Exploring multilevel determinants of co-occurring violence, HIV, mental health and substance use problems

Abstract

Multiple factors contribute to co-occurring issues such as violence, HIV, and mental disorders among people who inject drugs (PWID), particularly those residing in limited resource settings. Using an ecological framework, this study explored multilevel determinants of co-occurring violence, HIV, mental health, and substance use issues among PWID. Data were collected via semi-structured in-depth interviews with 31 men and women PWID in India. Findings revealed factors at the community (e.g., stigma), interpersonal (e.g., abusive partners), and individual (e.g., financial stress) levels. Findings highlight the need for prevention and intervention programs addressing factors at multiple ecological levels to reduce comorbidity among PWID.

India is home to 850,000 people who inject drugs (PWID) who experience serious health inequities heightened by the interaction of multiple epidemics including interpersonal violence (Ambekar et al., 2019). Interpersonal violence has been found to be a major cause of morbidity and mortality among PWID (Marshall et al., 2008). The term “interpersonal violence” refers to the intentional use of physical force or power against another person by an individual or a small group of individuals. It can be physical, sexual, and/or psychological, with perpetrators being family members, intimate partners, strangers, and/or acquaintances (Mercy et al., 2017). Women and men differ in the context and nature of experiences of violence and perpetrators involved. For instance, in a study of PWID, men were more likely to experience physical violence from strangers and the police and being attacked with weapons, while women were more likely to experience violence from acquaintances, intimate partners and individuals involved in sex trade. Women were more likely to experience threats of physical violence or violence using strangulation (Marshall et al., 2008). Further, women who use drugs are at greater risk than men of experiencing sexual assault from both intimate and non-intimate partners (e.g., drug dealers, commercial clients, and police) (Gilbert et al., 2015).

The health consequences of interpersonal violence are numerous and can range from injuries and adverse psychological effects to deaths. Research reveals a strong association between interpersonal violence exposures and psychological (e.g., depression, post-traumatic stress disorder (PTSD), substance use disorders), and physical health problems, including HIV infection (Lake et al., 2015; Lopez-Martinez et al., 2018; Mitchell et al., 2016; Sarin et al., 2013). In a study of health effects of interpersonal violence exposures in 25 countries, physical intimate partner violence and/or sexual violence victimization among men and/or among women was associated with sexual risk behaviors (e.g., multiple sexual partners, HIV diagnosis), poor mental health and drug use problems (Pengpid & Peltzer, 2020). For PWID, exposures to interpersonal violence and widespread stigma and discrimination can, not only result in poor health outcomes, but also hamper access to health and harm reduction services. This may partly explain disproportionate burden of health problems among PWID. For example, while the incidence of HIV infection globally for all ages declined by 22% between 2011 and 2017, HIV infections among PWID appeared to be rising (UNAIDS, 2019). Co-occurring health problems (e.g., impact of trauma from interpersonal violence, more frequent drug use, HIV) can interact with and reinforce one another giving rise to additional problems and may explain the disproportionate burden of diseases within a population (Yang et al., 2018). PWID with co-occurring health problems are likely to have greater impairment in functioning and unmet needs for care; and, if they are able to access services, are likely to be non-adherent or less responsive to treatment services (Minh et al., 2018). Co-occurring health problems are often the downstream consequences of factors at multiple socio-ecological levels that produce a context for negative health (Yang et al., 2018) within underserved and marginalized communities such as PWID.

A social ecological framework (World Health Organization, 2020) can be used to enhance our understanding of the effects of multiple factors at societal, community, interpersonal, and individual levels which could contribute to interpersonal violence exposures and co-occurring health issues among PWID. For example, according to the World Health Organization (2020), interpersonal violence is the outcome of interaction among factors at the societal, the community, the relationship, and the individual level. At the societal level, determinants such as socio-cultural norms and beliefs can increase risk for exposures to violence. The community-level determinants of violence exposures include contexts in which social relationships are embedded (e.g., neighborhood, schools, and work-places) and can include risk factors such as existence of a local drug trade. The relationship-level determinants of exposures to violence include factors in the immediate settings such as having violent friends or acquaintances. The individual level determinants include personal factors that could increase risk for becoming a victim of violence such as psychological disorders (World Health Organization, 2020). Using a socio-ecological framework, the purpose of the study was to identify multilevel contextual determinants of violence and other co-occurring health issues among PWID with lifetime exposures to interpersonal violence. Further, the study explored whether there were gender differences in factors associated with co-occurring health issues (Table 1). The study focused on the multilevel determinants of the following co-occurring health issues: mental health, violence, HIV, and drug use.

Table 1.

Multilevel contextual determinants of co-occurring health issues among PWID.

Determinants at Different Levels	Pathways	Co-occurring Health Issues (W = Women; M = Men)
Societal-Level Determinants
Gender-Inequitable Norms	Poverty (W) Greater burden of household responsibilities (W) Avoidance of drug use disclosure (W)	Violence victimization (W) Sexual risk taking to support oneself and/or family leading to HIV risk (W)
Community-Level Determinants
Stigma and discrimination	Social Isolation Mistreatment/Violence Punitive measures by police Continued connection to drug users Avoidance of disclosure Not receiving help or receiving inadequate care	Psychological distress (W & M) Violence victimization (W & M) HIV (W & M)
Interpersonal Level Determinants
Lack of family support	Reporting to the police and exposing PWID to violence by police Communication gap	Violence victimization (W & M) Illegal activities (M) Psychological distress (M & W) Suicidal thoughts (W) Drug use initiation or increased frequency of use (W) Violence victimization (W) HIV risk (W) Drug Use Violence victimization (W)
Abusive sexual partners	Abusive partner (W) Abusive clients (W) Peer pressure/curiosity (W & M) Coping with life issues (W & M) Being in an abusive relationship (W) Having a PWID spouse (W) Drive to earn money (M)
Drug using social networks
Individual Level Determinants
Co-morbid health issues	Clouded judgment regarding need for care (M & W) Craving for drugs (M & W) Lack of awareness (W) Need to access drugs	HIV risk (M) Psychological distress (M & W) Suicidal thoughts (W) Physical health (M & W) Violence perpetration (M) Violence victimization (W) Psychological distress (M&W) Sexual risk taking leading to HIV risk (W) Violence victimization (W) Psychological distress (W) Suicidal thoughts (W) Drug use (W)
Engagement in deviant behaviors
Financial issues and unemployment	Limited job skills and opportunities Drug use, stigma and discrimination Drug use and gender inequitable norms
Exposures to violence by multiple perpetrators

Although studies have examined determinants of separate health-related issues (e.g., HIV, mental health) among PWID in India, how multilevel determinants contribute to the co-occurrence of health issues among PWID with exposures to violence have not been explored in Indian socio-cultural context. The study addresses this gap by exploring how factors at multiple ecological levels play a role in co-occurring health issues among PWID with exposures to lifetime violence (i.e., physical, sexual, and psychological abuse by family and/or community members including neighbors and the police). An understanding of factors associated with co-occurring health issues may help identify areas of prevention and intervention efforts across ecological levels for PWID in India as well as PWID with similar risk factors residing in other countries. Findings could be used to develop culturally tailored trauma-informed risk assessments and tailored treatment plans for PWID from Indian origin and well as PWID from countries with similar cultural patterns as well as similar or common risk determinants.

Materials and methods

This study utilized an exploratory research methodology to conduct in-depth interviews to identify the determinants of violence, HIV, substance use, and mental health issues among PWID in India (Creswell, 2013). Using purposive sampling technique, 31 PWID (16 men and 15 women) were recruited via invitation by staff at the Y.R. Gaitonde Center for AIDS Research and Education (YRG Care) in Dimapur, Nagaland, North-east India, where PWID were seeking services. YRG Care provides integrated HIV services including counseling and testing, clinical services for co-occurring communicable and non-communicable diseases, and referrals. Participants were eligible for an in-depth interview if they a) were over 18 years of age, b) self-reported injection drug use within the past 2 years, c) have had an intimate partner (male or female) in the past 6 months, with reported risk for HIV (i.e., multiple partners and/or had sex with a high risk partner (e.g., partner who was an injection drug user), and d) lifetime exposures to violence by any perpetrator. Violence, in this study, refers to interpersonal violence, which is defined as violence between individuals, and include family violence, intimate partner violence and community violence (World Health Organization, 2020).

After obtaining oral consent, data were collected using face-to-face interviews via a semi-structured interview guide and a demographic sheet (age, education, marital status). The questions in the interview guide focused on PWID’s stressors, impact of violence exposures, health issues, coping strategies, service needs, factors leading to initiation of substance use, mental health problems, and HIV risk behaviors. The number of participants (i.e., 31) were adequate to reach data saturation. Less than 16 participants are considered adequate to receive data saturation for homogeneous groups and 20–40 participants for heterogenous groups (Hagaman & Wutich, 2017; Sandelowski, 1995). We reached saturation when no new themes were identified from the data generation from the interviews.

Interviews were conducted by a social worker trained in trauma-informed practice in a private office at the YRG Care clinic. Interviews lasted approximately 90–120 minutes. Interviews were conducted in English or Nagamese. A YRG Care staff member who was trusted by PWID seeking services served as the interpreter for Nagamese and simultaneously translated the interviews in English. Participants were compensated 500 Indian rupees (approx. $7) for their time. Interviews were audio-recorded using a digital recorder and recordings were transcribed by professional transcriptionists. To maintain confidentiality and anonymity, all identifying information was removed from the transcripts. All study procedures were approved by the institutional boards of the home institutions of the study investigators.

Data analysis

Data were analyzed using thematic analysis (Braun & Clarke, 2006). Two team members independently coded the transcripts. After initial reading and manual open coding of transcripts, data were organized in excel spreadsheet for analysis. Coding involved a hybrid process of inductive and deductive coding to analyze data. The process started with inductive coding to identify patterns in the data and identify themes such as gender norms and social environments. The codes with similar concepts were collapsed into themes. The themes were then organized by factors at multiple levels (i.e., community, interpersonal and individual) that were reported to have contributed to co-occurring health issues. Inconsistencies in coding were addressed in team meetings. To establish trustworthiness, we maintained an audit trail through detailed notes of thoughts and experiences, regular debriefing among the coders for reflexivity and analyst triangulation with the two coders. Credibility was established via peer debriefing, analytical triangulation as well as two team members present in the interviews and discussing the experience after each interview. These methods were also used to establish dependability and confirmability of the study findings. Analysis involved descriptions of the themes supported by illustrative quotations as well as examination of the relationship between themes and determinants across ecological levels, health issues, and gender. Lastly, we examined the relationship between themes as they were described by participants.

Results

Thirty-one PWID (15 women and 16 men) participated in the study. Men ranged in age from 26–55, with a mean age of 39 (SD = 7.25). Approximately, 38% had a high school education and 19% reported having a bachelor’s degree or more. Half of men were married and a small percentage (7.1%) reported a PWID partner. Women were on average 33.4 years old (SD = 7.19, range: 23–48). None of the women completed high school, with half of them educated up to middle school, 35.7% through primary school and 14.3% were illiterate. Most women (66.7%) were married and 78.6% of those married had a partner PWID. Further, 71.4% of women were engaged in sex work. Almost all participants reported concurrently experiencing four health issues: frequent substance use, mental health problems, HIV, and violence. Among types of violence exposures, all men and women reported experiencing community violence (i.e., abuse by community members). Almost half reported multiple forms of violence by the community, partner, and other family members. Eighty percent of women reported being a victim of intimate partner violence and 81.3% of men reported perpetration of intimate partner violence. While only a quarter of the men reported abuse by family members, more than half (53.3%) of the women had experiences of abuse by family members (i.e., parents, in-laws/relatives). Using the socio-ecological framework, we identified contextual determinants of co-occurring health issues at societal, community, interpersonal and individual levels (Table 1).

Societal-level determinant

Gender inequitable norms

Some male and female PWID shared that social norms hold women to different expectations and roles, which place them at risk of exposures to violence by their husbands, families, and communities, poor health outcomes and inability to access healthcare services. Female PWID reported having greater burden of household responsibilities than men. Most female participants reported having a male partner who also injected drugs, thus leading to a double burden of managing the household while also helping their husbands buy drugs. Many female PWID engaged in sex work to support themselves and their families, which placed them at risk for HIV. “Women with PWID male partners face more problems because they have more responsibilities for family management. Whether they earn or not, women cannot hold a sufficient amount of money in their hands because they need to also help their husbands to buy drugs” (Male, Age 42). According to some female PWID, women PWID are considered as bringing greater shame to their family and community relative to male PWID. Since women PWID are often more stigmatized than men, they hide their drug use from others which can prevent them from accessing services. “Women don’t want to disclose their drug use to others, especially to relatives and friends. People may say … being a woman, she is like that … no one will say being a man but always use the word being a woman” (Female, Age 36). Drug use placed women at risk for additional health issues, which in turn further placed them at risk for violence by their partners. “Women injecting drug users are physically weak and poor compared to men. If pregnant, baby may die because of their drug use. After miscarriage, they can face abuse by their husbands” (Male, Age 26).

Community-level determinant

Stigma and discrimination

Stigma and mistreatment by the community contributed to co-occurring health issues by exposing PWID to violence, causing mental distress, and creating numerous barriers to help-seeking and receipt of services.

Most people look down upon us. No one wants to try to understand the problem of drug use. Instead, they build hate and do not wish to communicate with us. It really affects us. People do not give us much importance or respect, even if we are trying to be very honest and respectful. We are very much hurt inside our heart

(Male, Age 55).

Almost all men reported experiencing stigma, discrimination and rejection by community members leading to isolation and distress. Community attitudes contributed to isolation, continued connection with drug using networks, exposures to violence, inability to receive help and psychological distress. Rejection by community members was perceived as a barrier to community inclusion or support: “In my colony they never give importance to people who use drugs. We are never included in their society. If we face violence, we never get help from public” (Male, Age 30). Since PWID are often rejected by friends who do not use drugs, a perceived last resort is to go back to friends who are injecting drugs. “My peers are not very friendly now, so I have to be with friends who are already involved in this. They don’t want to be with me because they feel that if they remain friends with me, they will be seen as me” (Male, Age 30).

Five men shared experiences of violence from the police. One male PWID was hospitalized because of being beaten up by the police. Another male participant shared his experience of mistreatment when he was not at fault. “Once police took me to the police station and slapped me when I failed to answer. Sometimes student union, the underground army also think that I’m a robber. They just come to me, and say, ‘Are you going to steal here?’ And then they beat me” (Male, Age 42).

Other men talked about their experiences of discrimination and violence by the community. “Community members verbally abuse us. If we do a small mistake, community members will beat us up because we are drug users” (Male, Age 30). Some felt that community perceptions of PWID contributed to their abuse. “People talk about us being dangerous. One time some guys came into my house, and they just bashed me up” (Male, Age 38).

These distressing and harmful experiences of community discrimination and violence were compounded by the limited access to services for PWID. Some men did not seek help for fear of mistreatment. In case they were HIV positive and would not get tested, it placed them at risk for HIV transmission to sexual and drug using partners. For instance, one participant mentioned:

They think that if they register in a drop-in center, their name will be revealed, and in society, their name will be spoiled since they must do HIV blood test. We are scared to do the test because if we happen to be HIV positive, then people will further discriminate against us

(Male, Age 50).

Although less frequently relative to men, women also reported stigma and discrimination as a barrier to help-seeking. “I thought that if I go to a drop-in center or hospital, people may think that I am a prostitute. This is the woman who takes drugs. That’s the reason why we hide many times and fail to go forward to seek help” (Female, Age 32). In situations of violence, women did not trust that the community would intervene or provide support. “Whenever I face violence, no one comes near me … help me out or stand on behalf of me” (Female, Age 30). Similarly, women reported structural discrimination by healthcare providers who wouldn’t adequately care for them after experiencing severe forms of violence. “One day, a partner beat me up badly and left me almost dead on the roadside. Slowly … I reached hospital. That’s the most painful experience I had in my life. All my clothes were torn. They didn’t treat me well at the hospital saying that I take drugs and I have just been doing around and that I am a prostitute” (Female, Age 32). Similar to men, these experiences of stigma and community rejection have negative impacts on women PWID’s mental health. “We feel depressed and sad when people look down upon us” (Female, Age 48).

Interpersonal-level determinants

Lack of family support

Lack of family support was described as both a determinant and consequence of substance use and related co-occurring health conditions. Some men (n = 6) shared how drug use negatively impacted their life, health, and family relationships. For example, one participant shared that due to his drug use, he could not get love and care from his family. This lack of support was reported to drive engagement in other high-risk and illegal behaviors. “I raped a lady known to me. The police caught me and then put me in jail for three years. After I came out, I just go around, and try to steal from others” (Male, Age 26). Lack of support was also reflected in some parents reporting PWID to the police. Lack of family support caused significant stress to many: “The relationship with my family members causes stress for me … I don’t talk too much with my brothers. There has been gap in communication with the family since I started taking drugs” (Male, Age 34).

Poor relationships with family created a sense of hopelessness in their ability to be successful parents. “I feel stressed because I always have problems with my family. How can I give a bright future to my children?” (Male, Age 45). Some women (n = 7) also reported lack of support by family members, spouses/relatives, which contributed to their psychological distress and increased drug use. “I feel angry and depressed because I never get love from my family members or from my in-laws … they used to beat me … this made me take more drugs” (Female, Age 48). One participant talked about her in-laws blaming her for her husband’s drug use.

Lack of family support caused significant stress and mental health problems to many. “I always think I better die, because there is no help from my family members. Nowhere to get comfort” (Female, Age 30). This participant shared how she became suicidal due to lack of family support, which ultimately led to her engaging in substance use.

When I am sick my family members never give me a helping hand. When I went to my sisters for help, they said ‘Your children are not our property. It’s your husband’s property. He needs to take care.’ Hearing all this, I just wanted to end my life. That is how I started using

(Female, Age 42).

Abusive sexual partners

Almost all women reported intimate partner violence and several reported being forced into prostitution by their male partners: “If I fail to go out for sex work and earn money, my husband beats me up … and keeps on abusing me … he sometimes forces me into having sex and threatens to sell our children” (Female, Age 32). Women who engaged in sex work often faced violence from clients, adding to the violence they were often experiencing within their households.

One customer took me promising that he will pay handsome amount of money, so I believed him and went along with him. After sex, I asked for money what he has promised. He then just tried to strangle my neck and then kick me out of the door

(Female, Age 32).

They also have limited negotiating power with their clients, which results in forced unprotected sex thus increasing their risk of HIV infection and other sexually transmitted diseases. “There are certain clients who force me not to use condom and I will be hit because of condom issue” (Female, Age 32).

Drug using social networks

Almost all (n = 14) men reported the role of peers in their initiation and continuation of drug use. The described reasons were curiosity, coping with pain, dealing with family issues, and bad school performance. One participant shared that his drive to earn money by engaging in drug trade led his drug use.

My neighbors were drug users. They told me … ‘Once you start selling all this, then we will be the customer. Why don’t you bring and sell? You will become rich.’ Earlier, I sold drugs but did not take … and then slowly I started to do drugs … then my life became dependent on illegal drugs

(Male, Age 30).

For women, the most common reasons for initiating drug use were having friends who used drugs, coping with pain or depression, having an abusive spouse and a drug using spouse. In contrast to men, only one woman reported initiation of drug use out of curiosity. Living in a high-risk environment also led to the use of drugs as a coping strategy. “In every colony, there is a peddler and a customer to buy and have the drugs. It’s not a good thing, but due to depression and craving, we all come down to have the drugs” (Female, Age 42). Living in these high-risk communities also exposed women to violence.

There are so many alcoholics … drug peddlers … in my neighborhood. Some drunk neighbors, came to my place, and shouted at me, saying that, ‘You’re staying alone at home. Where’s your husband? Your husband never comes.’ I face all this kind of abuse

(Female, Age 36).

Individual-level determinants

Co-morbid health issues

Male and female participants identified addiction and the compulsive need for obtaining and using drugs as clouding their judgment rendering them unable to protect themselves from health risks or seeking help when needed.

Some drug users are not concerned about their health. They think HIV is not a serious disease. They give importance in using drugs only. They come forward when they’re faced with severe problems only. For those who are infected with STI, if they take illegal drugs, it keeps them away from pain

(Male, Age 42).

Co-morbid health issues also exacerbated distress. “I’m stressed because I am not healthy like other people, I can’t play sports as before and now I’m weak” (Male Age 36). Substances were used to cope and temporarily alleviate psychological distress. Lack of access to drugs was very stressful and, as one participant noted, made her “more depressed when I fail to get sufficient drugs” (Female, Age 25). Women who may benefit from services for their substance use or comorbid health conditions reported not knowing about the resources available in the community. Multiple life stresses often led to suicidal thoughts. “Some women drug users reside in the home alone, without knowing the facilities of the NGOs. Some, knowingly, are not seeking help, because they are just living a reckless life, to end their life with drugs” (Female, Age 25).

Engagement in deviant behaviors

Some men (n = 8) reported engaging in risky or illegal behaviors for drug use such as stealing money from home, fighting with others and perpetration of violence against their partners. “I started stealing everything from my house to buy drugs. I even hit my brother because of money” (Male, Age 37). Four PWID mentioned that drug use caused them to be violent toward their partner. For example, one participant shared:

Whatever I earn, I invest money buying drugs. Whenever I am mad … I hit my wife. I snatch money from her … I use verbal abuse … I’ve forced sex twice because I am so dirty and smelly when I’m drunk … that’s why my wife doesn’t want to have sex or sleep with me, but I forcefully do sex

(Male, Age 42).

Financial issues and unemployment

Due to the drug use and associated stigma and discrimination, PWID are unable to access employment and become financially independent. Many male PWID (n = 9) shared that financial hardship and unemployment contributed to stress in their lives. “I am depressed because I am worried that I have no business. I cannot proceed in life because I’m helpless. I have been sitting around. I want to do something in life, but things have not been able to help me on my way like that” (Male, Age 55). Women PWID (n = 10) highlighted financial problems and the need to take care of their children as major causes of stress in their lives. Financial issues also caused them to indulge in sex work which placed them at risk for HIV. For some women, due to poverty, limited job skills and opportunities, sex trade was the only option. Some traded sex for money to buy drugs. Others traded sex to meet basic needs which often brought feelings of depression. “Because I have small children, I need to feed my children. I can’t do heavy work since I’m weak. My means of earning is through sex only. That makes me depressed, and down” (Female, Age 23). Their occupation not only placed them at risk for getting infected with HIV, but also at risk for transmitting to others.

I came to know about being HIV positive two years back … if I tell my customers that I am HIV positive, ‘Let me use condom also,’ customers used to respond, ‘Let it be.’ Even non-injection drug users will respond in that way

(Female, Age 32).

Exposures to violence from multiple perpetrators

All female participants reported lifetime exposures to multiple forms of violence from the community, partners, and family members. More than half of these women (n = 9) reported the negative impact of violence on mental health problems such as depression, loneliness, hopelessness, and suicidal thoughts. For instance, a sense of hopelessness was reflected in the following quotes: “This is not my village. If I pass away one day, it’s good if the drop-in center drops my dead body in my village, at least” (Female, Age 32).

Discussion

This study explored community, interpersonal, and individual-level determinants of co-occurring health issues among PWID in India. Many of the determinants we identified that contributed to the aforementioned co-occurring health issues among PWID in India are consistent with the fundamental social determinants of health (Hatzenbuehler et al., 2013; Link & Phelan, 1995; Phelan et al., 2004). Further, we identified gender differences in these determinants that affected PWID at different levels. These differences were particularly pronounced for violence, which was common to both men and women, yet presented differently. While men discussed their experiences of both victimization and perpetration of violence, women shared their experiences of violence victimization only. Men and women also differed in who perpetrated violence against them. For instance, while no men reported victimization by intimate partners, most women were victims of partner violence. Women were also more likely than men to have experienced sexual violence and abuse by family members. The abuse by family members may be attributed due to gender norms about appropriate behaviors for women in India (e.g., taking care of family versus engaging in drug use) (Sabri et al., 2017). The findings on gender differences are consistent with previous research showing that women are more likely to be attacked by acquaintances, partners, and sex trade clients, while men are susceptible to violence from strangers and police (Marshall et al., 2008). The mental health impact of violence may be worse for women since violence perpetrated by trusted people (e.g., intimate partner, family) and betrayal of trust in emotionally close relationships may result in hurtful emotions and poor mental health outcomes (Leary et al., 1998; Sabri, 2012; Stoicescu et al., 2019). While men in our study experienced violence victimization by community members including police, they also reported perpetration of sexual violence against their female sexual/intimate partners.

For both men and women, stigma, and discrimination increased vulnerability to co-occurring health conditions and were barriers to seeking help. Stigma can induce internalized or perceived self-stigma and can serve as an important barrier for treatment seeking behaviors among PWID (Churcher, 2013). Stigma can lead to psychological distress, depression and anxiety and risk-taking behaviors (Ahern et al., 2007; Wilson & Pant, 2010). In our study, women appeared to be more vulnerable to stigma and its consequences compared to men. This could be attributed to the Indian cultural context where women have a lower social status, are expected to assume more family responsibilities and are more likely than men to suffer from health disparities (Fikree & Pasha, 2004). Community-level programs addressing stigma and discrimination (Latkin et al., 2010) and generating awareness can reduce the negative impact of community attitudes and behaviors on the lives of PWID in India. Such programs can also help address basic needs of PWID and lead to increased help-seeking. We also found that many PWID were not aware of available services and resources in the community. Stigma and awareness campaigns should be accompanied by information about accessing resources to enable PWID who are motivated to seek support to know how to access these services.

Many of the observed gender differences may be attributed to socio-cultural norms. Indian society is based on the culture of collectivism which places importance on social/community norms and values as opposed to individual rights and concerns. Individual behaviors are often reflective of their family background, thus bringing shame to the families of PWID in the community and leading to rejection and mistreatment of PWID by their family members. Women often are expected to bear a significant part of the burden of family as well as family honor. Women largely have a subordinate position in society and are more likely to be stigmatized than their male counterparts because of their activities being considered as deviant from their traditional gender roles and expectations (Murthy, 2008).

Among PWID, drug using social networks played a role in the initiation and continuation of drug use as well as associated mental health problems. For PWID, social network members who inject drugs produce strong social ties that promote mutual injecting and create norms for risky behaviors (Tsang et al., 2015). In our study, social networks promoted drug use as a coping mechanism for life stressors. Social networks also played a role in arousing curiosity to experiment with drugs. Prior qualitative research on PWID in India has attributed initiation of injection drug use to securing belongingness to groups or identities, which included response to isolation within drug using social networks. The reasons to deciding to inject were influence of peers, pleasure-seeking, economic reason or a combination of these factors (Guise et al., 2017; Kermode et al., 2009). In this study, men were more likely than women to have initiated drug use out of curiosity. Drug use initiation in India may also be culturally linked to ideas of masculinity, with drug use a form of strategy to fill a social vacuum created by limited opportunities to meaningfully engage in adult roles within the community (Guise et al., 2017).

Beyond these societal and community-level determinants, interpersonal-level determinants such as lack of social support can also play an important role in the presence of co-occurring health conditions among PWID. Families play a very important role in health especially in a family-oriented culture such as India. Lack of family support was found to have a profound impact on PWID in the study. Because of mistreatment by their families, participants showed hopelessness, psychological distress and wanting to take more drugs. Drug use can be a precursor to lack of family support or a consequence of inadequate support. Individuals can initiate drug use to manage negative emotions and to develop social networks (Matthew et al., 2018). Thus, promoting healthy family relationships should be an important part of interventions to address co-occurring health conditions among PWID in India. Since Indian culture places importance in strength of families and communities, interventions may include strategies such as building communication skills, rule setting, addressing unhealthy family dynamics and identifying ways for improving the quality of family functioning (Matthew et al., 2018). A strong family support combined with enhancement of self-efficacy can be a strong strategy for support of recovery.

Access to positive social support networks including parents, siblings and other family members can help address issues PWID face and reduce their risk behaviors. For PWID with no families, informal social support groups such as religious organizations can be beneficial. Religion is a significant part of Indian culture and plays an important role in the lives of people in India. People often turn to religious figures for advice and support. Religious leaders can highlight the importance of responsibility toward self and family. Religious leaders can also generate awareness among people (e.g., before or after prayer service) on how families and communities can play a role in alleviating drug use by supporting PWID toward recovery and integrate them in families and communities without stigma and discrimination. Religious beliefs and spirituality can also be incorporated in treatment programs for PWID in India. Finally, individual factors such as poverty and unemployment can contribute to poor mental health, drug use as a coping mechanism, high risk behaviors and restricted healthcare engagement. Increasing opportunities for employment and alternate activities can be protective against drug use. Economic empowerment and vocational training opportunities can promote financial independence, reduce engagement in illegal activities and yield positive outcomes for both men and women.

Limitations of the study include use of self-report and recruiting all PWID from one region in the North-east India. This limits generalizability of the findings to other geographical locations. Despite these limitations, the study is an important contribution to the literature which identified multilevel determinants of co-occurring health issues (i.e., violence, HIV, substance use and mental health) among PWID in India. The findings highlight the need for multifaceted culturally congruent interventions that address needs of PWID at multiple levels. Interventions are needed that incorporate cultural beliefs and values in support toward recovery. For instance, values such as responsibility toward family and community and how PWID’s decisions to take drugs and engage in risky behaviors impact families can be beneficial. A gender-focused approach to interventions is critical to address the specific needs of men and women PWID that we identified. For instance, men PWID, in our analysis, expressed the need for more recreational services that kept them busy and also programs that provided financial independence via employment. Connecting them with employment opportunities via training in specific skills can be useful. One PWID mentioned how after recovery he received training as a peer navigator and worked with other PWID in the community to support their recovery by connecting them with services. Women PWID have unique needs which can be addressed via provision of special services such as childcare, housing, services for pregnant PWID, and empowerment programs that include vocational training opportunities. Interventions must consider the social determinants that are essential to the lived experience of PWID, such as stigma, social inclusion, and employment opportunities, in order to dismantle co-occurring health issues (Link & Phelan, 1995). These findings may inform the development and implementation of effective interventions for PWID in India as well as culturally-informed interventions for PWID of Indian origin residing in other countries. Future research is needed to develop and evaluate culturally informed interventions that address co-occurring health conditions among diverse groups of men and women PWID in India and outside India.