Stigma and discrimination against people who inject drugs in Serbia

Background: Stigma and discrimination against people who inject drugs (PWID) are present in many communities, but the level might vary depending on many factors. Due to stigma and discrimination, PWID often does not seek care when they need it, do not disclose substance use and thus misses opportunity for adequate care. They can also avoid harm reduction programs due to fear of being further stigmatized by police, close contacts, and even health care professionals.  This study aims to explore stigma and discrimination toward PWID, living in Belgrade, the capital of Serbia.

Methods: Data for this research were obtained from the survey conducted in Serbia in 2021 among 400 PWID people who inject drugs (average age 34.4±7.8 years). The survey instrument was the questionnaire that, among others, included a set of questions on self-stigma, anticipated and enacted stigma and discrimination in health care institutions, social protection institutions, and in the context of work and employment. To assess factors associated with stigma and discrimination we used a chi-square test with p-values <0.05 considered significant.  

Results: In the total sample, 5.5% reported anticipated stigma and discrimination as reasons for giving up on using health services. The vast majority of PWID didn’t use health services (83.3%) and social services (72.5%) in the last 12 months. Among those who did, 20.0% reported enacted stigma in health care and 20.5% in social protection institutions.   Among those who reported searching for a job or had one, 16% reported experience of losing a job or opportunity to be employed because the employer knew about their drug use, despite having better qualifications. More than half of PWID reported experience of stigma and discrimination through social contacts (54.5%) and 93.5% self-stigma. Self-stigma, anticipated and enacted stigma through social and health institutions were not statistically different according to socio-demographic characteristics such as sex, age, marital or employment status. However, experience of stigma and discrimination through social contacts was significantly higher among younger age groups (72,2% among 18-24 years old vs 43.8% among 35+ years), those living alone (68.1%) compared to those married (47.5%) and those without adequate family support compared to those with such support (59.5% vs. 42.7%). 

Conclusions:  Findings call for urgent interventions aimed at health and social care professionals to reduce stigma and discrimination toward PWID which are barriers to obtaining adequate treatment and social protection. Further qualitative and quantitative research should be conducted to get better behavioral insights and to identify individual and structural factors affecting the use of health and social services. The high prevalence of discrimination through social contacts highlights the importance of interventions at the family and community levels.