title: Safe havens and rough waters: networks, place, and the navigation of risk among injection drug-using Malaysian fishermen.
abstract: BACKGROUND
  HIV prevalence among Malaysian fishermen is ten times that of the general population. Fishing boats are a key place where drug use occurs, but we know little about how these environments shape HIV risk behaviour. Utilizing Rhodes' 'risk environment' framework, we assessed drug use contexts and how characteristics of place associated with fishing and fishermen's social networks served as key axes along which drug use and HIV risk behaviour occurred.
  
  
  METHODS
  Data were collected during 2009-2011 in Kuantan, a fishing port on the eastern coast of Malaysia, and include 28 in-depth interviews and 398 surveys collected using RDS. Logistic regression was used to determine the effect of occupational, network and risk environment characteristics on unsafe injection behaviour and access to clean needles/syringes; qualitative data were coded and analyzed thematically.
  
  
  RESULTS
  Drug injecting was common and occurred on boats, often with other crewmembers. Captains and crewmembers were aware of drug use. Unsafe injection practices were significantly associated with having a larger proportion of drug injectors in network (OR=3.510, 95% CI=1.053-11.700) and having a captain provide drugs for work (OR=2.777, 95% CI=1.018-7.576). Size of fishermen network (OR=0.987, 95% CI=0.977-0.996), crewmembers' knowledge of drug use (OR=7.234, 95% CI=1.430-36.604), and having a captain provide drugs for work (OR=0.134, 95% CI=0.025-0.720) predicted access to clean needles/syringes. Qualitative analyses revealed that occupational culture and social relationships on boats drove drug use and HIV risk.
  
  
  CONCLUSIONS
  While marginalized in broader society, the acceptance of drug use within the fishing community created occupational networks of risk. Fishing boats were spaces of both risk and safety; where drug users participated in the formal economy, but also where HIV risk behaviour occurred. Understanding the interplay between social networks and place is essential for developing HIV prevention and harm reduction policies appropriate for the unique needs of this fishing population.
authors: Department of Sociomedical Sciences, Columbia University, New York, NY, USA. Electronic address: bsw2110@columbia.edu.
authors: Brooke S
authors: BS
authors: West
authors: Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors: Martin
authors: M
authors: Choo
authors: Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA.
authors: Nabila
authors: N
authors: El-Bassel
authors: Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA.
authors: Louisa
authors: L
authors: Gilbert
authors: Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA.
authors: Elwin
authors: E
authors: Wu
authors: Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors: Adeeba
authors: A
authors: Kamarulzaman
mesh_terms: D000328:Adult; D000368:Aged; D003625:Data Collection; D005398:Fisheries; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D016015:Logistic Models; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009339:Needles / Q000592:standards; D016272:Occupational Health; D015279:Organizational Culture; D012309:Risk-Taking; D012767:Ships; D012919:Social Behavior; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*; D055815:Young Adult
keywords: Fishermen; HIV; Injection drug use; Malaysia; Place; Risk environment; Social networks