Women Drug Users and Partners of Male IDUs

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 substitution treatment for opiod- dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opiod 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” . These reductions in risk behaviors related to drug use result in lower rates of HIV (Gowan et al., 2008).. 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 (Jurgens et al., 2009b). (Gray III)

A 2009 review of international implementation of opiod substitution found that opiod substitution 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 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.

A methadone maintenance therapy resulted in decreased HIV prevalence in an IDU population in Iran from March 2003 to March 2007 from 3.39% to 2.99%, based on annual sero-surveillance data from 400 sentinel surveillance sites, using samples collected from about 100 sites each year, with 25% of samples collected from IDU criminals. Methadone maintenance coverage increased from 300 to 8,048 prisoners during this time . No sex disaggregated data was given, but according to the UK Prison Center, 3.7% of Iranian prisoners are women. According to UNDOC, 9.4% of the more than 1,200,000 IDUs in Iran are women.

Evidence from prospective cohort and case control studies show that continuous maintenance treatment, such as methadone, is associated with protection against HIV seroconversion.

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” ..

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.

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.

“Australia and New Zealand have maintained very low levels of HIV infection, despite a higher prevalence of injecting than in some other countries; this difference has been attributed to …swift introduction of needles and syringe programmes when HIV infection was first noted in the 1980s.

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.

In 2006, Taiwan instituted a harm reduction program for IDUs, including methadone treatment, syringe exchange, and VCT, along with educational campaigns. By 2007, 3,299 IDUs (no sex given) were enrolled in methadone programs and 109 stations provided no cost needle exchange and counseling. In 2006, the number of new HIV infections decreased by 43% in comparison with that in 2005; and decreased 44% in 2007 compared to 2006. In addition, crime events related to drug use dropped significantly from 2005 to 2007.

A 2008 study of IDUs (no sex disaggregated data provided) in Taiwan compared a region that instituted harm reduction with a region that did not institute harm reduction and found a statistically significant reduction in HIV prevalence in the region that instituted harm reduction. In the region with no harm reduction measures, HIV prevalence increased from under 2% to over 3%; in the region with harm reduction, HIV prevalence was reduced from over 37% to fewer than 19%. In-depth interviews and questionnaires were collected from 3,740 IDUs attending detention centers.

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.

In China, methadone maintenance treatment programs, needle-syringe programs, outreach and access to HIV testing has been scaled up. The introduction of harm reduction “has been a massive turn-around in thinking by the government, particularly law enforcement agencies, and “achieving this has required considerable cooperation and understanding between the Ministries of Health, Public Security, and Justice, and the Food and Drug Administration” . China’s most recent policy, “Five-year action plan to control HIV/AIDS, 2006-2010” officially endorses a harm reduction policy, with the Chinese central government openly supporting harm reduction. An initial trial of methadone maintenance treatment took place in eight clinics in 2004 with data indicating reductions in heroin use, and “importantly, of the 177 clients who were able to be followed for HIV status, none became infected” (Sullivan and Wu, 2007: 122). 320 clinics provided methadone maintenance with additional scale up planned and these have benefited 27,000 heroin users. Needle exchange programs are being scaled up from 93 locations, with plans to increase to 1,400 to serve 70,000 IDUs. Needle exchange programs also provide harm reduction services, such as condoms, HIV testing, antiretroviral treatment, etc. “China has made significant progress towards implementing and enhancing harm reduction programs…” (Sullivan and Wu, 2007: 126).(However, in 2007 and 2008 in China, arbitrary arrest of suspected IDUs, mandatory HIV testing without disclosure while detained in detoxification centers and withholding HIV and drug dependency treatment to detainees was reported (HRW, 2008). (Gray V).)

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 with trained peer outreach workers, along with referral data systems increased the numbers of IDUs and sex workers who accessed VCT, from 1,230 (23%) prior to the project between October 2004 and March 2006 to 5,585 (44%) between April 2006 and November 2007.

A pilot project in Vietnam that used peer educators to provide HIV care and support found that conducted focus groups discussions with 38 people living with HIV, including IDUs, found that peer support was critical. IDUs avoided health providers who they felt stigmatized them both for being IDU and HIV-positive.

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 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: 175).

In **Vietnam**, cross sectional surveys of 33 sexual partners of IDUs at baseline and 24 months later found that women’s clubs, peer education and condom distribution increased condom use and no surveyed female sexual partner of a male IDU became HIV-positive. Condom use increased among seven female partners from 28% at baseline to 100% after 34 months, and among 26 sexual partners in a different district from 29% at baseline to 46% after 24 months.

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” . 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% (Chen et al., 2007).

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.

In Central Asia, 62 percent of new HIV cases were caused by injecting drug use. An intervention in Uzbekistan and Kyrgyzstan, “Break the Cycle,” educated youth (no sex disaggregated data) about the risks of injecting drug use and also reached out to current IDUs to prevent drug initiation. The program encouraged current IDUs to refuse to help others inject drugs for the first time, to develop skills for refusing such requests, not to inject in the presence of non-users, and not to talk about the perceived benefits of injecting drugs. The intervention asked current IDUs to participate in the program’s design and implementation and built on existing harm reductions services by reaching out to current IDUs through rehab and clean needle syringe programs. Results indicate that estimated new IDUs dropped by 55% between 2006 and 2008. Additionally, “from 2006 to 2008, the percent of IDUs assisting with first injection dropped 14% in Uzbekistan and 9% in Kyrgyzstan.” The study also noted that “drug users appreciated being supported to deal with pressure from drug-curious youth,”.