What do needle and syringe programs do? An examination of the relations of service provision, engagement, and people who inject drugs.

Title: What do needle and syringe programs do? The relations of service provision, engagement, and people who inject drugs. Background: Needle and syringe programs (NSPs) are harm reduction interventions that distribute sterile injecting equipment to people who inject drugs, to prevent the transmission of blood-borne viruses (BBVs) such as hepatitis C. NSPs affect the material conditions of drug consumption, transforming drug use from harmful events into enactments of harm reduction and biopolitical citizenship. Recent critical drugs and alcohol scholarship has used a relational, assemblage approach, incorporating human and non-human actors, to develop analyses of drugs, drug use, and drug-related harm. Aim: To develop new understandings, informed by an assemblage framework, of what NSPs do, in addition to and alongside the distribution of sterile injecting equipment. Methods: This research utilised a qualitative methodology. Semi-structured, in-depth interviews were conducted with 31 clients and 12 workers from six NSPs in Western Sydney, an area with pockets of social disadvantage. Interview transcripts were coded and analysed using an assemblage framework, with the aid of qualitative data analysis software. Findings: Relations not directly related to obtaining injecting equipment were entangled in client service engagement, including basic material and social needs. Service engagement presented opportunities for demarginalisation through supportive, non-stigmatising encounters between clients and NSP workers. Additionally, NSP workers experienced discrimination from non-NSP health workers, which obstructed service provision. NSP workers balanced emotional labour, rapport-building and impression management, to facilitate better relations with health workers and improve the conditions of service provision. Conclusions and recommendations: This thesis provides sophisticated accounts of the contexts of NSP provision that develop better understandings of the realities, strengths, and limits of NSPs. The enactment of harm is an outcome of a given assemblage, irreducible to a single relation. Responsive, localised interventions can therefore be developed by addressing relations deemed ‘outside’ constructions of harm reduction as BBV prevention. Developing new measures and indicators for ‘outside’ relations will enhance understandings of the dynamics of service provision, and advance new possibilities for improving client health and well-being. This approach requires attention to how NSP and client capacities to engage with each other are enacted and constrained through social, political, and economic relations, the politics of service provision, and the opportunities and risks of neoliberal subjectivity