title: Within-prison drug injection among HIV-infected male prisoners in Indonesia: a highly constrained choice.
abstract: BACKGROUND
  In Indonesia, incarceration of people who inject drugs (PWID) and access to drugs in prison potentiate within-prison drug injection (WP-DI), a preventable and extremely high-risk behavior that may contribute substantially to HIV transmission in prison and communities to which prisoners are released.
  
  
  OBJECTIVE
  This mixed method study examined the prevalence, correlates, and social context of WP-DI among HIV-infected male prisoners in Indonesia.
  
  
  METHODS
  102 randomly selected HIV-infected male prisoners completed semi-structured voice-recorded interviews about drug use changes after arrest, drug use cues within prison, and impact of WP-DI on HIV and addiction treatment. Logistic regression identified multivariate correlates of WP-DI and thematic analysis of interview transcripts used grounded-theory.
  
  
  RESULTS
  Over half (56%) of participants reported previous WP-DI. Of those, 93% shared injection equipment in prison, and 78.6% estimated sharing needles with ≥ 10 other prisoners. Multivariate analyses independently correlated WP-DI with being incarcerated for drug offenses (AOR = 3.29, 95%CI = 1.30-8.31, p = 0.011) and daily drug injection before arrest (AOR = 5.23, 95%CI = 1.42-19.25, p = 0.013). Drug availability and proximity to drug users while incarcerated were associated with frequent drug craving and escalating drug use risk behaviors after arrest. Energetic heroin marketing and stigmatizing attitudes toward methadone contribute to WP-DI and impede addiction and HIV treatment.
  
  
  CONCLUSIONS
  Frequent WP-DI and needle sharing among these HIV-infected Indonesian prison inmates indicate the need for structural interventions that reduce overcrowding, drug supply, and needle sharing, and improve detection and treatment of substance use disorders upon incarceration to minimize WP-DI and associated harm.
authors: Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Universitas Indonesia, Faculty of Nursing, Center for HIV/AIDS Nursing Research, Depok, Indonesia; University of Malaya, Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia. Electronic address: gabriel.culbert@yale.edu.
authors: Gabriel J
authors: GJ
authors: Culbert
authors: Universitas Indonesia, Faculty of Nursing, Center for HIV/AIDS Nursing Research, Depok, Indonesia.
authors: Agung
authors: A
authors: Waluyo
authors: Universitas Indonesia, Faculty of Nursing, Center for HIV/AIDS Nursing Research, Depok, Indonesia.
authors: Mariska
authors: M
authors: Iriyanti
authors: Universitas Indonesia, Faculty of Nursing, Center for HIV/AIDS Nursing Research, Depok, Indonesia.
authors: Azalia P
authors: AP
authors: Muchransyah
authors: University of Malaya, Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia.
authors: Adeeba
authors: A
authors: Kamarulzaman
authors: Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; University of Malaya, Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia.
authors: Frederick L
authors: FL
authors: Altice
mesh_terms: D000328:Adult; D001290:Attitude; D015658:HIV Infections / Q000453:epidemiology* / Q000523:psychology*; D003932:Heroin; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D008297:Male; D008691:Methadone / Q000627:therapeutic use; D009294:Narcotics / Q000627:therapeutic use; D016485:Needle Sharing; D009293:Opioid-Related Disorders / Q000534:rehabilitation; D015995:Prevalence; D011329:Prisoners / Q000523:psychology*; D011330:Prisons; D012309:Risk-Taking; D015819:Substance Abuse, Intravenous / Q000453:epidemiology* / Q000523:psychology*
chemical_list: D009294:Narcotics; D003932:Heroin; D008691:Methadone
keywords: Antiretroviral therapy; Drug injection; HIV; Indonesia; Methadone; Prisons