WOMEN AND HARM REDUCTION
By Women for women.
Harm reduction among women who use drugs
Tasnim Azim
20th International AIDS Conference 2014
21 July 2014, Melbourne
www.icddrb.org
WOMEN WHO INJECT DRUGS ARE SIGNIFICANT IN
NUMBER: GLOBAL FIGURES
Number of people who inject drugs (PWID):
~16 million
Number of females who inject drugs (FWID):
~3.5 million
FWID are more likely to be HIV positive than males
who inject drugs (MWID):
1.18 times
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Mathers et al, 2008; Des Jarlais et al, 2012
HIV prevalence is higher among females who
use drugs around the world
70%
62%
60%
HIV
50%
42.8%
40.3%
38.5%
40%
34.6%
34.5%
33.0%
33.0%
31.3%
28%
27.9%
30%
FWID
MWID
20%
10.1% 9.5%
10%
6.30%
0%
Southern
and Eastern
Europé
North
Latin
Western Central Asia Tanzania
America America and and Central
Caribbean
Europé
Nepal
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Des Jarlais et al 2012 and 2013; Lambdin et al, 2013; Ghimire et al, 2013
HARM REDUCTION SERVICES FOR WOMEN
WOMEN SUBSTANCE USERS HAVE SPECIAL NEEDS
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Multiple vulnerabilities and risks faced by women who
use drugs and sell sex result in a high risk of HIV
sharing needles and syringes
street based sex work
sexual concurrency
high-risk sex
lack of control
experience sexual violence
highly stigmatized
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HIV and STI
risk
WOMEN, DRUG USE AND SEX WORK: A DUAL
RISK
The combination of selling sex and using illicit
drugs is common
Tanzania: 85%
Nepal: 50%
Bangladesh: 63%
FWID who
sell sex
FWID who do
not sell sex
Women often sell sex to support their own or their partner’s drug use
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Lambdin et al, 2013; Ghimire et al, 2013; Azim et al, 2006
WOMEN WITH PARTNERS WHO INJECT DRUGS
FWID are more likely to have
MWID as their intimate
partners and are often relying
on them for acquiring and
injecting drugs
The relationship is one of trust,
fear and dependence –
emotional and economic
BUT – often men control their
lives
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El-Bassel et al, 2014; Des Jarlais et al, 2012; Shanon et al, 2008
Control over drugs –
obtaining, taking
Increased
Relationship of
FWID with
MWID partners
Control over clients
of FWID-SW - Role
as pimps
Control over
condom use
Violence and threat
of violence –
physical and sexual
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vulnerability
to HIV/STI
SPECIAL NEEDS: REPRODUCTIVE HEALTH CARE
• Non-judgmental
antenatal clinics
• Birth control
• Advice on birth
spacing
• Point of Care STI
services
• Pelvic exams
• HPV vaccination
• Abortion services
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SPECIAL NEEDS: CHILD CARE
Having children and needing to provide care for them can be a
motivation for making lifestyle changes including reducing drug use
Relapse following drug treatment more
common among FWID and women
without children to support were more
than three times likely to relapse
Reasons for not accessing services for
child care:
•lack of child care services
•fear of losing their children if they
contact service providers
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Rolon et al, 2013; UNODC and icddr,b 2010; Maehira et al, 2013
STIGMA AND DISCRIMINATION
FWID are highly stigmatized and discriminated by all strata of
society
“when I visit any house they assume I am a thief” –FWID from
Bangladesh
“they (women who use drugs) are liars, big liars …and they are
ready to go as far as possible… they are ready to sell themselves…”
– Georgia, general view
“generally the attitude of police towards a drug user is similar to
their attitude towards criminals and not sick people… their attitude
towards women is even worse than to men…” – FWID from Georgia
Stigma can be a barrier for access to services
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UNODC and icddr,b 2010; Otiashvili et al, 2013; El-Bassel et al, 2014
VIOLENCE
Experienced commonly - physical and sexual
Perpetrators include:
Law enforcement
• Intimate partners
• Clients
There is a general feeling by FWID-SW that clients will not be
criminalized for the violence and that women will not be
protected by police
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Otiashvili et al, 2013
INTERVENTIONS: WHAT CAN WORK
Behavioural interventions:
Safer sex and injection practices, enhanced
negotiation skills, couple-based approaches
Structural interventions:
Access to safe housing and spaces for sex work,
access to non-discriminatory health services
Biomedical interventions:
HIV testing and treatment, PrEP, PEP and TasP
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TWO THEORY-BASED INTERVENTIONS
Trained female counselors used motivational interviewing , roleplays and worked with the women identify their risks and set goals
to reduce risks
• Interactive Sexual Risk Intervention (30 min.)
for negotiating condom use within the context of their own or
their clients’ substance use.
• Interactive Injection Risk Intervention (30 min.)
to identify where they felt their injection behaviors fit on a risk
ladder, and set goals for reducing their risks. A short video was
developed illustrating how injection equipment can become
contaminated.
• Lecture formats of each intervention (30 min each)
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Strathdee et al, 2013
Mujer Mas Segura: Ciudad Juarez, Mexico
The behavioural
intervention was associated
with:
•95% reduction in sharing
syringe equipment
•>50% reduction in STI/HIV
infections
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Strathdee et al, 2013
VANCOUVER, CANADA:
INTERVENING ON RISKY SPACES
“I think by them putting an eleven o’
clock curfew, they’re putting myself in
jeopardy, so I can’t do dates in my place
[SRO room] where it’s safe”
- Woman living in a SRO
“My landlord when he found out I was
working he gave me an eviction notice.
He said there’s no workers allowed
living here…I had to go in a shelter”
- Woman living in a shelter
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UNSANCTIONED SAFER SEX WORK ENVIRONMENT
MODEL
Building/Management Policies:
•Women-only building (including residents, staff, and management)
•Women allowed to bring clients into their rooms during facilities’
guest hours
•Clients required to register at the front desk
•Women not allowed to have ≥1 guest at a time
Environmental Cues/Security Measures:
•“Bad-date” reports of recent client violence are posted at the
building entrance
•A camera system throughout hallways to detect incidents of violence
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Krusi et al, 2012
UNSANCTIONED SAFER SEX WORK ENVIRONMENT
MODEL
Access to Health, Prevention, and Harm Reduction Resources
• Condoms, syringes, and other harm reduction
paraphernalia are available on site.
• Medication is dispensed on site (including methadone and
antiretroviral therapy).
• General practitioners, nurses, and mental health workers
regularly visit the buildings.
Women found this model made it easier for them to practice
safer sex, access harm reduction and treatment services
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Krusi et al, 2012
ACCESS TO TESTING AND TREATMENT INCLUDING
PreP, PEP and TasP
Community-based HIV testing
increases uptake among
stigmatized groups, with good
linkage to treatment and care
(up to 99% among FSW and
94% among PWID).
Oral pre-exposure prophylaxis
(tenofovir) reduced HIV by 79%
among FWID in Bangkok.
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Suthar et al, 2013; Choopanya et al 2013
ACCESS TO TESTING AND TREATMENT INCLUDING
PreP, PEP and TasP
Post-exposure prophylaxis (PEP)
effectively prevents HIV infection if
taken within 72h after high-risk
exposure, such as rape
Treatment as Prevention (TasP):
Antiretroviral treatment improves the
health of the infected person and
reduces the risk of further
transmission.
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WHO guidelines, 2013
RECOMMENDATIONS
• Harm-reduction, reproductive health and HIV services must be
available for women who use drugs in culturally sensitive and
non-judgemental environments
• Since sex work is common among FWID, harm reduction should
be included in all interventions for sex workers and safer sex
messages should be part of all harm reduction programs for
FWID.
• Couple-based interventions are effective for decreasing drug use
and HIV risk behaviours and should be widely available
• Interventions must focus on strengthening the ability of women
to achieve autonomy over HIV risk reduction practices, including
freedom from pimps and police harassment and availability of
safe places to take clients
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WE GRATEFULLY ACKNOWLEDGE ALL WOMEN WHO USE DRUGS AND WHO
HAVE SHARED THEIR STORIES WITH US
icddr,b thanks its Core Donors
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