The price of adherence: qualitative findings from HIV positive individuals purchasing fixed-dose combination generic HIV antiretroviral therapy in Kampala, Uganda.

Contrary to early expectations, recent studies have shown near-perfect adherence to HIV antiretrovirals in sub-Saharan Africa We conducted qualitative interviews with patients purchasing low-cost, generic antiretroviral therapy to better understand the social dynamics underlying these findings. We found that concerns for family well-being motivate adherence, yet, the financial sacrifices necessary to secure therapy may paradoxically undermine family welfare. We suggest that missed doses may be more due to a failure to access medication rather than a failure to adhere to medications, and that structural rather than behavioral interventions may be most useful to insure optimal treatment response.

Explaining the geographical variation of HIV among injection drug users in the United States.

Distinct physical and chemical types of street heroin exist worldwide, but their impact on behavior and disease acquisition is not well understood or documented. This article presents a hypothesis to explain the unequal diffusion of HIV among injection drug users in the United States by examining the distribution and use of one type of heroin--"Mexican black tar." Drawing on ethnographic, clinical, epidemiological, and laboratory data, we suggest that the chemical properties of black tar heroin promote the following safer injection practices: (1) the rinsing of syringes with water to prevent clogging; (2) the heating of cookers to promote dissolution; and (3) a rapid transition from venous injection to subcutaneous or intramuscular injections.

Buprenorphine: "field trials" of a new drug.

Buprenorphine is being introduced as a new treatment drug for narcotics addiction in the United States. The authors were asked by the National Institute on Drug Abuse to conduct a field trial to determine if buprenorphine might play a role in street markets. Because no street use of the drug existed in the United States, the authors used three sources of information: (a) "street readings" of clinical studies, (b) Internet discussion lists, and (c) research in other countries. By using an emergent style of analysis that relies on replication of patterns across disparate data sources, it was determined that buprenorphine has desirable characteristics from a street addict point of view. An evaluation of the field trial 5 years later evaluates its accuracy.

Disciplining addictions: the bio-politics of methadone and heroin in the United States.

Biomedical understanding of methadone as a magic-bullet pharmacological block to the euphoric effects of heroin is inconsistent with epidemiological and clinical data. An ethnographic perspective on the ways street-based heroin addicts experience methadone reveals the quagmire of power relations that shape drug treatment in the United States. The phenomenon of the methadone clinic is an unhappy compromise between competing discourses: A criminalizing morality versus a medicalizing model of addiction-as-a-brain-disease. Treatment in this context becomes a hostile exercise in disciplining the unruly misuses of pleasure and in controlling economically unproductive bodies. Most of the biomedical and epidemiological research literature on methadone obscures these power dynamics by technocratically debating dosage titrations in a social vacuum. A foucaultian critique of the interplay between power and knowledge might dismiss debates over the Swiss experiments with heroin prescription as merely one more version of biopower disciplining unworthy bodies. Foucault's ill-defined concept of the specific intellectual as someone who confronts power relations on a practical technical level, however, suggests there can be a role for political as well as theoretical engagement with debates in the field of applied substance abuse treatment. Meanwhile, too many heroin addicts who are prescribed methadone in the United States suffer negative side effects that range from an accentuated craving for polydrug abuse to a paralyzing sense of impotence and physical and emotional discomfort.

Theory, method, and power in drug and HIV-prevention research: a participant-observer's critique.

Why do most substance misuse and HIV-prevention researchers not practice what they preach concerning the complementarity of quantitative and qualitative methods? Why does most of the public health literature fail to address the important intellectual and political debates that substance misuse and HIV infection confronts? Why is the entire field so timid with respect to social science theory? Most drug researchers, and virtually all the anthropologists working on the subject, publicly acknowledge the need to combine quantitative and qualitative methodologies. Surprisingly, however, there are almost no successful examples of substance misuse and HIV prevention research projects that meld quantitative methods with participant-observation approaches organically. While this methodological schism also holds true for most of the social sciences more broadly, in few other fields besides that of substance misuse research is the complementarity of quantitative and qualitative methods more urgently and obviously necessary. On the one hand this methodological dialogue has practical utility for creating better public health interventions that might relieve human suffering; and on the other hand this applied dialogue has the potential for a critical, multidisciplinary, theoretical impact on academia.

The moral economies of homeless heroin addicts: confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments.

Ethnographic immersion among homeless heroin addicts in San Francisco documents far more risky practices than the public health literature routinely reports. The logics of street-based income-generating strategies and the moral economy of social networking among self-identified "dope fiends" results in almost daily shares of drug preparation paraphernalia. Public health researchers need to reconceptualize their psychological behaviorist paradigm of "individual health risk behavior" because the pragmatics of income-generating strategies and the social symbolic hierarchies of respect, identity, and mutual dependence shape risky behavior. The explanatory potentials and the applied interventions that participant-observation anthropological approaches could bring to epidemiological public health research have not been utilized effectively in the field of HIV prevention and substance use. The accuracy of quantitative public health databases and our understanding of the who/why/how/where of HIV infection could be improved by a cross-methodological dialogue with participant-observation fieldworkers and by a greater theoretical sophistication with respect to power, violence, and extreme social marginalization.