Structural and social determinants of healthcare avoidance among people who inject drugs in Albania

Background: In Eastern Europe and the Balkans, HIV epidemics among people who inject drugs (PWID) are shaped not only by injecting practices, but also by structural vulnerabilities, including stigma, criminalization, and barriers to healthcare access. In Albania, community-based harm reduction services have expanded, but healthcare avoidance and HIV risk persist among PWID.

Methods: This study analyzed data from an Integrated Biological and Behavioral Surveillance (IBBS) survey among PWID in Albania, using respondent-driven sampling. Bivariate analyses examined associations between social, structural, and behavioral factors and avoidance of healthcare services in the past 12 months. Multivariable logistic regression was used to identify factors independently associated with healthcare avoidance.

Results: Overall, 12.9% of participants reported avoiding healthcare services in the past year. In bivariate analyses, healthcare avoidance was strongly associated with internalized stigma, exclusion from family activities, and fear of police persecution, but not with injecting frequency or history of incarceration. In multivariable analysis, fear of police persecution emerged as the strongest independent determinant of healthcare avoidance (adjusted odds ratio [aOR] = 43.19, 95% CI: 22.20–84.04), followed by exclusion from family activities (aOR = 2.80, 95% CI: 1.55–5.07). Internalized stigma showed a positive, but reduced association, while imprisonment history and injecting behaviors were not independently associated.

Conclusions: Healthcare avoidance among PWID in Albania is driven primarily by structural and social factors rather than injecting behaviors alone. Addressing stigma and reducing the deterrent effects of policing are essential for improving healthcare engagement and HIV prevention outcomes.