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Official websites use. Share sensitive information only on official, secure websites. Correspondence to Dr Lakshmi Ganapathi; Lakshmi. We assessed perspectives of young PWID to guide development of youth-specific services. PWID were eligible to participate if they were between 18 and 35 years, had initiated injection as adolescents or young adults and knew adolescent PWID in their networks. Thematic analysis was used to develop an explanatory model for service engagement in each temporal stage across the injection continuum. Injection initiation followed non-injection opioid dependence. Lack of services for non-injection opioid dependence was a key gap in the preinjection initiation phase. Lack of knowledge and reliance on informal sources for injecting equipment were key reasons for non-engagement in the peri-injection phase. Additionally, low-risk perception resulted in low motivation to seek services. Psychosocial and structural factors shaped engagement after established injection. Housing and food insecurity, and stigma disproportionately affected female PWID while lack of confidential adolescent friendly services impeded engagement by adolescent PWID. Development of youth-specific services for young PWID in India will need to address unique vulnerabilities and service gaps along each stage of the injection continuum. Scaling-up of tailored services is needed for young female PWID and adolescents, including interventions that prevent injection initiation and provision of confidential harm reduction services. This is among the first studies in India to use qualitative methods to explore the engagement of young people who inject drugs PWID in harm reduction services. The recruitment of young PWID from multiple cities representing older and emerging injection drug use epidemics is a methodological strength. Our recruitment methods were limited, however, to young PWID already receiving services at integrated care centres and did not include young PWID who were completely unlinked with services. Our recruitment methods also did not include adolescent PWID under the age of 18, another limitation. There are approximately The limited available data in several countries indicate that adolescent and young adult PWID bear a disproportionate burden of new infections. India has the largest number of opioid users in the world. However, recent attention has been drawn to rapidly growing IDU with pharmaceutical opioids and burgeoning HIV and hepatitis C epidemics in states outside the Northeastern region previously considered to have low HIV prevalence. There is paucity of data on the availability, accessibility and effectiveness of youth-specific services for young PWID in India. In addition, their inputs can guide the types of services most likely to engage them. We chose these cities as our prior research identified low median age of injection initiation, corroborated also by other studies that have described youth susceptibility to IDU in these states. The Northeast region has been characterised for decades by high unemployment among young people despite high educational levels. In contrast, an insurgency that arose in the late s and early s in Punjab has long abated and the state has experienced decline in its relative affluence only recently, due to a stagnating agricultural sector and minimal industrialisation. The epidemiology of drug use and HIV also varies in these states. Services for female PWID, while less developed than those for men, have been in existence longer in the Northeastern states. In contrast, reports of IDU among women in Punjab have emerged recently, 27 and gender-specific services are underdeveloped. We employed purposive sampling using combined criterion and maximum variation strategies. Further, we defined young adulthood as the period between 18 and 24 years. Therefore, we initially sought to exclusively recruit young adult PWID ie, those between 18 and 24 years. While all male PWID were receiving OST, we intentionally recruited participants that varied in visit attendance levels regular or irregular. Given limited female-only programmes, we recruited all female participants from a single site in Imphal, a few of whom were receiving OST. Participants were provided a small monetary compensation for their time and transport needs. All PWID and providers who were approached accepted participation in the study. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. We used a grounded theory approach 30 to explore three areas specific to adolescent and young adult PWID, with the goal of developing an explanatory model for engagement with services: 1 injection initiation experiences, 2 motivating factors and perceived barriers to receiving harm reduction services and 3 perspectives on service gaps and types of interventions needed. Open-ended questions included in the FGDs were initially pilot tested in two study sites Aizawl and Amritsar. Feedback was sought from PWID and providers who participated in the pilot FGDs regarding language, cultural sensitivity and pertinent questions to be additionally included in the final FGD interview guide. Staff FGDs comprised 2—4 participants. Information regarding the study was provided ahead of the FGDs during recruitment of potential participants which was reiterated again before FGDs were conducted. Participants were informed that their participation was voluntary and that decision either to participate or not would not impact their care. Participants were also informed of various safeguards to maintain their confidentiality. All participants provided verbal informed consent and were offered a small monetary incentive for their participation. With assistance from facilitators trained in qualitative research, FGDs were conducted by LG corresponding author in the local dialect. LG introduced herself as a paediatric infectious diseases physician seeking to develop services for young PWID in India. Each FGD took place until saturation of themes was achieved this typically occurred over a span of 1—1. FGDs were audiorecorded, transcribed and translated to produce deidentified English-language transcripts. FGD guides contained semistructured questions to obtain narrative information in the three areas of interest. Motivating factors and perceived barriers to receiving harm-reduction services were explored by asking about personal experiences in relation to peri-injection initiation ie, the time immediately before and after injection initiation and after established injection behaviour. Finally, participants were asked to identify gaps in services for young PWID and suggest services and interventions to increase engagement in relation to temporal stages of injection: preinjection initiation, peri-injection initiation and after established injection behaviour. Deductive and inductive approaches were used for thematic analysis. We created an initial coding scheme based on collective discussion within the research team and findings from similar studies. Two researchers LG and CM independently coded FGD transcripts, and met to identify new themes, reconcile discrepancies, and produce a final coding scheme online supplemental table 1. Transcripts were evaluated by a third researcher AH who arbitrated the code reconciliation process and ensured consistency in code application. These descriptive statistics facilitated identification of common or salient themes and examination of relative differences in the prominence of specific themes by gender and across study sites. We then conducted a deeper analysis with the goal of identifying interconnections between themes to develop a broader explanatory model for understanding engagement in services at each stage of injection. To do this, we re-evaluated common or salient themes from our initial coding to ascertain larger categories into which themes clustered. Staff participants included programme managers, OST nurses, counsellors and outreach staff. Injection initiation experiences differed by gender and the time in life at which they were experienced. Representative quotes are presented in table 2. Across all sites, structural factors were among the major drivers of injection initiation for adult male PWID. Easy availability of drugs was cited as a key reason for drug use injection and non-injection in all cities table 2 , Q1. They are there to earn money. Nobody monitors them on a regular basis. Most of the drugs are manufactured for good medical use but they drug stores are using them for different purposes. Ideal thing is that nobody can get medicine without doctor prescription but in India everybody is doctor of their own. In all cities, personal factors shaped injection initiation during adolescence. Participants described being inherently curious in adolescence, leading to experimentation with drugs Q6. Transitions eg, between school years were periods of adolescent vulnerability Q8—9. Participants identified poor school attendance and drop-out as increasing drug use risk in some individuals. In Aizawl, where all PWID had at least secondary school education and were in school during injection initiation, many noted that it was drug use that led them to drop-out Q9. Specific psychosocial factors unique to adolescents, such as the desire to belong in peer groups Q10 , as well as notions of what constituted masculinity and normal behaviour Q11 , also contributed to injection initiation in all cities. Participants described adolescent injection networks as comprised of peers with slightly older members initiating younger users. Mobile phones and the internet fostered connectedness in networks. Participants in all cities described a rapid transition from non-injection to injection behaviour due to the development of drug tolerance and the need for economic efficiency. Specific to the northeastern states, although participants noted that the easy availability of heroin facilitated initiation to injection directly without a preceding period of non-IDU , participants indicated that the vast majority of young PWID in their networks had transitioned to injection after using pharmaceutical opioids and heroin via other routes. Participants described adolescents as initiating and continuing injection in locations where they would not be identified by family members ie, hotspots and peddler joints. Pharmacies were described as the primary sources of needles and syringes for male adolescents. Female PWID and staff described psychosocial factors as almost exclusively driving injection initiation among young women. While female participants described trajectories of adolescent experimentation that were similar to those described by male PWID, they also described stigma related to divorce and widowhood as leading to depression and subsequent drug use among older women Q Across all ages, drug use in women occurred in the context of differential power structures in relationships. Women related experiences of being introduced to drugs by their husbands or boyfriends, for whom they often procured drugs Q13— PWID who were sex workers described a vicious cycle of sex work and drug use. Women depended on informal sources, including partners, to obtain injecting equipment and drugs. Motivating factors for receiving harm reduction services did not vary by gender, therefore their findings are described together. In contrast, barriers to receiving and being retained in harm reduction services varied considerably by gender and the time of life in which they were experienced, so we describe these barriers separately for adult male PWID, female PWID, and adolescent PWID. Related quotations are presented in tables 3—5. PWID across all sites described personal factors as major reasons for engaging in harm reduction services, particularly OST. These included motivation stemming from experiencing injection-related health complications table 3 , Q15 , fear of death after witnessing overdose Q16 , and the fear of acquiring infections such as HIV Q In many cases, it was an immediate need to ameliorate withdrawal symptoms in the context of financial constraints that pressed many to seek OST Q18— Conversely, participants who received OST regularly described benefits such as diminished urge to inject, lack of withdrawal symptoms, and improved physical health Q20— Deteriorating personal relationships with family members was the single most frequently cited psychosocial reason to seek OST Q22 ; the desire to be accepted by their families and communities was universal Q23— Conversely, improved social acceptance and financial independence served as motivators to remain engaged Q Male PWID specifically described encouragement of members in their networks as key reasons for seeking services. Encouragement from staff was also cited as a reason to remain engaged with services Q I was coming home every day at 11 or 12 at night with high drug influence. Then I come to know about OST and decided to start it. In all cities, the main reason described for not accessing SSP was the convenience of needle sharing table 4 , Q For example, staff described lack of access to clean needles and syringes during periods of withdrawal as a key factor for PWID choosing to share needles rather than access SSP Q Both structural and psychosocial factors served as major barriers to receiving OST. With regard to structural barriers, there were considerable differences by region. Additionally, the need for daily attendance to receive OST was expressed by all participants as disruptive to social and work schedules Q31—32 , leading some to simultaneously inject while receiving OST. Others described delays and fragmented services. In the Northeastern cities on the other hand, the unpredictable occurrence of civil unrest made it necessary for OST programs to offer take-home doses. If I do not take medicine from here, then again, I need to rupees for drugs. Some boys are still using Injectables along with OST. With regard to psychosocial barriers to receiving OST, staff observed that the biggest difference between those who remained engaged and those who did not was the presence or absence of family support Q PWID across all sites generally agreed that lack of family support, and stigma from communities and healthcare workers were major challenges Q36— Some of their family members do not support them. Some of them have family disputes. They think what I am doing now is the same thing as the past. As a result, they experienced housing and food insecurity. If their families kick them out, society is not accepting of female injection drug users. With regard to personal factors, participants explained that adolescents lacked knowledge of and perceived need for harm reduction services in the peri-initiation period table 5 , Q41 because they did not envision themselves as being at-risk for negative consequences of drug use. Therefore, ongoing pleasurable experiences superseded their desire to seek harm reduction services Q42— Participants described various structural barriers for adolescent PWID. While adolescents could buy needles and syringes from pharmacies, participants described instances where prices were intentionally increased, leading to needle sharing Q Legal barriers for adolescents to receive services were implied through specific narratives. Participants at all sites described a stronger desire for anonymity among adolescent PWID when seeking services Q45— Staff described difficulties registering adolescents to access services due to a need for formal identity documents, which adolescents were unlikely to have Q They are afraid. With regard to psychosocial barriers, stigma and denial prevented family members of adolescent PWID from accompanying them to facilitate access to services Q In addition, adolescent PWID who had previous negative experiences at private centres—that generally did not employ evidence-based treatments—were subsequently dissuaded from seeking harm-reduction services Q Female PWID noted that while older women had some degree of agency in seeking services for themselves, adolescent female PWID on the other hand had little agency even if they desired engaging in services. However, they do not want to go to OST centers. Participants identified gaps and offered recommendations for services, which are summarised in table 6 and figure 1. Gaps and recommendations varied by the stage that PWID were in their injection careers. Explanatory model for engagement in services, service delivery gaps and recommendations along the injection continuum. Gaps identified in the preinjection initiation period included: 1 paucity of services for adolescents with non-injection substance use disorders, 2 failure to identify and support adolescents at risk of initiating injection and 3 lack of uniformly implemented longitudinal substance-use education programmes in high school. Participants suggested various ways to enhance school programs. These included conducting annual small group interactive educational sessions table 6 , Q , involving former PWID in education initiatives Q53 , investing in school-based counselors to address mental health issues that drive substance use in adolescents Q54 , and organising camps for adolescents with substance use issues. In addition, programs for parents were viewed as being crucial to improve awareness and reduce stigma Q Participants however noted that school-based programmes would be of limited value to out-of-school youth at greatest risk for substance use. Male PWID across all sites described the peri-injection initiation period as a period of vulnerability, despite noting that young PWID generally do not experience significant complications of drug use during this time. Participants were pessimistic about engaging adolescents in this stage, highlighting the challenges of trying to engage those with limited insight. Participants disagreed on the most effective interventions for this stage. Others felt that such interventions are unlikely to be effective, for a few reasons. This in turn led to low motivation among peer-educators to engage adolescent PWID. Overall, participants recognised that engaging adolescent PWID could only happen after establishment of trust and suggested training peer-educators in adolescent friendly methods Q The main gap identified by participants at all sites was the lack of sufficient OST centres particularly in rural areas and the need for rapid scale-up given burgeoning injection in these areas Q Some recommendations pertaining to adolescent PWID were applicable across the injection trajectory. At all sites, PWID identified the need for anonymous, adolescent-centric services, delivered ideally in locations close to hotspots Q61— Although adolescents desired anonymity, participants emphasised that family-centred services by engaging parents collaboratively would sustain adolescent engagement Q Some participants suggested alternatives to facility-based services, including exploring home-based service delivery models for adolescent PWID Q Participants also recommended using non-monetary incentives food, transport vouchers, etc to sustain engagement Q Additionally, harnessing technology mobile phone and social media to disseminate information about services was viewed to be powerful Q Most of them are using whatsapp, facebook etc. For female PWID, while the general lack of female-only facilities to provide harm-reduction services was recognised as a gap, participants noted that beyond provision of harm-reduction services, interventions need to address psychosocial determinants impacting outcomes among female PWID such as homelessness, food insecurity Q67 , and stigma and discrimination. Females need so many supports. They have no homes, no family support; most of them are homeless. In our explanatory model, we present key barriers to treatment engagement among young PWID in India, organised by stages within the injection continuum figure 1. In the preinitiation stage, the cross-cutting gap is the dearth of services and interventions aimed at preventing progression to injection, including the provision of services for non-injection opioid dependence. In the peri-injection initiation stage, lack of knowledge and dependence on informal sources of injecting equipment, combined with low risk- perception, result in low motivation to seek harm-reduction services. In the established injection stage, cumulative negative social and health consequences of IDU serve to motivate engagement with harm-reduction services, while structural and psychosocial barriers impede engagement. For adolescent PWID, lack of anonymous adolescent-friendly facilities impedes engagement across the continuum. Structural barriers eg, homelessness and psychosocial barriers eg, stigma reduce service engagement for all PWID, but disproportionately affect young female PWID. In this study conducted in three cities in India, we provide insights into the diversity of injection experiences, facilitators and barriers to service engagement, and gaps in services faced by young PWID in India. These findings, along with direct recommendations for service delivery from PWID, inform a broader explanatory model for understanding engagement in harm services by young PWID across the injection continuum. To our knowledge, there are no prior Indian studies that examine the unique vulnerabilities of young PWID along the entire injection continuum. Several motivating factors and barriers for young male PWID to receive services showed concordance with findings in other studies. A period of latency ensued after injection initiation, characterised by lack of readiness among young PWID to engage with harm reduction services and a perception that such services are not needed. Conversely, after established injection, additive negative physical and psychosocial experiences increased motivation to seek harm reduction services. At this stage of readiness, personal factors such as improved physical functioning, and psychosocial factors, in particular family support and social acceptance, facilitated engagement. Psychosocial factors impeding engagement, such as stigma and discrimination, and structural factors, such as distance to services and lack of sufficient services, have also been reported elsewhere. The tendency for young PWID to seek clean needles and syringes from convenient sources such as pharmacies and informal sources such as friends was also a manifestation of the inconvenience of receiving harm reduction services at facility-based service delivery models. Additionally, the use of vouchers such as transport vouchers as suggested by participants and initiatives such as secondary needle exchange programmes could also be of value. Some interventions suggested by our study participants to engage adolescent PWID have been proposed in other youth consultations. Participants held the view that education as well as identifying adolescents with non-injecting substance use dependence via school-based programmes would delay injection initiation and improve their linkage to services. Although historically the availability of certain forms of heroin suitable for injecting eg, Heroin No. While studies that examine the effectiveness of school-based programmes and services for substance use have been conducted in other settings and report variable benefit, 50—54 longitudinal studies that examine the impact of school-based interventions on substance use among adolescents in India are needed. It should also be noted that participants in our study acknowledged that school-based programmes were less likely to impact substance use in non-school going youth. Based on recommendations from our participants, such services may be more readily accessed if they are hassle- free, anonymous and physically close to where adolescent PWID congregate but also separate from locations where services are delivered to older PWID. Although anonymous services for adolescents were emphasised, there was also unanimous agreement on the need to develop family-centred service delivery models. Finally, our FGDs suggest that service delivery models for female PWID will need to extend beyond service provision and consider the psychosocial and structural factors that disproportionately affect women. Indeed, several prior studies among female PWID highlight the significant disparities that exist in this population. While this group was not represented directly in our study, narratives from older female PWID suggest that adolescent females possibly experience even greater stigma and possess lesser agency to seek services. The unique vulnerabilities and needs of this group are worthy of separate investigation and beyond the scope of this manuscript. Our study findings challenge some previously described methods for increasing engagement among young PWID, including use of older network members. Several studies show that adolescent PWID prefer to obtain needles and syringes from pharmacies even where SSP services exist, 41 70 71 a finding that also emerged in our study. Although diversion of pharmaceutical drugs was described at all study sites, participants did not recommend empowering pharmacists to deliver harm reduction education to young PWID, a strategy that has been explored in other countries. Our study has some limitations. While we sought to understand the needs of adolescent and young adult PWID, we were first, unable to recruit any adolescent PWID directly due to ethical constraints. Second, although we intended to recruit young adult PWID exclusively, only a third of our participants ultimately fell into this age group. The findings in this study, therefore, should be viewed as representing the perspectives of young PWID broadly, but not fully representative of the needs of adolescent PWID. Nevertheless, the narratives of our participants, particularly that of young adult PWID on the needs of adolescents and service delivery gaps adolescents experience are valuable for several reasons. While adolescent injection initiation experiences of older PWID participants could have been subject to respondent and recall bias, young adults are much more proximal to these experiences, as well as the challenges they encountered in receiving services as adolescents in the pre and peri-injection phases of the injection continuum. We also recruited participants who were already receiving services. Hence, their narratives may not be representative of PWID who have never engaged with harm reduction services. This recruitment strategy may also be a reason why we were unable to recruit a greater number of young adult PWID and further emphasise the broader challenge of engagement among this group of PWID. However, this format precluded exploring sensitive issues such as inter-personal violence including sexual violence experienced by young PWID and how these impact engagement in services. Participant narratives may also have been influenced by social desirability bias. While we observed common themes across cities in this study, our findings are not generalisable to other cities in India. Limitations notwithstanding, these findings represent some of the first qualitative data to explore engagement with services, specifically among young PWID in India. Our study also offers insights to support the development of adolescent-specific interventions and services along the injection continuum. The inclusion of multiple cities adds to the strength of our observations. Given high HIV incidence among young PWID in India, there is an urgent need to address their engagement with services in a specific, systematic and sustained manner. Services designed for young PWID need to be multi-pronged and implemented simultaneously across the injection continuum, addressing challenges in each phase. Disclaimer: Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Supplemental material: This content has been supplied by the author s. Any opinions or recommendations discussed are solely those of the author s and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Data are available on reasonable request. De-identified qualitative interview transcripts are available upon request. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. BMJ Open. Find articles by Lakshmi Ganapathi. Find articles by Aylur K Srikrishnan. Find articles by Clarissa Martinez. Find articles by Gregory M Lucas. Find articles by Shruti H Mehta. Find articles by Vinita Verma. Find articles by Allison M McFall. Find articles by Kenneth H Mayer. Find articles by Areej Hassan. Find articles by Shobini Rajan. Find articles by Sion Kim Harris. Find articles by Sunil S Solomon. No commercial re-use. See rights and permissions. Published by BMJ. Open in a new tab. Structural factors Representative quotation Easy availability of drugs Q1. Punjab is adjoining with Pakistan. Drugs are cheaper here than in other states and easily available. Drugs are like a fashion and easily available. The drug stores are selling pharmaceutical drugs to some bad medical representatives who then supply them to the peddlers — Male PWID, Aizawl Q3. Pain tablets from private de-addiction centers are also easily available. To be employed is a very big problem in our state because it is a very corrupt place. Experimentation is there, excitement is there. Teenagers easily indulge because due to their growing age they are not able to recognize what is right or wrong for them. They easily adopt those things in which their peers are involved. Some start using after finishing school. In Punjab there is trend to go abroad after 12 th grade. They do not want to do any work for the short-term. In that period, they easily indulge in drug addiction — Program manager, Amritsar Q9. I started using drugs at the end of the year after I finished the school year. It was fun, as I got to hang out with my friends and got to talk about drugs. Then I dropped out after 3—4 years. It depends on the group they associate with. Mainly to escape from family problems. After getting divorced from my husband I was unhappy and had many problems, so I took drugs. Personal factors Representative quotation Health issues Q My condition was very bad, health was poor, and family was not taking care of me. I was having abscesses on my arms. I have taken drugs for a long time. One of my friends died due to overdose. I have found big relief now with OST. Earlier I was very unhappy due to withdrawals. It OST lasts longer — better than before when I used to take four or five hits of heroin in a day. I was stealing money and other things from my own home and always fighting with my family. To escape the stigma associated with injecting heroin, and to at least feel accepted by society, plus declining money and family conditions compelled me to switch to Methadone — Female PWID, Imphal Q Since I started taking this medicine, people are more affectionate towards me, they welcome me and trust me. They even offer me jobs whenever possible. Earlier people did not trust me and did not welcome me. Now my mother trusts me since I quit drugs and started working. Here my peer group is changed. My daily schedule is better now. The boys outside they have no schedule. Personal factors Representative quotation Convenience of sharing needles Q Peddlers they keep syringes and they give needles. Some inject and just get a fix somewhere hidden in the corner of the room and if the next person comes, because of the withdrawal they just quickly wash up with any available water and push. Major challenge is the distance to some OST centers. Especially since there are not enough of them. My work starts at AM. Sometimes we have to go to meet my relatives who are in other cities, but we cannot stay there. Main problem is that we have to wait for 3 days to start medicine. One day for doctor and on second day for testing, we need to go to the government hospital. The people who decide to leave drugs may have not an issue with waiting 3 days, but others may get frustrated and think there is no advantage in waiting. Instead they will detain me and call my family and try to extort money. Also, the medication sometimes has 'OST' label but many times it does not have label. Initially some clients come regularly but when they face peer pressure among their community, they become irregular. Programs implemented by NGOs comparatively have less stigma than government setup. Clients fear that if they go to government centers they might be labeled. Staff are less cooperative there — Program manager, Amritsar Q They do not guide us properly. Personal factors Representative quotation Lack of knowledge Q Mostly teenagers are picking used needles and syringes from hot spots or they are taking it from old users. They are least bothered for use new needles and syringes. They have no concern of having about infection. They are just beginners. They are just enjoying. After some time when they realize about infections, weakness of body then they will look to some medicine or treatment. Because, even though they cannot stop using, they understand how drugs have affected their lives. Pharmacy people refuse to give needles or syringes to any stranger. Especially they refuse to teenagers. They demand around 70— rupees for it. The main problem is that the young ones do not want to be seen with older users. If we find adolescents at any active site or hotspot, we do guide them. I have visited some families before to try and persuade them to have their teenage girls who are using drugs to get HIV tested, but I was not welcomed and asked to leave. It shows lack of acceptance by families and fear of the stigma associated with drug use. They fear if someone saw them visiting OST centers they would be judged. Some distrust the rehabilitation system as they have been subjected to forceful enrolment at rehab centers by their parents — Female PWID and peer educator, Imphal. Preinjection initiation Representative quotation Small group sessions in schools Q Right now, school programs are mainly lecture based to many at the same time. Even though these programs do exist, in reality, we found the awareness spread to young people is very limited. First of all, not every school is covered, and many are left out. Second, if one school is covered this year there will be new students — a new generation — the following year. One good program would be involving those who have been using in the past should be asked to give awareness or run a course about ill effects in smaller groups — Male PWID, Aizawl Strengthening school health programmes, investing in school-based counsellors Q When we talk about adolescents there should be good counseling centers and strengthening school health programs. Every school should have position of health educator or counselor. All these are basic steps which are currently neglected — Program manager, Amritsar Parent specific programmes Q There should be two tier programs. One should be for parents for example how they empower themselves to counsel children and to avoid drugs. Second, school health programs should be better. If it is difficult to improve it then there should be one strong awareness program at school level especially for government schools in rural areas and urban or slum areas. These programs should not be lecture based. These should be interactive with students. The best way to convince them is to approach them through us ex-users. They will tell us everything. It is because we are also users. They look down on us. I think it also depends on how we approach them and talk to them. Some OST centers are newly initiated in rural areas for drug users. They are like OST centers but there is need to scale up these centers because number of drug users is very high. Idea is definitely good but how it is implemented it is very important. A place like Punjab where demand of drug use is so high it is very difficult to ensure that there should not be any misuse like selling of medicine. Anonymous programs would be best. Perhaps a separate program, a separate drop-in center and such sort just for them. Every parent knows whether their child is taking drugs or not. Some of these young people are linked but they are not coming regular basis. If, their families kick them out, society is not accepting of them — Program manager, Imphal. Provenance and peer review: Not commissioned; externally peer reviewed. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Median age of injection initiation, male PWID; range. Median age of injection initiation, female PWID; range. Some start injecting for fun, but some start injecting because they are unhappy and depressed due to unemployment, family problems, love failure — Male PWID, Amritsar. When any sort of celebration occurs with friends who are already using drugs they can start taking too — Male PWID, Imphal. Diminished withdrawal and urge to inject following OST. Improved social functioning and financial independence. Lack of access to clean equipment during withdrawal. That is a more common practice here causing rapid hepatitis C to spread among injectors — Outreach worker, Imphal. Delays in obtaining OST due to fragmented services. Whereas those who come regularly, they have a lot more family support — OST nurse, Amritsar. Stigma from family, community, healthcare workers towards male PWID. Stigma from family, community towards female PWID. Intentional increase in price of needles and syringes. Most teenagers fear their parents; they also feel shame and hesitation in the front of their parents — Male PWID, Amritsar. Desire to not be seen with older established users at harm reduction facilities. Difficulties in linkage due to need for formal identity documents for registration. So, it has to be a non-stop, uniform foundation for everyone to benefit —Program manager, Imphal. One good program would be involving those who have been using in the past should be asked to give awareness or run a course about ill effects in smaller groups — Male PWID, Aizawl. Strengthening school health programmes, investing in school-based counsellors. All these are basic steps which are currently neglected — Program manager, Amritsar. Smart initiatives are required — Program manager, Amritsar. There are thousands in one village or city — Program manager, Amritsar. We try to motivate the teenagers in a different manner, and it would be helpful to segregate them from the older lot — OST nurse, Imphal. Initially we can give them some incentive for the transportation, refreshment like tea as encouragement — Male PWID, Amritsar. Use of technology mobile phones, social media. Teenagers use mobile phones to communicate with their friends to visit hotspots, so it would be possible to persuade them via social media to come visit the drop-in centers instead — Female PWID and peer educator, Imphal. Addressing social determinants affecting female PWID.

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