Drug treatment and the conditionality of HIV treatment access: a qualitative study in a Russian city.

AIMS: We explored social factors affecting access to antiretroviral HIV treatment (ART) among people who inject drugs (PWID) in a Russian city with a large HIV burden. DESIGN: Qualitative interview study. SETTING: Community settings in Ekaterinburg, Russian Federation. PARTICIPANTS: 42 PWID living with HIV and 11 health practitioners. MEASUREMENTS: Thematic analyses of in-depth qualitative interviews. FINDINGS: Access to ART was felt by participants to be contingent upon their capacity to demonstrate a commitment to becoming 'drug free'. We identify, across interview accounts, a treatment access narrative of 'treat drugs before HIV'. This narrative is upheld by ART providers' concerns to maximize clinical outcome in the face of adherence doubts, as well as by would-be patients' perceptions of expectations placed upon them by the treatment system and their own doubts regarding treatment engagement. This has the effect of reproducing a habit of ART delay and disengaging people from the treatment system. Difficulties accessing ART, and the perceived rationing of treatment on account of untreated drug use, were experienced as 'moral discipline' for falling short of treatment 'deservedness'. Participants describe a 'Catch 22' system, where they are invited to treat their drug use in a setting where effective drug treatment was perceived as unavailable. CONCLUSIONS: Inadequate drug treatment practices act as structural obstacles to realizing HIV treatment. Evidence internationally suggests that effective drug treatment, including opioid substitution therapy, improves access and adherence to antiretroviral treatment among people who inject drugs. Policy shifts are urgently needed in this setting to enable systemic improvements to drug treatment, especially given large HIV treatment demand.