By Women for women. Harm reduction among women who use drugs

1. By Women for women. Harm reduction among women who use drugs WOMEN AND HARM REDUCTION Tasnim Azim 20th International AIDS Conference 2014 21 July 2014, Melbourne

2. 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 Mathers et al, 2008; Des Jarlais et al, 2012

3. HIV prevalence is higher among females who use drugs around the world HIV Des Jarlais et al 2012 and 2013; Lambdin et al, 2013; Ghimire et al, 2013

4. HARM REDUCTION SERVICES FOR WOMENWOMEN SUBSTANCE USERS HAVE SPECIAL NEEDS

5. 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 HIV and STI risk high-risk sex lack of control experience sexual violence highly stigmatized

6. WOMEN, DRUG USE AND SEX WORK: A DUAL RISK The combination of selling sex and using illicit drugs is common FWID who sell sex FWID who do not sell sex • Women often sell sex to support their own or their partner’s drug use Lambdin et al, 2013; Ghimire et al, 2013; Azim et al, 2006

7. 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 El-Bassel et al, 2014; Des Jarlais et al, 2012; Shanon et al, 2008

8. Control over drugs – obtaining, taking Increased vulnerability to HIV/STI Control over clients of FWID-SW - Role as pimps Relationship of FWID with MWID partners Control over condom use Violence and threat of violence – physical and sexual

9. 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

10. 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 Rolon et al, 2013; UNODC and icddr,b 2010; Maehira et al, 2013

11. 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 UNODC and icddr,b 2010; Otiashvili et al, 2013; El-Bassel et al, 2014

12. VIOLENCEExperienced commonly - physical and sexual 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 Perpetrators include: • Law enforcement • Intimate partners • Clients Otiashvili et al, 2013

13. INTERVENTIONS: WHAT CAN WORK Behavioural interventions: Safer sex and injection practices, enhanced negotiation skills, couple-based approaches Structuralinterventions: Access to safe housing and spaces for sex work, access to non-discriminatory health services Biomedicalinterventions: HIV testing and treatment, PrEP, PEP and TasP

14. TWO THEORY-BASED INTERVENTIONS Trained female counselors used motivational interviewing , role-plays 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) Strathdee et al, 2013

15. MujerMas Segura: Ciudad Juarez, Mexico • The behavioural intervention was associated with: • 95% reduction in sharing syringe equipment • >50% reduction in STI/HIV infections Strathdee et al, 2013

16. 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

17. UNSANCTIONED SAFER SEX WORK ENVIRONMENT MODEL Building/Management Policies: Women-onlybuilding (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 Krusi et al, 2012

18. 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 Krusi et al, 2012

19. ACCESS TO TESTING AND TREATMENT INCLUDINGPreP, 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. Suthar et al, 2013; Choopanya et al 2013

20. ACCESS TO TESTING AND TREATMENT INCLUDINGPreP, 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. WHO guidelines, 2013

21. 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

22. WE GRATEFULLY ACKNOWLEDGE ALL WOMEN WHO USE DRUGS AND WHO HAVE SHARED THEIR STORIES WITH US icddr,b thanks its Core Donors