Volume 376, Issue 9738, Pages 312 - 314, 31 July 2010
HIV and women who use drugs: double neglect, double riskNabila El-Bassel a b , Assel Terlikbaeva b, Sophie Pinkham c
HIV infections continue to rise in drug-involved women, especially injecting drug users in Asia and eastern Europe,1 and in crack-cocaine users in the USA and other countries.2 Women who use drugs are doubly at risk for HIV infection via unprotected sex and unsafe injections.3 These women have exceptional needs that have not been addressed in current global HIV-prevention strategies.2, 4 Drug-treatment and HIV-prevention programmes are usually designed and run by men, and therefore might not be sensitive to the unique needs of women. Drug treatment, harm reduction, and HIV programmes for women are near universally underfunded despite evidence of efficacy.5 The challenges facing drug-involved women mandate a call to action for this often hidden and neglected population.
Many women who use drugs lack the power to negotiate safer sex.2, 4, 6 Yet, most available HIV-prevention strategies put the onus on women to insist on safe sex, increasing their risk of physical and sexual abuse.4, 6 Drug-involved women often rely on their partners to procure the drugs that they share,3, 4, 6 and because women are often injected by their partners,3 they are “second on the needle”, which increases their risk for infection by HIV and other pathogens. Refusing to share needles and syringes can also increase women's risk of physical and sexual intimate partner violence, further potentiating risks for HIV infection.6 Women who turn to alternative survival methods, such as sex trading,7 increase their risk of HIV infection and intimate partner violence and other traumatic experiences. The prevalence of lifetime sexual and physical intimate partner violence in drug-involved women, particularly in crack-cocaine users, are three times higher than in women who do not use drugs, and intimate partner violence is a major factor in HIV-infection risk.2, 4 However, too few evidence-based HIV-prevention strategies address these complex interactions holistically.
Few drug-treatment and HIV-prevention programmes attempt to help women who suffer intimate partner violence and sexual trauma, and fewer still emphasise reproductive health.2, 4 In many countries, pregnant drug users face major barriers to accessing HIV-prevention services and to staying in treatment, and many face criminal sanctions if they continue to use while pregnant.7 Most programmes do not educate clients on the effects of drug use on pregnancy, and many lack child-care provisions. The stigma and criminalisation of drug use during pregnancy drives women to conceal their addictions from health-care providers, keeping them from accessing HIV prevention, treatment, and care and from learning about prevention of mother-to-child transmission.7, 8 Failure to address the needs of pregnant drug-involved women will ensure that the cycle of addiction and HIV infection are passed to the next generation.
While some women and their partners make use of services for HIV prevention and for drug treatment, such programmes rarely offer couple-based interventions. Among drug-involved couples in the USA and Central Asia, many women prefer to include their partners in the prevention of HIV infection. Counselling couples together sends a message that the responsibility for HIV risk reduction rests with both partners, and underscores that each places the other at risk for HIV acquisition. Couple-based HIV-prevention modalities can help couples more safely disclose extra-dyadic sexual relationships, sexually transmitted infection histories, injection drug use, or histories of abuse. Partners are more able to discuss gender differences, power imbalances associated with sexual coercion, and the inability to negotiate condom use, and gender inequalities in needle sharing.6
Although social network, peer-led, and community mobilisation are effective in reducing HIV infection and improving access to HIV prevention, treatment, and care,9 too few focus on women who use drugs. Drug-involved women face economic difficulties: unemployment rates are high, and job access is limited.10 Income-generating interventions are rarely incorporated into services to prevent HIV infection and need to be to address the life issues these women face.10, 11
To address this neglected component of global HIV, we call for action on evidence-based multilevel strategies to prevent HIV infection in drug-using women, targeting individuals, couples, social networks, and public policy (panel). Women-focused efforts to prevent HIV infection will remain a major public health priority even when vaccines and microbicides become available. It is, therefore, imperative that such efforts address women's complex needs to slow HIV spread, and save lives.
Strategies to prevent HIV infection in drug-using women
- Trauma-informed strategies that concurrently address co-occurring problems of intimate partner violence and drug use.
- Couple-based HIV prevention, treatment, and care options for drug-involved women and their sex partners that include skills building for safe-sex negotiation within context of ongoing drug use.
- Empowerment strategies, such as social network, community-based, community mobilisation, and peer-led interventions.
- Income-generating interventions for women (including job training and microfinance, access to employment).
- Public policies that: fight discrimination and gender-based violence; stop police mistreatment, arrest, and registration of female drug users; and increase access to drug treatment and care.
- Increased funding to make drug treatment, harm reduction, and HIV-prevention services more available and friendly to women, by addressing the needs of pregnant women, mothers, and women with a history of intimate partner violence and trauma; and by protecting human rights of women who use drugs.
- Increased research funding to improve and support women-specific evidence-based services, and to improve knowledge on global epidemiology of women who use drugs, especially in developing countries. Researchers must make greater attempts to include women, even if they are harder to recruit due to being fewer in number and hidden.
We declare that we have no conflicts of interest.
1 Joint UN Programme on HIV/AIDS. 2008 Report on the global AIDS epidemic. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008. (accessed June 13, 2010).
2 Wechsberg WM, Luseno W, Riehman K, Karg R, Browne F, Parry C. Substance use and sexual risk within the context of gender inequality in South Africa. Subst Use Misuse 2008; 43: 1186-1201. CrossRef | PubMed
3 Bryant J, Brener L, Hull P, Treloar C. Needle sharing in regular sexual relationships: an examination of serodiscordance, drug using practices, and the gendered character of injecting. Drug Alcohol Depend 2010; 107: 182-187. CrossRef | PubMed
4 El-Bassel N, Gilbert L, Wu E, Go H, Hill J. HIV and intimate partner violence among methadone-maintained women in New York City. Soc Sci Med 2005; 61: 171-183. CrossRef | PubMed
5 Carael M, Marais H, Polsky J, Mendoza A. Is there a gender gap in the HIV response? Evaluating national HIV responses from the United Nations General Assembly Special Session on HIV/AIDS country reports. J Acquire Immune Defic Syndr 2009; 52 (suppl 2): S111-S118. PubMed
6 El-Bassel N, Gilbert L, Wu E, Go H, Hill J. Relationship between drug abuse and intimate partner violence: a longitudinal study among women receiving methadone. Am J Public Health 2005; 95: 465-470. CrossRef | PubMed
7 Pinkham S, Malinowska-Sempruch K. Women, harm reduction and HIV. Reprod Health Matters 2008; 16: 168-181. CrossRef | PubMed
8 Open Society Institute. Women, harm reduction, and HIV: key findings from Azerbaijan, Georgia, Kyrgyzstan, Russia, and Ukraine. http://www.idpc.net/sites/default/files/library/wmhreng_20091001.pdf. (accessed June 13, 2010).
9 Latkin CA, Donnell D, Metzger D, et al. The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA. Soc Sci Med 2009; 68: 740-748. CrossRef | PubMed
10 Auerbach J. Transforming social structures and environments to help in HIV prevention. Health Aff (Millwood) 2009; 28: 1655-1665. CrossRef | PubMed
11 Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet 2008; 372: 669-684. Summary | Full Text | PDF(261KB) | CrossRef | PubMed
a Columbia University School of Social Work, New York, NY 10025, USA
b Columbia University Global Health Research Center of Central Asia, Almaty, Kazakhstan
c AIDS Foundation East West, Kiev, Ukraine