08BACKGROUNDWomen who inject drugs are more likely to share contaminated injection equipment than are men and also have weaker accessto harm reduction services than do male drug users. This Information Brief provides basic information about women's gender-specific vulnerability to HIV infection via contaminated injection equipment, strategies for addressing the barriers women face tosafe injection, and basic tools to support women to inject themselves safely. It also includes links to KEY REFERENCES that areuser-friendly on safe-injection instruction.

WHAT ARE THE ISSUES?

Women who inject drugs tend to have riskier injectionbehaviours than men who inject drugs.

that are important tokeep in mind are:

Women tend to share injecting equipment morefrequently than men, and when women are injecting in agroup that includes both men and women, women tendto be “last on the needle.”

Many women who inject drugs have husbands or intimatepartners who also inject drugs. Women drug users maychoose to share needles with their husband or intimatepartner as a symbol of trust in the context of theirrelationship. A woman may also be reluctant to ask hermale partner to use clean injecting equipment becausethis implies a lack of trust between them. Women whoshare needles in the context of an intimate relationshipoften report using the needle after their partner.

Women who share needles in the context of an intimaterelationship often (but not always) report having theirpartner inject them. (Training Module on Female DrugUsers developed by the Eurasian Harm ReductionNetwork).

Being injected by another person is associated with higherrisk of HIV infection (due to higher likelihood of sharing

Key Gender-Specific Injection Behaviours

Women tend to share injection equipmentfrequently:

Women tend to share injection equipment witha spouse or intimate partner:

Women are more likely than men to be injectedby someone else rather than injectingthemselves:

Women are more likely to be injected byanother person than are male drug users:

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contaminated equipment). Women tend to have smallerveins than men and may be more likely to requireassistance injecting. In the context of a marriage or otherintimate relationship, a woman being injected by her malepartner may be part of their relationship. In addition,women injectors tend to have significantly weaker accessto harm reduction services that can teach safe self-injection.

Harm reduction services are critical to supportingbeneficiaries to practice safe injection and thereby reducethe likelihood of parenteral transmission of HIV viacontaminated sharing of contaminated injectionequipment. For women who inject drugs, a number of

are important to keep in mind:

decreaseswomen's access to harm reduction services and injectingequipment: Many women drug users suffer severe societaldisapproval and their fear of being exposed as a drug usermakes some women avoid drop-in-centres and dislikeand avoid buying injecting equipment.

In some cases, her partner may want to hide her drug useand he may attend services, such as NSP, himself-bringingsupplies back home for his female partner. This practice-while it does serve the useful purpose of providing criticalsupplies to women drug users-also means that womencan be cut off from direct access to services, weakeningwomen's access to and understanding of key HIVmessages, as well as to counselling and other importantHIV-related services.

Gender-specific barriers to accessing harmreduction services

Gender-specific stigma about drug use

A woman's male intimate partner or spousemay oppose her attending harm reductionservices:

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MacFarlane Burnet Institute for Medical Research and Public Health, Resource Module for Trainers: Comprehensive Responses for HIV/AIDS Prevention and Care among DrugUsers in India. 2006. p. 170Eurasian Harm Reduction Network, Developing Services for Female Drug Users: Training Module, available for download at http://www.harm-reduction.org/hub/knowledge-hub/ehrn-training-modules.htmlKatya Burns, Women, Harm Reduction, and HIV: Key Findings from Azerbaijan, Georgia, Kyrgyzstan, Russia, and Ukraine, International Harm Reduction Development Program,Open Society Institute, October 2009. http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/wmhardred20091001.pdfHunter, G.M. and A. Judd. 1998. “Women injecting drug users in London: The extent and nature of their contact with drug health services,” Drug and Alcohol Review 17:267-276.

POLICY AND PROGRAMMINGIMPLICATIONS

Women drug users need access to harm reductionservices that can address obstacles to safe injection forwomen and to instruction on safe self-injection. Thismeans:

at functioning male-dominated drop-in-centres, such as a women-only time, awomen-only room, and/or women-only support groups.

to attract womento harm reduction services, such as a woman doctor,childcare, women counsellor.

and equip outreach workers with women-

Provide women-safe spaces

Provide women-specific services

Access women with Peer Female OutreachWorkers,

friendly outreach kits, in addition standard harm reductionservices.

instruction, through outreach,women's support groups, and other women-safe spaces.Provide strategies to address these barriers such as accessto gender-based violence services, couples counselling.

Address women's barriers to safe injection andprovide safe-injection

For more information on theUNODC Country Office, PakistanPlot No. 5-11, Diplomaic Enclave, G-4, Islamabadwww.unodc.org/pakistan

w w w . u n o d c . o r g / p a k i s t a nPreventing Parenteral Transmission (sharingof contaminated injecting equipment) ofHIV for Women Who Inject Drugs

status of outreach workers can give them authority whenworking with clients and protect them and their clients incases where they may be approached by police.

outreach workers empowers outreach workersthemselves by providing an income-generatingopportunity. Peer outreach workers accessing womenIDU should be supported: Legalizing or formalizing the

Preventing Parenteral Transmission (sharing of contaminated injectingequipment) of HIV for Women Who Inject Drugs

Harm reduction services themselves may not befemale-friendly:Many harm reduction services have primarily male clientsand male service providers. Some women drug users maynot be comfortable interacting with male serviceproviders and some women have experiencedharassment or assault from male service providers andmale drug users. Women drug users also have gender-

specific reproductive health, pregnancy, childcare, andexperience with gender-based violence such as sexualassault. Many harm reduction services do not provide thegender-specific services that women require and maytherefore be unattractive to women. Women drug usersmay also feel uneasy about coming to a drop-in centre orspeaking with a male outreach worker.

EVIDENCE: GOOD PRACTICES

Successfully addressing women's gender-specificvulnerabilities to HIV infection via sharing of contaminatedinjection equipment requires:

Key services that can attract women include:

Providing women-friendly outreach kits that can includetampons, sanitary pads, and female-specific literature,supplies for children, along with needles, syringes, maleand female condoms.

Offering secondary needle and syringe exchange (extraneedles and syringes for women to pass on to others) on-site and via outreach is a good way to reach female IDU aswell.

Having a female doctor available and a gynaecologist

Offering childcare on-site

Providing referral services to female-specific services suchas gender-based violence counselling, pre- and post-natalcare, child health care, and women's shelters.

Outreach services can also work with women IDU tosupport women's negotiation skills to engage in safer druguse and safer sex.

Home visits via outreach can also provide opportunitiesto reach out to female care-givers.

offered to women in agender-sensitive manner. Because women are less likelythan men to access services that provide information on

1. Incorporating gender-specific servicesfor women into harm reduction services in orderto make the services useful and attractive towomen:

2. Offering services that specificallyaddress women's vulnerability to parenteralHIV infection including simple instructions onsafe-injection techniques

safe injecting and teach safe injection, it is especiallyimportant for service providers to offer safe-injectioninstruction when women do access services.

Opportunities to instruct women on safe-injectioninclude: via outreach, during home-visits, at women-onlydrop-in-centres, in women-only spaces or time withindrop-in centres

Discuss the gender-specific obstacles women face to safe-injection, such as opposition from an intimate partner andlack of direct access to clean injection equipment, in thecontext of women's support groups, female outreach andfemale-safe spaces.

Provide simple instruction on safe injection to women,using the steps below and the reference materials in thissection. Below are some simple instructions for reference.Please make sure to read carefully the referencematerials listed below before attempting to instructwomen in safe injection! Simple instruction stepsare:

Clean your skin before you shoot. Every time. If youdon't have alcohol wipes, use soap and water.Wash your hands before you use, every time. If youcan't wash your hands use gloves or at least clean thetips of your fingers with swabs.Mainline (inject into the vein), don't skin or muscledope! If you have to skin or muscle cut your dope witha lot of water. This will not only help your body toabsorb the drug more easily it will also help you to healfaster.Try to use a new equipment each time you use. If youhave to re-use your own equipment make sure toclean it with bleach, soap and water, or if you don'thave those at least warm water.Mix your drugs on a clean surface.Mix your own drugs and never let your usedequipment or anyone else's come into contact with agroup mix. 5The Social Awareness Service Organisation, Breaking New Ground, Setting New Signposts: A Community-Based Care and Support Model for Injecting Drug Users Living with

HIV. The SASO-Alliance Experience. December 2007

Cook your drugs until they boil (about 10-15seconds) this probably won't kill HIV or Hep C but itdoes help kill bacteria.If you “pound” or “wash” cottons make sure to cookthem again with extra water.Never lick your point before you inject.Only use water from clean sources.Wipe the injection site once with a new swab.Place the tourniquet around your upper arm (orabove the injection site). Don't leave it on too long. Ifyou have trouble finding a vein, release the tourniquetand try again.Put the needle into your arm at a 45-degree angle,with the hole facing up. Blood will sometimes appearin the barrel when the needle is inserted in the vein.Pull back the plunger and blood should appear. If thereis still no visible blood in the fit, remove the needle andtourniquet from your arm, apply pressure (using acotton ball, tissue or toilet paper) to stop anybleeding, take a deep breath and start again.When you are sure the needle is in the vein, loosenthe tourniquet and slowly depress the plunger. If youfeel any resistance or pain, you may have missed thevein and will need to start again.

There are a number of excellent resources on safeinjection. Make sure to read them! They are short anduser-friendly! These are:

by the AustralianIntravenous League. Available for download at

by theAustralian Intravenous League. Available for download at

by the Harm Reduction Coalition.Available for download at

by the Harm Reduction Coalition.Available for download at

Available for download at

by the Harm Reduction

A Guide to Safer Injecting

A Guide to Cleaning Used Syringes

Avoiding Arteries and Nerves When YouWant a Vein

The Right Hit

Taking Care of Your Veins by the HarmReduction Coalition.

Think Sink! Think Light!

http://www.aivl.org.au/?p=60#p=72

http://www.aivl.org.au/?p=60#p=72

www.harmreduction.org/downloads/arteries.pdf

www.harmreduction.org/downloads/hitright.pdf

www.harmreduction.org/downloads/rotate.pdf

C o a l i t i o n . A v a i l a b l e f o r d o w n l o a d a t

There are a number of strategies that can effectivelyincrease women drug users' access to harm reductionservices:

The Social Awareness Service Organisation (SASO) inImphal, Manipur, India, established a drop-in centre (DIC)specifically for women in 2006. The DIC has women staff,a woman doctor-who was particularly welcomed byclients, provides referral to women-specific services,offers recreational activities include TV, newspapers andwomen's magazines, and space for socializing. Womenhave space to bath and make-up kits are provided.Women received standard harm reduction servicesincluding needles and syringes, health check-ups andmedicines, clinic-based detoxification, OD managementand medicine, counselling. In addition, the DIC provides anumber of gender-specific services for women such asreferrals to reproductive health services, antenatal careand PMTCT/HIV-related care, as well as support groupsfor WLHIV, women IDU, SWs, and adolescent girls. TheDIC has links to two rehabilitation centres that werepersuaded to accept women.

Drop-in Centres that are already operational and servicemainly male drug users can improve female attendance ina number of ways: by providing special times for womenonly, such as a “ladies night,” by providing a separate roomfor counselling services for women with a femalecounsellor, by including women on staff, by offeringwomen-only support groups, and by providing on-sitegender-specific services for women as described above.

Outreach is a critical component of any service designedfor female IDU. The key is to meet them where they are-i.e. meet them in the places where they feel safe andcomfortable, in their own environment. In some countriesthere is a belief that peers should not do outreach becausethis work puts peers at risk of relapse. Peer outreach-FIDU or former FIDU for accessing women IDU clients-isthe most effective way to reach vulnerable populationsand especially effective for the most hidden andvulnerable populations. In addition, employing peers as

www.harmreduction.org/downloads/thinksink.pdf

3. Making harm reduction servicesaccessible to women:

A woman-only drop-in centre:

Providing services for women at a drop-in centrethat is primarily attended by men:

Female peer outreach workers:

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