Women Drug Users and Partners of Male IDUs
Approximately 16 million people in 148 countries are injecting drug users (IDUs). The largest numbers are in China, the United States and Russia, with HIV prevalence among IDUs at 12% in China, 16% in the United States and 37% in Russia. Worldwide, about three million people who are IDUs are also HIV-positive (Mathers et al., 2008).
Though precise data on women who are injecting drug users 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, 2004; UNODC, 2005 cited in Pinkham and Malinowska-Sempruch, 2008; Ralon et al., 2008).
Female IDUs Risk Acquiring HIV from Needle Sharing and Unsafe Sex
There are two major sets of HIV-related risk behavior associated with IDUs: needle sharing, especially borrowing used and contaminated needles from someone else (one of the most direct transmission pathways of HIV transmission), and unsafe sex (Choi et al., 2006). Yet country progress reports for UNGASS found that only 30 out of 145 low- and middle-income countries reported on HIV knowledge and behavior, condom use, HIV testing, safe injecting practices or access to prevention services for IDUs. Median coverage of IDUs with any type of prevention and care services was only 24% and three quarters of countries had prevention services for less than half of the IDUs (Degenhardt et al., 2008).
Despite the limited research on female IDUs and HIV-related behavior, there is evidence that the high HIV risk in female IDUs is associated both with injecting and sexual risk taking (Burrows, 2004). A study of 2,512 male and 672 female IDUs 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. Women are also more likely to be injected by a friend or partner, which increases risk (Pinkham et al., 2008). There is also greater HIV risk in the overlap between injecting drug use and sex work. 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; Nguyen et al., 2008a; Azim et al., 2006; Ross et al., 2008; Galvez-Buccollini et al., 2009; Lau et al., 2007b).
Women Face Greater Stigma and Lesser Access to Harm Reduction Programs Than Men
Although they are at high risk of HIV acquisition, female IDUs in every country have lesser access to services than male IDUs. “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 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). Women lack access to harm reduction and other health services because of even greater stigmatization than male injecting drug users as well as women IDUs’ fear of losing custody of their children (Malinowska-Sempruch, 2002).
Increasing women drug users’ access to needed services, including drug treatment, harm reduction programs, and sexual and reproductive health care services, is crucial. Women IDUs 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 substitution 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, women’s shelters, and violence prevention services” (Pinkham and Malinowska-Sempruch, 2007: 3).
Harm Reduction Programs Can be Scaled Up
It is critical to ensure that governments, donors, and service providers are aware of the HIV risk for female IDUs; that HIV prevention, treatment, and care interventions take account of the needs of female drug users; and that female IDUs participate in policy and program development. There are effective evidenced-based interventions that reduce HIV risk for female IDUs and some of them are being brought to scale (see example on China, Sullivan and Wu, 2007 in this section). However, many harm reduction programs remain at a pilot stage for years, due to a lack of political will to bring them to scale (IHRD, OSI, 2008). It is time for successful programs to be scaled up in order to more effectively reduce HIV prevalence, particularly among IDUs.