Faithful to What? Competing Logics of Care in a Jail-Based Harm Reduction Clinical Trial

The integration of harm reduction into U.S. criminal-legal settings represents a pivotal shift in overdose prevention policy. Recently, its integration has been formalized through federally funded clinical trials attempting to develop and test “evidence-based” practices to prevent overdose upon jail and prison release. Central to the internal validity of a clinical trial is “treatment fidelity.” Like ensuring the right compounds in a pharmaceutical drug, fidelity is usually described as the degree to which therapeutic actions, processes, and “essential elements” match up to what is specified by evidence-based program developers. Despite fidelity's proliferation as a mechanism of accountability and standardization both in clinical trials and everyday social and health services, little research has examined how researchers, practitioners, and other clinical staff experience its development and implementation. Drawing on a 2-year ethnographic study of a harm reduction clinical trial in Midwestern jails, this article examines intervention fidelity not as a neutral measurement tool, but as a contested social practice and site of ideological negotiation. To do this, we analyzed three processes through participant observation and semi-structured interviews: fidelity protocol development, fidelity training, and fidelity implementation. Using the framework of the “evidence-making intervention,” we analyze how the HaRP fidelity protocol actively reconfigured care and redistributed power within the research context. At the fidelity development stage, we examine how researchers negotiated the tension between the study's clinical imperative to promote Medications for Opioid Use Disorder (MOUD) uptake and the harm reduction mandate to prioritize participant self-determination. At the training and implementation phase, despite efforts toward flexibility, peer workers reported that adherence to fidelity requirements conflicted with their experiential expertise and experience navigating carceral systems themselves. Ultimately, this study demonstrates how fidelity frameworks can actively reconfigure harm reduction practice as usual, devaluing peer knowledge in the process.