LAUSR

Background: Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections. Methods: We searched PubMed, EMBASE, Scopus, CINAHL, and PsycINFO from January 1, 2000, to February 18, 2021. Informed by Rhodes' "risk environment" framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; (3) consolidating descriptive themes into conceptual categories to identify higher-order analytic themes. Results: We screened 4,841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytic themes. The first analytic theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health care policies and practices, leading to negative experiences that discourage access to care; and (4) harm reduction programs, including structural barriers to effective service provision. The second analytic theme, practices of care among people who inject drugs, addresses protective strategies that people who inject drugs employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g., HIV transmission). Conclusions: Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including unregulated drug quality, criminalization, insufficient housing, limited harm reduction services, and harmful health care practices. Enabling environment interventions that address these factors could further empower people who inject drugs to protect themselves and their community.