Women Who Use Drugs and Female Partners of Men Who Use Drugs
Gaps in Research
- 1.
- Interventions are needed to provide women and their partners with a better understanding of the risk of acquiring HIV through sexual practices as well as through injecting drug use (IOM, 2007).
- 2.
- Family-friendly interventions are needed for women and couples who use drugs so that women are not forced to choose between harm reduction programs and caring for their families.
- 3.
- Women who use drugs need access to services for violence against women, dual method use, effective contraception and reproductive health.
- 4.
- Interventions are needed to inform women who use drugs of harm reduction early in pregnancy and to ensure systematic access to opioid agonist treatment during pregnancy and in hospitals for birth and postpartum.
- 5.
- Additional research is needed to assess which opioid agonist therapy is best for pregnant women.
- 6.
- Adolescent girls who use drugs need risk reduction programs to meet their needs.
- 7.
- Integrated harm reduction programming is needed for sex workers who use drugs.
- 8.
- HIV prevention information and confidential services are needed for PWID receiving treatment for substance use.
- 9.
- Interventions are needed to scale up and increase access to methadone and buprenorphine—effective agonist therapy for the treatment of drug dependence, as well as needle exchange/distribution programs.
- 10.
- Efforts are needed to eliminate compulsory drug detention and instead, provide PWID with HIV prevention and testing services and effective drug dependency treatment by medical professionals.
- 11.
- PWID need equitable access to antiretroviral therapy.
- 12.
- HIV prevention interventions are needed for methamphetamine, crack, midazolam and/or heroin.
- 13.
- Migrant PWID are at high risk of acquiring HIV and require programming collaboration between countries.
1. Interventions are needed to provide women and their partners with a better understanding of the risk of acquiring HIV through sexual practices as well as through injecting drug use (IOM, 2007). Studies found low rates of condom use despite sexual relationships with IDUs, lack of knowledge by IDUs on sexual and reproductive health and lack of access to clean needles. A study also found that many MSM and male intravenous drug users avoid disclosure of their sexual and drug risk behavior along with their HIV status due to stigma and gender norms and that most wives reported violence and little or no condom use. HIV-positive male IDUs want help with disclosure to their wives. Most wives of IDUs reported only a single lifetime sexual partner and only a tiny proportion reported injecting drug use.
Gap noted, for example, in Vietnam (Hammett et al., 2010); China (Jiang et al., 2010); India (Solomon et al., 2010a); Brazil (Nappo et al., 2011); globally (Roberts et al., 2010); Russia (Toussova et al., 2009); Vietnam (Nguyen and Scannapieco, 2008; Go et al., 2006); Brazil (d'Oliveira et al., 2007); Ukraine (Strathdee et al., 2010); South Africa (Parry et al., 2010); and generally (IOM, 2007; Roberts et al., 2010).
2. Family-friendly interventions are needed for women and couples who use drugs so that women are not forced to choose between harm reduction programs and caring for their families.
Gap noted in Ukraine (Needle and Zhao, 2010) and Kenya and Tanzania (Nieburg and Carty, 2011).
3. Women who use drugs need access to services for violence against women, dual method use, effective contraception and reproductive health. Studies found high rates of violence, including rape, and lack of access to reproductive health services among women who use drugs. One study found high rates of unintended pregnancies.
Gap noted, for example, for Russia (Abdala et al., 2011; Sarang et al., 2010); Cambodia (HRW, 2010a); Kyrgyzstan, Kazakhstan, and Tajikistan (Shapoval and Pinkham, 2011); South Africa (Wechsberg et al., 2008 cited in El-Bassel et al., 2010; Parry et al., 2009) and Kenya and Tanzania (Nieburg and Carty, 2011).
4. Interventions are needed to inform women who use drugs of harm reduction early in pregnancy and to ensure systematic access to opioid agonist treatment during pregnancy and in hospitals for birth and postpartum. Some studies have shown increased risk adverse health impacts as well as of vertical transmission among women who use drugs which may be mitigated by harm reduction [See Antenatal Care - Treatment]
Gap noted, for example, in Ukraine (Pinkham and Shapoval, 2010); Kyrgyzstan, Kazakhstan, and Tajikistan (Shapoval and Pinkham, 2011); Kenya and Tanzania (Nieburg and Carty, 2011); globally (Wang and Ho, 2011).
5. Additional research is needed to assess which opioid agonist therapy is best for pregnant women. A Cochrane review assesses methadone as compared to buprenorphine and oral slow morphine, but only three trials were found with 96 pregnant women and further research is needed [See Antenatal Care - Treatment]
Gap noted globally (Minozzi et al., 2009).
6. Adolescent girls who use drugs need risk reduction programs to meet their needs. A study found high rates of HIV risk behaviors among adolescent girls who use drugs, especially those who lived on the streets, as well as high rates of forced sex. Risk behaviors start at early ages (up to 30% reported being under age 15 when they first injected) (UNICEF, 2013; UNESCO, 2012c), yet younger girls who inject drugs are not being reached by existing harm reduction and HIV prevention services. Current guidelines also do not consider how best to reach adolescents (Krug et al., 2015). Age restrictions hinder adolescent access to services (Krug et al., 2015).
Gap noted, for example, in Bosnia and Herzegovina; Romania; Moldova; Serbia and Roma in different countries (UNICEF, 2013) Ukraine (Busza et al., 2010; Teltschik et al., 2008).
7. Integrated harm reduction programming is needed for sex workers who use drugs. Site visits and a meeting of service providers, NGOs and people who use drugs found that programs for drug users and sex workers are provided separately, with the result that drug using sex workers are excluded from most services.
Gap noted, for example, in Kyrgyzstan, Kazakhstan, and Tajikistan (Shapoval and Pinkham, 2011).
8. HIV prevention information and confidential services are needed for PWID receiving treatment for substance use. Increased skills training for HIV disclosure to sexual partners is needed. Despite high numbers of PWID who are HIV-positive, no HIV nor drug prevention programs focus on PWID. No national guidelines exist for drug treatment.
Gap noted, for example, in Hungary (Gyarmathy et al., 2011a); Russia (Niccolai et al., 2010); South Africa (Scheibe et al., 2011; Parry et al., 2010) and Central Asia (Thorne et al., 2010).
9. Interventions are needed to scale up and increase access to methadone and buprenorphine—effective agonist therapy for the treatment of drug dependence, as well as needle exchange/distribution programs. Studies found only tiny fractions of those who need maintenance medication had access. A study found that user fees for methadone maintenance programs presented a barrier to access to care. In places where no needle exchange programs are operating, high rates of borrowing of used syringes occur, placing IDUs at high risk of acquiring HIV.
Gap noted, for example, in Iran (Claeson, 2011); Ukraine (Izenberg and Altice, 2010); Vietnam (Nguyen et al., 2012b); Indonesia (Afriandi et al., 2010); Thailand (Kerr et al., 2010c); China, Russia, Vietnam, Ukraine and Malaysia (Wolfe et al., 2010); Mexico (Moreno et al., 2010); Thailand, Indonesia, Bangladesh, Myanmar, India and Nepal (Sharma et al., 2009); and generally (Piot et al., 2008; Mattick et al., 2003; Gowing et al., 2005 cited in IOM, 2007).
10. Efforts are needed to eliminate compulsory drug detention and instead, provide PWID with HIV prevention and testing services and effective drug dependency treatment by medical professionals. Detention centers are administered by police, military or other national government public security authorities and operate outside the form criminal justice system with detainees held without trial or right of appeal and those detained do not allow people to leave voluntarily (Wolfe, 2012). Studies found that women who use drugs were not given reproductive health services, including PMTCT services in compulsory detention and/or prison settings. Detoxification programs were substandard and ineffective. Despite high rates of HIV, antiretroviral treatment is largely unavailable in compulsory drug detention centers. One study found high rates of injecting drug use within prison and high rates of syringe sharing within prisons plus incarceration was not associated with reduction in drug use, with over a quarter of these female drug users. PWID in and out of prison who have started antiretroviral treatment should be able to continue treatment with access to medical supervision. Treatment in compulsory drug detention takes the form of sanction rather than therapy, with high relapse rates.
Gap noted, for example, Azerbaijan, Georgia, Kyrgyzstan, Russia and the Ukraine (OSI, 2009); Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan (UNODC, 2010a); China (Jia et al., 2010; HRW, 2010b; Sullivan and Wu, 2007: 121; Liu et al., 2006a: 119); Cambodia (HRW, 2010a); Ukraine (Strathdee et al., 2010); South Africa (Parry et al., 2010); Thailand (Hayashi et al., 2009); Vietnam (Thanh et al., 2009a); and generally (Wolfe et al., 2010; Jurgens et al., 2010; Cowan et al., 2008); Cambodia, China, Malaysia and Vietnam (WHO et al., 2011b).
11. PWID need equitable access to antiretroviral therapy. PWID have successfully started antiretroviral therapy in at least 50 countries but PWID are disproportionally less likely than other patients with HIV to receive antiretroviral therapy, even in the countries where PWID represent most of the HIV-positive population. In 2008, PWID were 67% of HIV cases in five countries with the largest HIV epidemics concentrated in PWID yet only 25% of those receiving ART (Wolfe et al., 2010). [See also Treatment]
Gap noted, for example, in Malaysia (Bergenstrom and Abdul-Quader, 2010); Russia, Vietnam and China (Wolfe et al., 2010).
12. HIV prevention interventions are needed for methamphetamine, crack, midazolam and/or heroin. People who use various drugs are at high risk of acquiring HIV and amphetamine is often used to enhance and prolong sexual pleasure and to reduce sexual inhibitions. High rates of HIV were found in a group of female crack users and sex workers using amphetamines. There is no effective pharmacotherapy, such as methadone, for cocaine or methamphetamine.
Gap noted, for example, in Thailand (Martin et al., 2010); Cambodia (Couture et al., 2011); Burkina Faso, Niger, South Africa, Uganda, Brazil, Mexico, Guatemala, Jordan, Saudi Arabia, Czech Republic, Latvia, Slovakia, Estonia, Ukraine, Philippines, South Korea and Indonesia (Colfax et al., 2010); Brazil (von Diemen et al., 2010).
13. Migrant PWID are at high risk of acquiring HIV and require programming collaboration between countries. A study of PWID at a border town found high rates of sharing injecting equipment and that border crossing was strongly associated with sharing injection equipment.
Gap noted for China and Myanmar (Williams et al., 2011a).