Women Who Use Drugs and Female Partners of Men Who Use Drugs

Despite injecting drug use being a main driver of the HIV epidemic in many parts of the world, evaluated tailored responses for women who use drugs or for female sexual partners of men who use drugs have not matched the needs of this population. Injecting drug use is globally widespread and the main driver of the HIV epidemic in some parts of the world. Approximately 16 million people in 148 countries are injecting drugs users or PWID people who inject drugs. The largest numbers are in China, the United States and Russia, with HIV prevalence among PWID at 12% in China, 16% in the United States and 37% in Russia. Worldwide, about three million PWID are also living with HIV (Mathers et al., 2008). "...Outside sub-Saharan Africa, injecting drug use accounts for about one in three new cases of HIV" (Wood et al., 2010: 3). "Ukraine... is experiencing one of the fastest growing HIV epidemics in the world" (Taran et al. 2011: 65) with 22% of those newly infected with HIV through sexual transmission reporting a PWID as a regular sexual partner in the previous 12 months (Taran et al., 2011). In sub-Saharan Africa, PWID is a "relatively recent reported phenomenon" (WHO et al., 2011b: 27). However, among PWID in Dar es Salaam, Tanzania, HIV prevalence was 42% and 36% in Nairobi, Kenya (WHO et al., 2011b). In Mauritius, 47.4% of PWID are HIV-positive (Johnston et al., 2011). Of the new cases of HIV reported in 2007 for which information was available on the mode of transmission in countries of the former Soviet Union, 57% were attributed to injecting drug use (UNAIDS, 2009 cited in Rechel, 2010). "Despite the high burden of HIV among [people who inject drugs], national responses aimed at prevention, treatment and care for this population have been inadequate in scale" (Bergenstrom and Abdul-Quader, 2010: S26).

Injecting Drug Use is an HIV Risk for Both Women Who Use Drugs and Female Partners of Men Who Use Drugs

"Women who inject drugs have substantially different needs and face higher risks of disease and violence than do men who inject drugs" (Roberts et al., 2010: 7).The HIV risks related to injecting drug use stem from, among others, sharing contaminated needlesone of the most direct transmission pathways for HIV transmission (Choi et al., 2006), exchanging sex for money or drugs, low condom use, and low levels of HIV testing and treatment. For example, a recent study in Tanzania found that of 319 males who inject drugs (MWID) and 219 females who inject drugs (FWID), 33% traded sex for money, 49% did not use condoms during vaginal sex, 31% had injected with a needle used by someone else, 41% had given a used needle to another, and 42% were HIV-positive and almost none of those who tested HIV-positive knew their serostatus (Williams et al., 2009). PWID, besides being at high risk of acquiring HIV are also at high risk of acquiring Hepatitis B and C (Cook, 2010). [See also Preventing, Detecting and Treating Critical Co-Infections] A survey of 3,711 PWID in 16 cities in Ukraine, 25.4% female, with an HIV prevalence of 32% and found that 85.6% reported having sexual contact in the past months, and just over half reported using a condom during last sexual contact (Taran et al., 2011). Many may not know their HIV status: in a study in St. Petersburg, Russia, of 661 PWID (35% female), 19% reported being living with HIV but seroprevalence was 38% based on blood tests. Of 687 heterosexual dyads with a sexual partner who injects drugs, 74% reported engaging in unprotected sex; in couples that self-reported serodiscordancy, the majority engaged in unprotected sexual intercourse and FWID were more prone to sexual risk from their MWID partner (Gyarmathy et al., 2011b).

Women Who Inject Drugs Have Higher HIV Risks Than Men

"Many women who use drugs lack the power to negotiate safer sex" (El-Bassel et al., 2010: 8).Though precise data on women who inject drugs are rarely available, women are estimated to represent about 20% of drug users in Eastern Europe, Central Asia and Latin America, 17-40% in various provinces of China and 10% in some Asian countries (UNODC, 2005 cited in Pinkham and Malinowska-Sempruch, 2008). In Kazakhstan, a study found that FWID were at least twice as likely to be HIV-positive (Zhussupove et al., 2007 cited in Thorne et al., 2010). In a sample of 56 FWID in Estonia, 64.3% were HIV-positive, while of the 294 MWID, 53.4% were HIV-positive (Uuskula et al., 2010). A survey of 3,711 PWID in 16 cities in Ukraine, with 25.4% female, found an HIV prevalence of 32%. Being female was significantly associated with HIV-positive status (Taran et al., 2011).

In China, prevalence of unprotected sex among 1,422 sexually active FWID was 75.4% and 43.5% reported syringe sharing, with 25.2% reported that they injected others used syringes in the last month and 29.3% reported lending, giving or selling used syringes to others (Lau et al., 2011). A study of 2,512 MWID and 672 FWID surveyed in 10 sites in developing countries found that females were more likely to engage in risk behaviors in the context of a sexual relationship with a primary partner (Cleland et al., 2007) and that women are more likely than men to borrow or share injection equipment, particularly with their sexual partners. A study of 570 PWID (32% female) in Russia, found that 15% had sexual partnerships, 29% reported syringe sharing, 38% had never been tested for HIV and 43% were HIV-positive (Gyarmathy et al., 2010). Unprotected sex between PWID accounts for 15 to 45% of new HIV infections in Ukraine (Strathdee et al., 2010). Women are also more likely to be injected by a friend or partner, which increases risk (Pinkham and Malinowska-Sempruch, 2008; Roberts et al., 2010). Of FWID in Pakistan, 60% were married, 66% had no education, half shared syringes with other PWID, only 22% knew that HIV can be transmitted by needles and only 3% used condoms. However, 73% wanted treatment for drug use (UNODC, 2010b).

There is also greater HIV risk in the overlap between injecting drug use and sex work. An estimated one-third of sex workers in the Russian Federation also are PWID (WHO et al., 2011b); as are a high proportion of FWID in South Africa, with high rates of HIV (Hedden et al., 2009). A study in China found that female sex workers who were also intravenous drug users had HIV prevalence rates as high as 35.5% (Jia et al., 2010). Studies in South America, Tanzania, China and Vietnam have found that sex workers who are injecting drug users are at higher risk of acquiring HIV than sex workers who are not injecting drug users (Bautista et al., 2006; Azim et al., 2006; Ross et al., 2008; Galvez-Buccollini et al., 2009; Lau et al., 2007b). Three community based surveys of 4,310 PWID in China from 2004 to 2006 found that over 30.5% of PWID who had been an PWID for less than one year were female, an increase from 17.8% for PWID who had been PWID for more than three years, with high rates of unprotected sex (Zhang et al., 2010a).

In South Africa, a study found that men exercise more control over drug and sexual transactions than females, with drug-using female sex workers controlled to a great extent by male pimps, who threaten women with loss of shelter or violence if insufficient income is produced. Drugs are used to increase stamina for sex work, enhance sexual pleasure or cope with stress of sex work. Female sex workers who inject drugs may not use condoms in order to access drugs (Needle et al., 2008).

"Women who inject drugs have substantially different needs and face higher risks of disease and violence than do men who inject drugs. Given this difference, it is surprising that much of the literature on injecting drug users does not distinguish between men and women when discussing prevalence, needs, risks and outcomes of injection... where women are discussed, there is a tendency to focus on women of reproductive age who are sexually active, referring to them as 'bridges for disease' into the general population. This suggests the epidemiological and policy concerns around these women in most cases are based on concerns for their sexual partners and children instead of their own human rights, health and wellbeing" (Roberts et al., 2010: 7). In fact, research on drug use and HIV suffers from a dearth of sex-disaggregated data and gender analysis. Evaluated interventions that meet womens needs are scarce.

Female Partners of Men Who Inject Drugs are Also at Higher Risk for HIV

"The majority of [MWID] have non-injecting female sex partners" (Roberts et al., 2010: 10). Some women may not be aware that their partner uses drugs. Because of traditional gender norms which value submissiveness and ignorance of their partners' sexual practices or injecting drug use, women with MWID partners may not know they are at high risk of acquiring HIV from their partners' sexual or needle-sharing practices. A profile of 1,158 injecting drug users in India, mostly male, found that most shared needles and had limited condom use, yet 45% had vaginal or anal intercourse with female partners in the last month (Solomon et al., 2010b). Another study in Vietnam with 299 MWID found that 43% were HIV-positive and 48% had had unprotected sex in the last 12 months (Go et al., 2011b). A study in Vietnam with widows living with HIV found that 18 of the 24 widows had found out after their marriage that their husband was an active drug user (Go et al., 2011b).

A study in China with 234 non-institutionalized sex workers who use drugs found that those with submissive gender attitudes, such as agreeing that "men always make decisions on sexual matters," was positively associated with inconsistent condom use during sex work and was significantly associated with having injected with others' used syringes (Gu et al., 2010). About half of MWID in Karachi, Pakistan are married and 47% report sex with sex workers, two-thirds of whom did not use condoms (Altaf et al., 2007 cited in Strathdee et al., 2010; Bokhari et al., 2007; Emmanuel et al., 2008 cited in Strathdee et al., 2010). In fact, numerous studies demonstrate that MWID have unprotected sex with sex workers (Todd et al., 2006 and Nashkoev and Sergeyev, 2008 cited in Thorne et al., 2010; Khan and Khan, 2011).

A study in South Africa found that "there seemed to be a choice not to use condoms due to the 'trust' between drug users and their 'safe partners' or as one male intravenous drug user put it: "... because I trust my wife. I don't use anything" (Parry et al., 2009: 895). In order to understand the dynamics of injecting and sexual risks, more research is needed "into how projects can work specifically with serodiscordant couples to break down myths of love and fate and to introduce ideas of protection" (Jianhua et al., 2010: 71).

Interventions to Reduce Drug Dependency Can Reduce HIV Risk for Women Who Use Drugs and Female Partners of Men Who Use Drugs.

"... No country that has started harm reduction has ever regretted doing so and then terminated their programmes" (Wodak and McLeod, 2008: S88)."Harm reduction seeks to reduce the spread of HIV associated with injection drug use through outreach, education in safer practices, needle and syringe exchange programs, access to counseling and drug treatment, and non-judgmental approaches... Harm reduction programs [such as opioid agonist therapy and needle exchange programs] are supported by an extensive body of evidence to show that they are cost-effective, can reduce HIV and other blood-borne pathogen transmission and can serve as effective bridges to drug treatment and health care" (Des Jarlais and Friedman, 1998 cited in Gauri et al., 2007: 314). However, despite the evidence of effectiveness of harm reduction programs, they are usually not designed to address the specific needs of women and women usually have less access to harm reduction services than men.

After three decades of research, there is no convincing evidence that needle exchange programs have been accompanied by serious negative consequences. Instead, needle exchange has been associated with enrollment in drug treatment programs. It's important to note that while getting clean needles through needle exchanges reduces HIV risk, cleaning needles with bleach does not reduce risk (Vlahov et al., 1994 cited in Vlahov et al., 2010). Pharmacy access can be a good source of sterile needles. Safer injection facilities have been established in Canada, but none in low or middle-income countries (Vlahov et al., 2010). Unfortunately, law enforcement can deter needle exchange implementation efficacy by challenging legality, threatening staff and arresting those who try to access clean needles.

Where opioid agonist therapy such as methadone has been easily available without strict regulation, PWID have HIV prevalence rates of 1% for the last almost fifteen years, such as in Croatia (WHO, 2006 cited in Kenny and Saucier, 2010). However, most opioid agonist therapy programs in developing countries have been small scale, leading to urgent unmet needs (Vlahov et al., 2010; Mathers et al., 2010).

Unfortunately, current coverage of interventions for injecting drug use is inadequate, with 5% of drug injections covered by a sterile needle covered by a needle exchange program; eight received opioid agonist therapy for every 100 PWID and four PWID receive antiretroviral therapy for every 100 HIV-positive PWID (Degenhardt et al., 2010). "Among 107 reporting countries, 42 had needle and syringes programmes and 37 offered opioid substitution therapy... In the subset of 30 countries that provide data on needle and syringe programmes, the median number of syringes distributed per year per person who injects drugs was 50.7, still below the internationally recommended level of 200 syringes per person who injects drugs per year... Less than 2.5% of people who inject drugs received opioid substitution therapy among 32 reporting countries" (WHO et al., 2011a: 17). Needle exchange was confirmed to be absent in 55 countries (Mathers et al., 2010). "Worldwide, there are few countries in which the level of intervention coverage is sufficient to prevent HIV transmission... This is a serious missed opportunity and will have long-term effects on overall public health..." (Mathers et al., 2010: 1025 and 1026).

In both Ghana and Kenya, HIV prevalence among PWID exceeds 10% yet neither country provided opioid agonist therapy nor sterile needles (WHO et al., 2011b). However, in Iran, 84% of those who inject drugs had access to opioid agonist therapy (WHO et al., 2011b). Yet, "chemical dependence is a chronic, relapsing and treatable disease..." (Altice et al., 2010: 60). An analysis estimated the overall resource need for achieving universal access in 20009 for PWID in Asia that included access to antiretroviral therapy, opioid agonist therapy and needle exchange programs was US$ .5billion (Bergenstrom et al., 2010). However, there is "scant costing and benchmark budgeting information for prevention and treatment interventions. This makes it difficult to objectively and efficiently allocate resources to those programmes that have the highest impact" (Bergenstrom et al., 2010: 108).

Women Face Greater Stigma and Have Less Access to Harm Reduction Programs Than Men

Although they are at high risk of HIV acquisition, women who inject drugs in every country have lesser access to services than MWID. "Drug treatment, harm reduction and HIV programmes for women are near universally underfunded despite evidence of efficacy" (El-Bassel et al., 2010: 8). In Georgia, only 12 of the 1,000 patients who have access to methadone treatment were women (Belyaeva et al., 2011). Interviews with 1,391 FWID in Pakistan found that "unlike male drug users who congregate and use drugs with other drug users, drug use is a discreet, hidden and more of an individual activity for female drug users" (UNODC, 2010a: 11; Khan and Khan, 2011).

Women lack access to harm reduction and other health services because of even greater stigmatization than male injecting drug users as well as FWID's fear of losing custody of their children (Malinowska-Sempruch, 2001). Women who use drugs are more likely than men to have dependent children. Access to treatment should be de-stigmatized and decriminalized so that fear of losing their children is not stronger than the desire to seek help. Women also need child care while they complete treatment (Roberts et al., 2010). A study of 252 PWID including 66 FWID in Thailand found that women were less likely to access harm reduction services (Kerr et al., 2010a). Specific outreach, such as referrals from maternity hospitals and those working with PWID and sex workers, is needed to reach FWID (Pinkham and Shapoval, 2010). "Few drug-treatment and HIV prevention programs attempt to help women who suffer intimate partner violence and fewer still emphasize reproductive health" (El-Bassel et al., 2010: 8).

Increasing access for women who use drugs to needed services, including drug treatment, harm reduction programs, and sexual and reproductive health care services, is crucial. "Substance abuse disorders are chronic, relapsing but treatable diseases" (Bruce et al., 2010: 332). Women who use drugs also need legal services to reduce police and health service abuse, to access services and to gain custody of children (OSI, 2008). Achieving this goal requires policies that encourage women to seek drug treatment and harm reduction rather than punishing or stigmatizing them for drug use during pregnancy or motherhood; increasing availability of opioid agonist therapy; incorporation of sexual and reproductive health and other women's services into harm re-education programs; flexible, low-threshold services that are more convenient for women with children; and links between harm re-education, drug treatment, womens shelters, and violence prevention services" (Pinkham and Malinowska-Sempruch, 2007: 3).

Harm Reduction Programs Can be Scaled Up But Must be Tailored to the Needs of Women

An estimated 20% of the 16 million PWID worldwide are living with HIV. In at least 69 countries where injecting drug use has been documented, no program to provide even sterile needles exists. And in many countries with needle exchange programs, the number of sterile needles distributed per person using drugs is inadequate to stem the AIDS pandemic. Opioid agonist therapy is not available in 77 countries in which injecting drug use has been documented (UNAIDS, 2011a). Modeling suggests that in concentrated epidemics, an approach which dramatically increases coverage of antiretroviral therapy and access to harm reduction is much more effective than interventions that target a whole range of populations (Schwartlander et al., 2011). "Opioid substitution therapy in most countries with low and middle incomes remain in perpetual pilot status" (Wolfe et al., 2010: 53, IHRD, OSI, 2008). And even where harm reduction programs are available, women rarely have access. A recent study of 403 women who use drugs in Vietnam found that these women would like harm reduction services but had rarely been beneficiaries, with less than 58% having heard of needle exchange and less than 27% receiving free needle exchange (Oanh et al., 2011).

"Drug abuse treatment is HIV prevention... Drug users who enter and continue in treatment are more likely than those who remain out of treatment to reduce risky activities, such as sharing needles and injection equipment or engaging in unprotected sex" (NIDA and IAS, 2010: 23). "In contrast to the many areas in which HIV has spread rapidly in PWID populations, there are also many areas in which HIV has been contained at low levels (prevalence under 5%) in PWID populations... It is important to note that preventing HIV epidemics among PWID does not require elimination of injecting drug risk behavior" (Des Jarlais, 2010: 97).

"... As reported by the majority of governments, current laws and policies hamper access to and uptake of existing services" (Bergenstrom and Abdul-Quader, 2010: S26). Opioid agonist therapy using methadone and buprenorphine, which are on WHOs list of essential medicines, can reduce HIV incidence and increase adherence to antiretroviral treatment, yet is illegal in some countries such as Russia (Uhlmann et al., 2010). In some countries, harm reduction programs are prosecuted for providing services to PWID (UNODC, 2010a). Studies in numerous countries have shown that police presence does not reduce drug use, but rather increases HIV risk behaviors, such as sharing syringes, and reduces access to opioid agonist therapy and HAART adherence (Werb et al., 2009; Strathdee et al., 2010; Mimiaga et al., 2010; Sarang et al., 2010; Chakrapani et al., 2011b). In order to prevent AIDS pandemics in those countries with large populations of HIV-positive people who inject drugs, there is a need to endorse a "public health approach that treat(s) PWID as patients," rather than "law enforcement approaches that seek to arrest them" (Wolfe et al., 2010: 55). "Important public health funds diverted towards prisons that house largely non-violent offenders are wasted on cost-ineffective programmes. Annual costs of treating addiction are five times less than costs of incarceration," especially for non-violent offenders (Altice et al., 2010: 75). Harm reduction programs such as needle exchange programs may be correlated with increased disclosure of HIV-positive results to sexual partners, as was the case in a needle exchange program in Hungary, but further work on this is needed (Gyarmathy et al., 2011a). "Too many opportunities to prevent new HIV infections and drug-related deaths have been missed because of our collective failure to implement evidenced-based responses to illicit drug problems" (Wood et al., 2010: 6).

It is critical to ensure that governments, donors, and service providers are aware of the HIV risk for FWID and female partners of MWID; that HIV prevention, treatment, and care interventions take account of the needs of these women; and that they participate in policy and program development. There are effective evidenced-based interventions that reduce HIV risk for women who use drugs and some of them are being brought to scale (see example in this section on China Sullivan and Wu, 2007)). In some countries, HIV and drug services are seen as fragmented with no coordination by both service providers and IDUs (Parry et al., 2010). "Treatment of substance-use disorder should follow a chronic disease model and should be maintained in parallel to HAART treatment" (Volkow and Montaner, 2010: 1423). A recent WHO guide issued essential interventions for HIV prevention, treatment and care among people who inject drugs, along with links for guidance, but unfortunately does not have any sex-specific interventions nor are indicators for reaching targets recommended to be disaggregated by sex (WHO, 2009k). Furthermore, women who use drugs face great barriers in accessing reproductive health services that meet their needs.

Inadequate funds are being spent on harm reduction (Stimson and Lines, 2010). It's important to begin prevention efforts early, when prevalence is under 5% and provide large-scale, legal access to sterile injecting equipment and community outreach and HIV education for PWID (Des Jarlais, 2010: 99). HIV epidemics in people who use drugs can be largely controlled... What is needed... in opioid-driven epidemics (is)... an essential minimum package of safe injection programs, opioid substitution therapy and antiretroviral treatment" (Beyrer et al., 2010a: 108).

People Who Inject Drugs Need Access to Antiretroviral Therapy

"I wish I had known something about HIV... because when I was diagnosed, all I knew was that... I was going to die soon... I went through treatment and I do not use drugs anymore... I am getting treatment now; I feel good. The antiretroviral drug treatment is a miracle. It is a great chance for life. Life is a miracle. Recently, I have become a mother and my daughter is also a miracle... All people, including people who use drugs, deserve the miracle of life." Sasha Volgina, former IDU, director of Svecha, a Russian community based organization representing people living with HIV (UNAIDS, 2011a: 63)Of the 38 countries reporting antiretroviral therapy coverage for PWID in 2010, 19 reached less than 10% of PWID eligible for treatment (UNAIDS, 2011a). In Russia, HIV prevalence among PWID is 37% (Vitek et al., 2011); yet at the end of October 2009, out of 14,256 HAART patients, only 940 were PWID. In 2009, less than five PWID received ART per 100 HIV-positive PWID globally (Mathers et al., 2010). In Chile, Kenya, Pakistan, Russia and Uzbekistan, less than one HIV-positive PWID had access to ARVs (Mathers et al., 2010). In 2010 in Europe and Central Asia, people who inject drugs represented 62% of the cumulative number of reported HIV cases with a known route of transmission but only 22% of those receiving antiretroviral therapy (WHO et al., 2011a: 17).

"This is despite cost-effectiveness data showing clear benefits of targeting ART to people who inject drugs in areas with concentrated epidemics and savings ratios as high as 7:1 for providing drug treatment compared with the social and medical costs of drug use" (UNAIDS, 2011a: 59). Modeling of the HIV epidemic in a country such as Vietnam, where the highest HIV prevalence is among people who inject drugs, show that early ART initiation for this key affected population could have a major impact on Vietnams HIV epidemic (Kato et al., 2012).Mathematical modeling that included HIV transmission to injecting drug users from sex partners who were not drug users found that reduction of the unmet need of opioid substitution, needle and syringe programs and antiretroviral therapy by 60% between 2010 and 2015 could prevent 41% of incident infections in Odessa, Ukraine; 43% in Karachi, Pakistan and 30% in Nairobi, Kenya (Strathdee et al., 2010).

A modeling study in Ukraine found that providing methadone maintenance programs can be cost effective and financially sustainable. In 2007, PWID represented more than 40% of newly registered HIV infections. In 2007, only 7,700 people with CD4 counts under 350 received ART of the 91,000 eligible patients. In 2008, only 500 of Ukraine's 400,000 PWID received agonist therapy of any kind. In 2007, Ukraine approved use of methadone for agonist therapy. Reflecting Ukrainian data and published literature on costs, the model assumed that baseline ART access is 10% for non-PWID, 2% for PWID not receiving methadone and 25% for PWID receiving methadone. A high methadone substitution therapy scenario would reach 25% of PWID. The model also considered a low ART treatment scenario with 20% of eligible patients receiving ART and a high treatment scenario with 80% of those eligible receiving ART. The model also assumed that PWID receiving methadone substitution therapy (MST) reduced equipment sharing by 85% and that only 5% of those receiving MST stopped injecting drugs. Costs and Quality-adjusted Life Years (QALYs) were measured. Under the status quo, 33,700 new HIV infections would occur over the next 20 years, with 18,000 in PWID and 15,700 in non-PWID. High MST with high access to ART for those eligible would avert the most infections (8,300), with 3,630 averted among PWID and 4,760 among non-PWID. After this the high MST scenario averted the most infections (4,700), with the majority (2,970) averted among PWID and 1,730 among non-PWID because of reductions in sexual transmission from PWID. The most effective strategy is "high MST, high ART with modestly lower costs but less efficient at US$2,240/QALY gained. According to WHO guidelines, these scenarios are cost-effective as they cost less than Ukraine's per capita gross domestic product" (Alistar et al., 2011).

A study in Indonesia of hospital-based methadone maintenance treatment (MMT) also found that services are financially sustainable. The study used one-year observation period from 2006 to 2007 using a micro-costing approach and a survey of 48 methadone clients. Total costs of running the clinic for 129 clients were US$123,672 or $7.57 per client visit. Clients are charged $1.64 per client visit, while actual costs are $1.11 per client visit and thus giving the hospital a profit (Afriandi et al., 2010).

Regarding the medical implications of opioid agonist therapy and antiretroviral therapy, buprenorphine is safer, compared with methadone, for those PWID who are HIV-positive who are receiving HAART, because there are fewer known medication interactions (Carrieri et al., 2000 cited in Vlahov et al., 2010; Fainey et al., 2002 cited in Vlahov et al., 2010). For information on drug interactions associated with harm reduction and antiretroviral treatment, see (McCance-Katz, 2011).