques while controlling for relevant confounders. Results: The systematic review found a low number of studies that described MMT service delivery in detail and a lack of information on the effectiveness of social support within MMT programs on improving HIV care outcomes. Among HIV-positive PWUD in Vancouver, complex ART regimens, as demonstrated by greater number of pills, were significantly associated with suboptimal adherence; MMT-ART co-dispensation was positively associated with optimal adherence in a low-threshold setting; and although material insecurity was associated with institutional structures, it was not significantly associated with adherence. Conclusions: The alignment between institutional domains may potentially enhance HIV care outcomes among PWUD as they navigate institutional structures. Public health strategies that feature PCC approaches are needed to meet the complex needs of PWUD. Thus, future research should explore the application of implementation science as a potential avenue to align treatment and care services across institutions for HIV-positive PWUD.
Illicit drug markets and drug use have long been associated with violence and disorder, especially in marginalized communities. Previous research on governance frameworks in drug markets has focused on violence and other modes of control enacted by drug distributors and dealers. This work has thus far neglected the experiences of marginalized people who buy illicit drugs for their own consumption as well as informal debt structures that exist outside the dealer/buyer relationship. Drawing on interviews with 75 people who use drugs within a disadvantaged neighborhood in Vancouver, Canada, we explore the role of social ties and negotiation in navigating credit and debt associated with drug procurement as well as managing conflict within a drug market contingent on credit. Our findings show that people who use drugs strategically engage in non-violent tactics to mitigate harm linked to drug procurement and, to a greater extent, debt and default. These strategies involve cultivating reputation capital to build trust and strengthen the relationship between buyer and dealer, which stabilizes the drug market and discourages violent retaliation. We also uncover reciprocal arrangements within social networks that strengthen social cohesion in the community. Our findings highlight the significance of the broader risk environment of poverty, structural vulnerability, drug policy, and unintended harms arising from government systems of financial support for marginalized populations. Further research is urgently needed to explore programmatic and policy interventions to complement existing community processes and structures that could further mitigate harms associated with purchase and use of illicit drugs.