The risk environments of people who use drugs accessing two harm reduction centers in Tehran, Iran: A qualitative study

Background: Iran has developed the most robust harm reduction infrastructure in the Middle East, marked by availability of low threshold methadone maintenance treatment (MMT), needle and syringe program (NSPs), and condom distribution services. However, little is known about the socially situated risk factors that make harm reduction clients specifically those enrolled in MMT vulnerable to relapse or continued illicit drug use. In this study, we sought to understand the "risk environment" of clients enrolled in harm reduction services in Tehran, Iran. Methods: Through observation and in-depth interviews with 22 drop-in-center clients and 8 staff members from July to August 2017, we explored the risk environments of clients of two drop in centers (DICs) in Tehran. All interviews were transcribed, coded and analyzed using a qualitative thematic analysis. Results: We found that compulsory drug treatment programs, social stigma, police encounters, and difficulties in obtaining governmental identification documents, among other factors, contribute to social marginalization of DIC clients. Conclusion: Many interviewed DIC clients continued to use illicit substances (particularly methamphetamine) despite having access to methadone treatment. This study underscores the panoply of social and structural barriers that DIC clients face while attempting to engage in treatment and harm reduction services. Following the "risk environment" framework, it is essential to identify the structural factors shaping individual behaviors that perpetuate experiences of social marginalization and poor health outcomes in this population.