WOMEN, DRUGS AND HIV

Science Addressing Drugs And Health: State of the Art

20th International AIDS Conference 201421 July 2014, Melbourne

Tasnim Azim, icddr,b, Dhaka, BangladeshIrene Bontell, Karolinska Institutet, Stockholm, SwedenSteffanie Strathdee, University of California, San Diego, USA

WOMEN WHO INJECT DRUGS ARE SIGNIFICANT IN NUMBER: GLOBAL FIGURES

Number of people who inject drugs (PWID): ~16 million

Number of females who inject drugs (FWID): ~3.5 million

FWID are more likely to be HIV positive than males who inject drugs (MWID): 1.18 times

Mathers et al, 2008; Des Jarlais et al, 2012

HIV prevalence is higher among females who use drugs around the world

Southern and Eastern

Europé

North America

Latin America

and Caribbean

Western and Central

Europé

Central Asia

Tanzania Nepal0%

10%

20%

30%

40%

50%

60%

70%

33.0% 34.5%38.5%

42.8%

10.1%

62.0%

33.0%

27.9%31.3%

34.6%

40.3%

9.5%

28.0%

6.3%

FWIDMWID

Des Jarlais et al 2012 and 2013; Lambdin et al, 2013; Ghimire et al, 2013

HIV

WOMEN, DRUG USE AND SEX WORK: A DUAL RISK

The combination of selling sex and using illicit drugs is common

Women often sell sex to support their own or their partner’s drug use

Tanzania: 85% Nepal: 50% Bangladesh: 63%

Lambdin et al, 2013; Ghimire et al, 2013; Azim et al, 2006

FWID who sell sexFWID who do not sell sex

experience sexual violence

high-risk sex

sexual concurrency

sharing needles and syringes

Multiple vulnerabilities and risks faced by women who use drugs and sell sex result in a high risk of HIV

street based sex work

highly stigmatized

lack of control

HIV and STI risk

PWID ARE NOT AN ISOLATED POPULATION GROUP…..

PWID AS BRIDGE POPULATIONS FOR A GENERALIZED HIV EPIDEMIC

Des Jarlais et al, 2012

Transitions from PWID concentrated epidemics to heterosexual epidemics are likely to have occurred in at least six countries:

•Argentina•Brazil•China•Indonesia•Netherlands•Ukraine

WOMEN WITH PARTNERS WHO INJECT DRUGS

FWID are more likely to have MWID as their intimate partners and are often relying on them for acquiring and injecting drugs

The relationship is one of trust, fear and dependence – emotional and economic

BUT – often men control their lives

El-Bassel et al, 2014; Des Jarlais et al, 2012; Shanon et al, 2008

Relationship of FWID with

MWID partners

Control over drugs – obtaining, taking

Control over clients of FWID-SW - Role

as pimps

Control over condom use

Violence and threat of violence –

physical and sexual

Increased

vulnerability

to HIV/STI

NON-DRUG USING PARTNERS OF MWID

• Condom use is uncommon with intimate partners and often MWID have high levels of risk behaviour

• Violence or threat of violence by intimate partners – a voice from Bangladesh “…..if I don’t give money to my husband for his drugs, he beats me and threatens to kill me”

• Marginalised by society – they call me “wife of a heroinchi....”

Robertson et al, 2014; UNODC and icddr,b, 2010

SPECIAL NEEDS: REPRODUCTIVE HEALTH CARE

• Non-judgmental antenatal clinics

• Birth control• Advice on birth spacing• Point of Care STI

services• Pelvic exams• HPV vaccination• Abortion services

SPECIAL NEEDS: CHILD CAREHaving children and needing to provide care for them can be a motivation for making lifestyle changes including reducing drug use

Rolon et al, 2013; UNODC and icddr,b 2010; Maehira et al, 2013

Relapse following drug treatment more common among FWID and women without children to support were more than three times likely to relapse

Reasons for not accessing services for child care:•lack of child care services•fear of losing their children if they contact service providers

STIGMA AND DISCRIMINATIONFWID are highly stigmatized and discriminated by all strata of society

“when I visit any house they assume I am a thief” –FWID from Bangladesh “they (women who use drugs) are liars, big liars …and they are ready to go as far as possible… they are ready to sell themselves…” – Georgia, general view “generally the attitude of police towards a drug user is similar to their attitude towards criminals and not sick people… their attitude towards women is even worse than to men…” – FWID from Georgia

Stigma can be a barrier for access to services

UNODC and icddr,b 2010; Otiashvili et al, 2013; El-Bassel et al, 2014

VIOLENCEExperienced commonly - physical and sexual

Perpetrators include:• Law enforcement• Intimate partners• Clients

There is a general feeling by FWID-SW that clients will not be criminalized for the violence and that women will not be

protected by police

Otiashvili et al, 2013

INTERVENTIONS: WHAT CAN WORK•Behavioural interventions: •Safer sex and injection practices, enhanced negotiation skills, couple-based approaches

•Structural interventions:•Access to safe housing and spaces for sex work, access to non-discriminatory health services

•Biomedical interventions:•HIV testing and treatment, PrEP, PEP and TasP

CONCLUSIONS• FWID often have higher rates of HIV than MWID.

• FWID who sell sex are more likely to share injection equipment, have unprotected sex with their clients and their intimate partners, have high rates of STIs and to experience sexual and physical violence and incarceration

• Women are often reliant on their male partners and may be controlled by their intimate male partners for drugs, clients, condom use

• FWID have special needs e.g. pregnancy women and child care

• FWID are highly stigmatized by all strata of society and violence, both physical and sexual, is common

• Women who do not use illicit drugs but have MWID as their intimate partners are also stigmatised and vulnerable

• Behavioural, structural and biomedical interventions can work and should be made available

CONCLUSIONS

RECOMMENDATIONS• Harm-reduction, reproductive health and HIV services must

be available for women who use drugs in culturally sensitive and non-judgemental environments

• Since sex work is common among FWID, harm reduction should be included in all interventions for sex workers and safer sex messages should be part of all harm reduction programs for FWID.

• Couple-based interventions are effective for decreasing drug use and HIV risk behaviours and should be widely available

• Interventions must focus on strengthening the ability of women to achieve autonomy over HIV risk reduction practices, including freedom from pimps and police harassment and availability of safe places to take clients

WE GRATEFULLY ACKNOWLEDGE ALL WOMEN WHO USE DRUGS AND WHO HAVE SHARED

THEIR STORIES WITH US