Women Who Use Drugs and Female Partners of Men Who Use Drugs
- Opioid agonist therapy, particularly maintenance programs with methadone and buprenorphine, leads to reduction in drug use, HIV acquisition and risk behavior among PWID, is safe and effective for use by pregnant women.
- Comprehensive harm reduction programs, including needle exchange programs, condom distribution, agonist therapy and outreach, and nonjudgmental risk reduction counseling can reduce HIV risk behaviors and prevalence among PWID.
- Peer education can increase protective behavior, including condom use, among women who use drugs and female partners of men who use drugs.
- Gender-sensitive sex-segregated group sessions for couples who use drugs can result in increased condom use and safer injection practices.
- Instituting harm reduction programs for PWID in prisons can reduce HIV prevalence in female prison populations.
1. Opioid agonist therapy, particularly maintenance programs with methadone and buprenorphine, leads to reduction in drug use, HIV acquisition and risk behavior among PWID, is safe and effective for use by pregnant women. (Metzger and Navaline, 2003 cited in Strathdee et al., 2006; Demaan et al., 2002 cited in Strathdee et al., 2006; Metzger et al., 2003 cited in Strathdee et al., 2006; Ball et al., 1988 cited in Strathdee et al., 2006; Bruce, 2010; Roberts et al., 2010).
A review of the evidence based on a global ‘review of reviews’ using two randomized controlled trials, four cohort studies, one case control study and one cross-sectional study found that opioid agonist therapy protects against HIV seroconversion based on biologically verified outcomes. Those who remained on methadone maintenance therapy were less likely to acquire HIV.
A Cochrane review of randomized clinical trials of buprenorphine maintenance versus placebo or methadone maintenance with 24 studies and 4,497 participants found that methadone was the most effective at retaining patients compared to buprenorphine or placebo if prescribed at doses of between 60 mg and 120 mg per day. Buprenorphine was statistically significantly superior to placebo medication in keeping patients in treatment, with medium and high dose buprenorphine suppressing heroin use.
A Cochrane review of randomized clinical trials of methadone maintenance therapy compared with placebo or other non pharmacological therapy with 11 studies and 1,969 participants found that methadone was statistically significantly more effective in retaining patients in treatment and in suppressing heroin use as measured by urine and hair analysis and self report.
A double-blind, double-dummy placebo-controlled randomized controlled trial in Malaysia of 126 detoxified heroin-dependent patients were randomly assigned to 24 weeks of manual-guided drug counseling and maintenance either with naltrexone (43 IDUs); buprenorphine (44 IDUs); or placebo. Buprenorphine was significantly associated with greater time to first heroin use and maximum consecutive abstinent days than were naltrexone or placebo. HIV risk behaviors were significantly reduced from baseline across all three treatments due to counseling. No sex-disaggregated data was provided. Prior to randomization, all patients completed a 14-day detoxification protocol in a residential setting, during which they were given buprenorphine and naltrexone, along with medication as needed for withdrawal symptoms. Nurses received four days of training and provided individual counseling sessions of 45 minutes.
A Cochrane review with 33 studies involving 10,400 participants found that “studies consistently show that oral agonist treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting drug use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money” (Gowing et al., 2011: 1-2). These reductions in risk behaviors related to drug use result in lower rates of HIV (Gowing et al., 2011) (Gray IIIb). A sufficiently high dose of methadone (more than 60 mg per day is required and programs need to allow for sufficiently long treatment duration i.e. at least more than six months if concomitant drug use is to be reduced.
Evidence from prospective cohort and case control studies show that continuous maintenance treatment, such as methadone, is associated with protection against HIV seroconversion (Moses et al., 1994 cited in IOM, 2007; Serpellini and Carrieeri, 1994 cited in IOM, 2007).
A 2009 review of international implementation of opioid substitution found that opioid agonist treatment is the most effective treatment available for heroin dependence, resulting in reduced heroin use, HIV transmission and mortality.
A retrospective review in the United States of 81 mothers who received methadone and their 81 offspring found that a higher dose (mean of 132 mg compared to the lower mean of 62 mg) had a positive effect on maternal drug use with no increased risk of neonatal abstinence symptoms.
A national harm reduction was instituted in Taiwan in 2006. New IDU-associated HIV/AIDS cases have dropped from 60% in 2006 to 22% in 2008.
A review of literature on methadone use for pregnant addicts in the United States, Europe, and Australia from 1995 to 2000 found that it is key to provide a sufficient methadone dose to pregnant women so as to reduce illicit drug supplementation.
2. Comprehensive harm reduction programs, including needle exchange programs, condom distribution, agonist therapy and outreach, and nonjudgmental risk reduction counseling can reduce HIV risk behaviors and prevalence among PWID.
A review of the international evidence on needle exchange programs found that needle exchange programs reduce HIV infection among IDUs. Studies were mostly based in the US, Canada and Europe, but included studies from Nepal and Russia. A review of ten studies that evaluated HIV seroconversion or seropositivity as outcomes found the needle exchange programs were protective in six studies; had no effect in two studies and were negatively associated in two studies. “There is compelling evidence that increasing the availability, accessibility, and both the awareness of the imperative to avoid HIV and utilization of sterile injecting equipment by IDUs reduces HIV infection substantially… There is no convincing evidence of any major unintended negative consequences” (Wodak and Cooney, 2006: 802).
A two-armed, prospective, community-randomized trial in China that provided access to clean needles over a nine-month period resulted in needle sharing dropping significantly in the intervention community. Four counties and townships in Gungxi and Guandong provinces were randomized to intervention and control in each province. The intervention effect was assessed on 443 IDUs in the intervention area and 382 in the area of no intervention at the start of the project and 415 IDUs in the intervention area and 407 in the area of no intervention at the end of the project. Of these, only 47 women received the intervention and only 32 women were in the control group that received the intervention at the end of the project. The intervention consisted of health education sessions between health workers and IDUS, peer education and dispensing and recall of needles, with increased access to safe needles. While needle sharing behaviors among IDUs were similar in the intervention and nonintervention areas (68.4% compared to 67.8%), needle sharing dropped significantly to 35.3% after a year of the intervention in the intervention area. Lab testing was conducted for both HIV and Hepatitis C.
A pilot clinical trial with 37 heroin-dependent IDUs in China were randomly assigned to either methadone maintenance therapy only or maintenance methadone therapy plus weekly individual manual-guided behavioral drug and HIV risk reduction counseling and found that at six months, those who received maintenance methadone therapy plus weekly individual manual-guided behavioral drug and HIV risk reduction counseling achieved greater reductions of HIV risk behaviors and of opiate use. Of the participants, 81% were male and 17 participated in the methadone maintenance therapy only. AIDS Risk inventory was used to measure reduction in HIV risk behaviors and opiate use was also measured by testing for opiates.
Rates of sharing equipment at last injection declined from 55% in 2001 to 26% in 2006 in north-east India, with HIV prevalence declining from 52% in 2002 to 13% in 2007.
Annual cross-sectional seroprevalence studies among attendees of sentinel needle exchange programs in Australia from 1995 to 2009 with data for 21,248 individual needle exchange attendees found that aggregate HIV prevalence was 1.1% and has remained stable since the late 1990s. Bipartisan political support enabled the establishment in 1986 of legal, publicly funded needle and syringe programs, which have become widespread. Needle exchange programs operate on a distribution rather than an exchange basis, with no requirement that used syringes be exchanged for sterile needles. Australia has a rate of 213 clean syringes per year per injector and a comprehensive harm reduction policy approach, thus managing to avert a generalized outbreak of HIV among IDUs.
A study of a cohort of 1,228 injection drug users (38.4% women) between 1998 and 2003 in Canada found that syringe borrowing decreased from 201.1% in 1998 to 9.2% in 2003 and syringe lending decreased from 19.1% in 1998 to 6.8% in 2003 following a change in policy on clean needle access for IDUs. Between 2000 and 2002, health authorities modified policies so that the focus of health interventions for IDUs was syringe distribution rather than syringe exchange. This in turn led to substantial reductions in HIV incidence among IDUs.
A harm reduction program by CARE SHAKTI in Bangladesh which instituted a harm reduction program for IDUs found that early intervention is more cost-effective than delaying activities, although this should not preclude later interventions. Economic cost data were collected and combined with impact estimates from a model the project was established in 1995. Data were collected between 1997 and 2002. In 2001, 66% of the IDUs were married. Interventions consisted of increasing the number of IDUs contacted through clinics or outreach workers; needle exchanges. Needles sharing dropped from 62% in 1997 to 18% in 2001. Condoms, STI services, and needle exchange were also part of the program. The cost per HIV infection averaged among IDUs and their partners was US$110.40. Cost-effectiveness increased based on increasing number of years of the program.
A 2004 quantitative and qualitative study of NGO services by the Women Federation for 226 male and female IDUs in China resulted in safer drug and sex practices. VCT services that respected confidentiality were implemented by three male and three female counselors experienced in delivering health education to IDUs. Ten focus group discussions were held with seven males and three females in each. Exit surveys found that 63% of IDUs were ‘highly satisfied’ with VCT services and the remainder were ‘satisfied.'” One IDU noted: “I was impressed that the Women Federation counselor did not discriminate against me and talked to me politely” (Chen et al., 2007c: 784). Sharing needles was reduced from 45% to 33%; those who always used condoms with non-main partners increased from 7% to 24%. While at the start of the project, 82% never used condoms, this decreased to 35%.
A harm reduction program in Salvador, Brazil that focused on sexual and drug risk reduction among females for 12,198 IDUs in 2002 or 70% of the IDUs in the city resulted in a decrease of contaminated injection equipment from 60% to 18% during the 1990s. Condom use by IDUs increased from 3% to 30%. HIV prevalence among IDUs fell from 50% in 1996 to 7% in 2001. IDUs receiving health services increased from 28% to 68%. The program provided outpatient drug treatment, prevention education and care provided by community outreach workers, needle syringe programs, drug prevention programs in schools and mobile vans.
A 2007 meta-analysis of literature in English on HIV and injecting risk behavior, with three core reviews and 15 supplementary reviews, found that needle exchange programs resulted in reduced self-reported injecting risk behavior but none of the studies assessed HIV prevalence and incidence as an outcome and none of the studies were randomized.
3. Peer education can increase protective behavior, including condom use, among women who use drugs and female partners of men who use drugs.
A meta-analysis of 34 articles from 1990 to 2006, 16 from Sub-Saharan Africa, 16 from East and Central Asia and 2 from Latin America, of which four articles were on IDUs, found that peer education was significantly associated with increased condom use.
A study in Vietnam from 2008 to 2010 that implemented peer-based HIV prevention interventions for the female sexual partners of male IDUs increased self-reported consistent condom use from 16% at 12 months to 27% at 24 months. Condom use at last sex with their primary partner increased from 19% to 38%. Self-reported condom use was 3.5 times higher among those in the intervention group. The most frequently cited reason for not using condoms was that their male partner objected. The intervention reached an average of 1,513 female sexual partners of male IDUs per year of the project, with each having 34 contacts per year. The women were sexual partners of male IDUs who were former or currently put in drug detention centers and most were married with children. Interviews and surveys were conducted.
4. Gender-sensitive sex-segregated group sessions for couples who use drugs can result in increased condom use and safer injection practices.
A Cochrane Review of 35 trials with 11,867 participants found that single sex educational interventions with PWID are effective in reducing sexual and injection drug behavior associated with a greater risk of developing HIV, particularly for those in formal treatment programs.
A study from 2005 to 2006 at Shu Policlinic Needle Exchange Program in a city along a major drug trafficking route in Kazakhstan found a comparison between 40 couples who had single gender group sessions with female and male partner IDUs results in increased condom use and safe injection practices compared with 40 couples who did not have single gender group sessions. None were HIV-positive. Adapted from an HIV prevention intervention with heterosexual couples in the US, in-depth interviews were conducted with IDUs in Kazakhstan to adapt the intervention to Kazakhstan. After consent was obtained with one partner, this partner was asked to invite his or her main partner to participate. If both partners agreed to participate, they were included unless one reported violence. All couples received training consisting of practicing couples communication, problem solving and assertiveness skills. At each session, participants set a risk reduction goal for the week and this is reviewed at the following session. However, the intervention group had two sessions designed to help women anticipate and manage partner negative reactions in response to requests to use condoms or not to share needles. Current and past drug and alcohol use was assessed using the US National Institute of Drug Abuse’s Risk Behavioral Assessment, validated internationally (NIDA, 1991 cited in Gilbert et al., 2010) and condom negotiation self-efficacy was assessment with a five-item scale (Wingood and DiClemente, 1998 cited in Gilbert et al., 2010). All partners reported living together and 41 of 80 reported having children. At baseline, participants reported using condoms only 2% of the time they had vaginal sex (an average of 20 sexual acts) with their study partner in the last 30 days. All reported injecting drugs and participants reported sharing needles with an average of 3.7 different people in the past 30 days and indicated using unclean needles 63% of the times they injected in the past 30 days. Those participants who had single gender group sessions were significantly more likely to report a higher proportion of condom use during vaginal sex with their study partners and a lower number and proportion of injection acts in which syringes were shared at three month follow-up, after adjusting for age, education and sex. In addition, those couples who had single gender group sessions were significantly more likely to increase condom use self-efficacy and couple communication skills. Future research with large randomized trials using biological markers in warranted. “Although no participants tested positive for HIV, if HIV enters the risk networks of IDUs, the pervasive patterns of drug-related and sexual HIV risk behaviors suggest that HIV will spread rapidly” (Gilbert et al., 2010: 173).
An NGO in Russia which established a woman-only IDU drop-in center; mobile bus clinics; provision of supplies, such as sanitary pads for women and diapers for their babies; and female outreach workers resulted in an increase from 2,000 women at one site in 2007 to close to 3,000 in 2009.
5. Instituting harm reduction programs for PWID in prisons can reduce HIV prevalence in female prison populations. [See Women Prisoners and Female Partners of Male Prisoners]
6. Offering no-cost HIV testing and counseling to women who use drugs can lead to reduced HIV risk behaviors.
A 2004 to 2007 study in Ukraine with 1,798 IDUs, 30% married, (76% male) found that those who had HIV testing and counseling, and knew that they were HIV-positive were significantly more likely to practice safe sex than those who did not know their serostatus or who knew that they were HIV negative. For both those who received HIV testing and counseling and those who received HIV testing and counseling plus outreach by a former drug user showed that the proportion of respondents engaged in drug, needle and sex risk behaviors was reduced significantly from the start of the intervention through the six month follow up. HTC is as effective as “more expensive and time consuming approaches” with outreach (Booth et al., 2009: 1872). However, females were more likely to have had unprotected vaginal or anal sex and more likely to have sex with a partner who was also an IDU.
A study in South Africa with 28 drug-using sex workers found that 23 accepted HIV testing when offered no cost rapid testing (Needle et al., 2008; Parry et al., 2008; Parry et al., 2009).
A study from 2002-2004 evaluated the needle use and sexual practices of 266 injecting drug users in Tallinn, Estonia found that those who knew they were HIV-positive engaged in some protective behaviors. The participants had an average age of 25, were 88% male, and had HIV tests. The study found that although 93% of participants knew that HIV could be passed through shared needles and 98% knew that it could be spread through unprotected sex, half of the participants had shared a needle in the last ninety days and 26% had engaged in unprotected sex. However, those who knew that they were HIV-positive were found to be significantly less likely to have given their needles to others: 9% of HIV-positive participants who knew their status lent their needles after use, as compared to 25% of participants who were HIV-positive but did not know their status. Knowledge of one’s HIV serostatus did not impact the likelihood of having unprotected sex.