Women, Harm Reduction and HIV

Abstract

Gender shapes the experience of drug use and its associated risks. In most parts of the world, however, harm reduction and drug treatment programmes that tailor their services to meet women’s needs are rare or nonexistent. Many existing services inadvertently exclude women, and discriminatory policies and social stigma drive women drug users from care and expose them to human rights abuses. Women drug users often provide sex in exchange for housing, sustenance and protection, suffer violence from sexual partners and practise unsafe sex. This paper, drawing upon evidence from existing studies, examines ways in which gender-related factors can increase women drug users’ vulnerability and decrease their access to harm reduction, drug treatment and sexual and reproductive health services. It recommends designing services with low-threshold access for women drug users that help them to become more independent, involving the women in designing services and policies, making programmes available for mothers, incorporating sexual and reproductive health into harm reduction services, providing gender-sensitive drug treatment and integrated harm reduction programmes for drug-using sex workers, connecting with domestic violence and rape prevention services and educating mainstream providers. Overall, investigating the circumstances women drug users face will help to formulate policies and programmes that better serve women who use drugs.

Résumé

L’homme et la femme ne sont pas égaux face à l’usage de drogues et aux risques associés. Pourtant, les programmes de réduction des risques et de désintoxication adaptés aux besoins des femmes sont rares ou inexistants. Beaucoup de services excluent sans le vouloir les femmes, et les politiques discriminatoires et la stigmatisation sociale les privent souvent de soins et les exposent aux violations de leurs droits. Fréquemment, les consommatrices de drogues ont des relations sexuelles en échange d’un logement, de nourriture et de protection, elles subissent des violences de leurs partenaires et ont des rapports sexuels non protégés. Cet article, fondé sur les études disponibles, examine comment les facteurs propres à leur sexe peuvent accroître la vulnérabilité des consommatrices de drogues et diminuer leur accès aux services de réduction des risques, de désintoxication et de santé génésique. Il recommande plusieurs mesures : concevoir des services aisément accessibles aux consommatrices de drogues afin de les aider à devenir plus indépendantes ; les associer à la conception des services et des politiques ; proposer des programmes aux mères ; inclure la santé génésique dans les services de réduction des risques ; assurer des services spécifiques de désintoxication et des programmes intégrés de réduction des risques pour les professionnelles du sexe qui consomment des drogues ; faire la liaison avec les services de prévention des violences conjugales et des viols ; former les praticiens non spécialisés. Dans l’ensemble, étudier la situation des consommatrices de drogues aidera à formuler des politiques et des programmes mieux adaptés à leurs besoins.

Resumen

El género influye en la experiencia del consumo de drogas y los riesgos asociados. Sin embargo, en la mayor parte del mundo, rara vez existen programas de reducción de daños y tratamiento de drogodependencia que adaptan sus servicios para atender las necesidades de las mujeres. Muchos de los servicios ya establecidos inadvertidamente excluyen a las mujeres, y las políticas discriminatorias y el estigma social ahuyentan a las usuarias de drogas de la atención que necesitan y las exponen a abusos de los derechos humanos. Las usuarias de drogas a menudo tienen relaciones sexuales a cambio de vivienda, sustento y protección, sufren actos de violencia perpetrados por parejas sexuales y practican sexo sin protección. En este artículo, basado en la evidencia de estudios ya realizados, se examinan las formas en que los factores relacionados con el género pueden aumentar la vulnerabilidad de las usuarias de drogas y disminuir su acceso a los servicios de reducción de daños y tratamiento de drogodependencia, así como de salud sexual y reproductiva. Se recomienda diseñar servicios con acceso de bajo umbral para usuarias de drogas, que las ayuden a ser más independientes, incluir a las mujeres en la elaboración de servicios y políticas, tener programas disponibles para las madres, incorporar la salud sexual y reproductiva en los servicios de reducción de daños, proporcionar tratamiento de drogodependencia sensible al género e integrar los programas de reducción de daños para trabajadoras sexuales usuarias de drogas, conectar a los servicios para la prevención de violencia intrafamiliar y violación, y educar a los prestadores de servicios convencionales. En general, al investigar las circunstancias de las usuarias de drogas, se facilita la formulación de políticas y programas que las atiendan mejor.

Key Words:

• injection drug use
• HIV
• gender
• sexual and reproductive health
• Eastern Europe region
• Asia region
• United States

Growing numbers of women are in need of services to reduce harms related to drug use, including HIV spread through contaminated injection equipment and high risk sexual behaviour associated with drug use.

According to the United Nations Office on Drugs and Crime (UNODC), about 25 million people worldwide are “drug addicts or problem drug users”.¹ Though precise data on women who are injection drug users (IDUs) are rarely available, women have been estimated to represent about 40% of drug users in the United States and some parts of Europe, 20% in Eastern Europe, Central Asia and Latin America, 17–40% in various provinces of China and 10% in some other Asian countries.²³ In recent years, there has been a rapid increase in the portion of IDUs who are women, especially in Asia and Eastern Europe.⁴ In China, researchers have documented a rapid increase in the number of women IDUs who share injection equipment.⁵ In Central Asia, drug use is increasing rapidly among women.⁶

Inattention to women drug users

Research into drug use outside high-income countries has largely neglected women drug users. Many studies have included so few women that analyses of the effects of gender are unreliable, while others do not mention gender at all. UNODC’s 2006 World Drug Report, which relies in large part on national self-reporting, makes more references to the female cannabis plant (14) than to women drug users (5), despite assertions in its 2005 report that the number of women drug users was increasing and that women who injected drugs were at heightened risk of HIV.

Existing research is in many ways culturally specific and bound by its context. The vast majority of research has been done in North America, Western Europe, and Australia. In developing and transitional countries, women drug users have been overshadowed by their male counterparts. The one exception is IDU sex workers, who have received attention because of their elevated HIV risk and potential to act as a “bridge” between their sex work clients and their clients’ non-sex worker partners. Such research is often narrowly focused, concentrating on the containment of IDU sex workers as a “vector of disease” rather than on the health, safety and human rights of drug users and sex workers themselves.

Women who inject drugs are especially vulnerable

Studies in nine European Union (EU) countries showed that the average HIV prevalence was more than 50% higher among women IDUs than among their male counterparts.⁷ It is likely that this disparity is even greater in countries without the EU’s relatively well-developed harm reduction programmes. In Yunnan Province, China, HIV prevalence was significantly higher among women IDUs than among male IDUs,⁵ and in Mombasa, Kenya, the prevalence of HIV infection was 50% among all IDUs, but 85% among women IDUs.⁸

The stigma attached to women’s drug and alcohol use has been documented throughout the world. Hostile attitudes promote sexual and physical abuse of women drug users, suggesting that those who use drugs do not deserve respect. In a survey across seven regions of Russia, 21% of respondents said that a wife’s drug or alcohol addiction was a valid reason for her husband to beat her.⁹

Women drug users’ disproportionate sexual risk

A growing body of evidence has shown the intimate relationship between sexual and injection-related risk of HIV among IDUs. Most IDUs are sexually active, and many engage in a range of sexual behaviours that increase their risk of HIV.^10–13 Studies in many countries have observed infrequent condom use by IDUs during encounters with sex workers, casual partners and other drug users at risk of HIV through injection.^14–17 Some studies have found an association between syringe sharing and inconsistent condom use.¹⁸¹⁹

In the United States, sexual practices have a greater effect on HIV risk for women IDUs than for men. In Baltimore, high risk sexual activity surpassed risky drug use practices as the main predictor of HIV infection among women IDUs during the period observed; HIV incidence more than doubled among women IDUs who had an IDU sex partner.²⁰ This variance is likely due to a greater correlation between women’s drug use and high risk sexual practices,²¹²² and to the fact that women are more easily infected through vaginal sex. Some studies have shown that women IDUs’ social networks contain more IDUs than those of male injectors and that there is greater overlap between women’s sexual and injection networks, perhaps because women’s drug use is more stigmatised and thus more isolating than men’s.²³

Transactional sex and commercial sex work

Poverty and an absence of employment opportunities make transactional sex a survival strategy for some women who use drugs.²⁴ Women may have sex with someone who provides a place to stay, food, drugs or protection. Compared to commercial sex work, transactional sex is less likely to take the form of an explicit exchange of goods for services, and is more likely to be framed in terms of gratitude, indebtedness, trust and dependence, which can leave little space for women to insist that their partners use condoms. Moreover, the choice between food or shelter and safer sex is not a free one, since almost everyone will choose daily survival over the comparatively abstract risk of HIV.²⁵

In some parts of the world, there is a substantial overlap between commercial sex work and injecting drug use. It is estimated that 20–50% of women IDUs in Eastern Europe and 10–25% of women IDUs in Central Asia are involved in sex work.²⁶ In a study of 82 women IDUs in Sichuan, China, 47 were sex workers,⁵ and 21% of women IDU participants in a study in Yunnan were sex workers.¹³ For those who become sex workers primarily to support their drug addiction, commercial sex work has much in common with transactional sex, with the same absence of genuine choice in the face of urgent need. This absence of options translates into higher levels of HIV: in many places, HIV prevalence among IDU sex workers is higher than it is among either non–sex worker IDUs or non-IDU sex workers.^13,27–29

Drug-using sex workers often engage in higher risk forms of sex work. This is largely because of the financial pressures imposed by poverty and the need to support their own and sometimes their partners’ habits, and because IDUs are seen as undesirable and at high risk of HIV, and are therefore often excluded from brothels.^30–32 In Asia, Russia and Ukraine, studies have found that IDU sex workers are more likely than non-IDUs to work on the street³²³³ and experience violence from their clients.⁴ Studies in Russia and Bangladesh, among other places, have shown that IDU sex workers are more likely than non–sex worker IDUs to engage in risky injecting practices.³⁴³⁵ In China, compared to non-IDU sex workers, IDU sex workers have more clients, use condoms less often and are more likely to share syringes.¹³³⁰

The greater likelihood that IDU sex workers will be street-based may also increase the likelihood that they will have IDU clients, and evidence from many regions of IDUs’ inconsistent condom use^{16,17,36–39} suggests that this is a particularly high risk activity. For example, a study in Hanoi showed that street-based sex workers’ poverty forced them to accept drug user clients who were rejected by higher status sex workers.³² A sex worker’s injecting drug use may be linked with a higher proportion of IDU clients: in Iran, a service provider reports that women sex workers who are IDUs usually have only IDU clients (Personal communication, Faranak Chamanyzadeh, Rangin Kaman/Persepolis, 2007).

Poor sexual health services for IDUs

Despite evidence of the link between sexual and injection risk behaviours, integrated interventions are relatively unusual in many parts of the world. Even in San Francisco, a city with a well-developed harm reduction movement, high-coverage syringe exchange programmes achieved drastic reductions in injection-related HIV risk behaviour, but IDUs continued to be infected with HIV through sexual contact. Sexual health messages and services were not reaching drug users, and instead targeted gay men or the general population.⁴⁰

In Eastern Europe and Central Asia, sexual and reproductive health services for drug users are rare, and often operate on a very small scale. Even sexual health services for the general population are poorly developed, and it is safe to assume that IDU women face drastically reduced access to these services. High STI rates in some countries of the region – particularly Russia – suggest widespread HIV risk behaviour.⁴¹ A lack of high quality, affordable STI services likely increases STI prevalence and allows STIs to go untreated.⁴²

In some countries of Eastern Europe and Central Asia, those who test positive for STIs are registered as “STI carriers” and hospitalised for STIs that most countries treat on an outpatient basis. In some Central Asian countries, those who test positive for STIs are subject to compulsory treatment for up to 28 days and required to provide the names of their sexual partners for notification. The police are involved in the notification process, which can extend to employers and community members.⁴³ These policies are a particularly severe deterrent for caregivers (usually women) of children or elderly parents, for women who are at risk of violence if their partners are notified, for active drug users and for anyone who cannot afford the loss of a month’s income.

Injection risk

Women drug users’ heightened sexual risk is intertwined with an increased risk of contracting HIV through shared injection equipment. Research indicates that a significant number of women begin injecting drugs in the context of a sexual relationship⁴⁴ and that women are more likely than men to borrow or share injection equipment,^31,45,46 particularly with their sexual partners.⁴⁷⁴⁸ According to a cross–sectional study in Russia, 24% of women IDUs reported sharing injection equipment with their IDU sexual partner, compared to 11% of male IDUs.⁴⁹ Some studies have found that women are more likely to report that someone else injected them with drugs, which has been found to be an independent predictor of HIV incident infection, and that in cases in which the injecting partner is male, women often inject last when sharing equipment.^50–53 Some women IDUs stay at home to inject and rely on their male partners for drugs and injection equipment, which can make it especially difficult for them to avoid already-used injection equipment or access harm reduction services. On the physiological level, women’s smaller surface veins make them more likely to need help injecting⁵⁴ and thus to share injection equipment. Finally, a history of sexual violence is associated with drug-related and other risks. In a Vancouver study of 932 male and 505 female IDUs, 68% of women and 19% of men reported a history of sexual violence. Study participants with a history of sexual violence were more likely to have knowingly shared injecting equipment with HIV-positive people and to have accidentally overdosed.⁵⁵

Transgender women and women who have sex with women

The disfavoured and often illegal status of transgender women and women who have sex with women (WSW) reduces their access to health care from non-discriminatory providers who will give them care and information appropriate to their needs,⁵⁶⁵⁷ and reduces their leverage when bargaining for safer sex and clean injecting equipment.⁵⁸ Research from the United States confirms a fairly high prevalence of same-sex sexual behaviour among women IDUs⁵⁹ and a high prevalence of risky sexual and drug use practices among drug-using WSW.⁶⁰ A study in New York and Boston investigated markedly higher HIV rates among WSWs⁶¹ than among other injectors, and attributed the elevated rates to multiple forms of marginalisation that promote unsafe sexual and injection practices.⁶³ Another study in the United States found that over 50% of 231 women who had reported female sex partners in the previous month had also had sex with men. Of these, 70% had not used condoms for vaginal sex and 74% had not for anal sex. Over 66% had shared injection equipment, and 53% had shared needles.⁶²

Similarly, studies in the United States have shown that the risk factors driving HIV transmission in transgender people include social stigma, transactional sex for survival needs, and lack of regular, informed, confidential and non-stigmatising medical care. Studies have found evidence of risky behaviour during illicit drug, hormone and silicone use. In a 2002 study of 81 transgender participants, eight of the 12 respondents who reported a history of injecting drug use said they had used a needle that was not new or clean.⁶³ For a variety of reasons, notably lack of access to affordable, legal hormone therapy and plastic surgery, some transgender women use contaminated needles for illicit hormone or silicone injections, putting them at risk of HIV and other blood-borne illnesses.⁶¹

Drug use, pregnancy and motherhood

Ill-informed and punitive policies, ferocious stigma and lack of access to accurate information jeopardise the health of women drug users and their children. Media rhetoric, popular belief and some health care providers promote the idea that any drug use precludes the possibility of a healthy pregnancy, despite evidence that secondary factors often have a more profound effect than drug use.⁶⁴ Many of the health problems and behaviours once attributed to antenatal exposure to cocaine are in fact the result of malnutrition, lack of sleep, lack of medical care, tobacco and alcohol use, and lack of early mother–child bonding due to isolation of babies in specialised units.⁶⁵⁶⁶ Good antenatal care, a healthy diet, drug treatment and other forms of support allow women drug users to give birth to healthy babies. Medication-assisted treatment with methadone, which is safe for use during pregnancy, is essential in helping opiate users to avoid withdrawal, overdose, HIV transmitted through unsafe injection and other drug-related risks that endanger the health of a woman and her fetus.

Because regular opiate use and the poor nutrition and stress associated with many types of addiction can cause amenorrhoea, women drug users may not know they are pregnant for several months. As a consequence, they may not attempt to enter drug treatment, safely reduce drug use or improve nutrition and sleep habits until the third trimester. By then, risk-reduction strategies benefit the woman’s health but have less effect on the outcome of the pregnancy, as most potential injury to the fetus has already been done. In many countries, the third trimester is also too late for women to have an abortion, should they wish to do so. The stigma of drug use during pregnancy also encourages women to conceal their drug use from providers, similarly limiting their access to harm reduction information and specialised care.⁶⁷

Myths and half-truths about drug use during pregnancy can spur pregnant drug users to try to cease all drug use abruptly and without medical support, inadvertently causing injury to the fetus through withdrawal. If a woman relapses or is unable to abstain, she may assume that all is lost and that nothing more can be done to protect the fetus. Some women remain in denial about their pregnancy until the last moment, giving them little opportunity even to consider services to prevent mother-to-child transmission of HIV (PMTCT), drug treatment or risk reduction strategies.⁷² Failure to provide pregnant women drug users with harm reduction, drug treatment services and other medical and social support is particularly regrettable since pregnancy is often a powerful motivator to reduce problematic drug use and related harms.⁶⁸⁷² Pregnancy is an excellent opportunity for providers to offer care that can lead to long-term changes that can protect a woman’s health long after her baby is born.

Hostility in the media and in the popular imagination is compounded by hostility from health care providers, family members and even other drug users. Accounts of pregnant drug users in San Francisco and Glasgow indicated that partners became abusive or violent when the women continued using drugs during pregnancy, that drug dealers sometimes refused to sell to women who were visibly pregnant and that partners, family and friends pressured them to abort.⁷²⁷³ The stigma attached to a pregnant drug user can force women into riskier practices, such as injecting alone, paying someone else to buy their drugs, concealing their pregnancy and engaging in the most marginal, high risk forms of sex work.^69,72,73

In the United States, drug-using women have been shackled immediately after childbirth, arrested and tried in court for endangering their unborn children.⁷⁰ In 2004, a woman from South Carolina was convicted of murder after cocaine was found in her stillborn baby’s system, and is now serving a 12-year sentence.⁷¹ In the United States, Canada, and some Western European countries, detection of a mother’s drug use is often a central factor in her loss of custody. As a consequence, some women avoid contact with health care providers, giving birth outside hospitals or not seeing a doctor until they go into labour.⁷²

In other countries, including Russia and Ukraine, drug-using or HIV-positive women are pressured or coerced to abort or to give up their children to the care of the state, and are denied accurate information about PMTCT or drug use and treatment during pregnancy.⁷² In 1996–2001, most HIV-infected infants in Ukraine and the Russian Federation were born to mothers who were either injecting drug users or sexual partners of injecting drug users.⁷³ In Poland, only 50% of pregnant drug-using women receive antenatal care; a six-month study in obstetric clinics found that of those who identified themselves as drug users during delivery, 54% were HIV positive.⁷⁴

Punitive drug policies, incarceration and police abuse

Harsh drug policies have a disproportionate impact on women. According to UNODC, the proportion of drug users among female prisoners is higher than among male prisoners, injecting drugs with shared equipment is particularly common among female prisoners and the HIV rate among female prisoners is higher than among male prisoners.⁷⁵ In the United States, the country with the world’s highest rate of incarceration, harsh drug policies increased the number of women in prison by as much as 888% between 1986 and 1999.⁷⁶ Drug possession and complicity in drug transactions often carry heavy penalties, and women who are carrying drugs only for personal use or who are in the vicinity of a partner or family member’s drug dealing receive substantial prison sentences that separate them from their families and expose them to an array of physical and psychological harms. In some countries, including the United States, Russia and Georgia, those convicted of drug offenses or identified as drug users can suffer consequences that include denial of public housing and other benefits, increased risk of losing custody of their children, and discrimination by employers, doctors, courts, and educational institutions (Personal communication, Lev Levinson, International Center on Human Rights; Yuri Ivanov, narcologist, Tver’; David Otiashvili, Union Alternative Georgia, 2006–2007).⁸¹ Compared to men, incarcerated women in the United States have higher rates of HIV, hepatitis C and serious mental illness, yet can be denied even basic medical services, including antenatal care.⁷⁷

Criminalisation of possession of drugs for personal use also exposes women drug users to abuse or sexual exploitation by the police, and can make it difficult or impossible for users to report crimes. Women drug users are especially vulnerable to such abuse, which can take the form of sexual exploitation. In Kazakhstan, for example, police come to drug-dealing points to conduct body cavity searches, which women IDUs report lead to sex in exchange for the return of seized drugs.⁷⁸

Lack of confidentiality from service providers and police

In many countries of Eastern Europe and Central Asia, drug treatment, arrest or even admission of drug use can lead to registration as a drug user, which can have a range of detrimental consequences, including ineligibility for free antiretroviral treatment and public housing, loss of driver’s license and police harassment.⁷⁹ Registration can be especially threatening to women, whose custody of their children can be jeopardised and who face severe stigma and discrimination when their drug use is exposed. In Russia, a diagnosis of drug addiction is legal grounds for loss of parental rights, providing women with a clear reason to avoid drug treatment (Personal communication, Lev Levinson, 2007).

A lack of safeguards to protect women drug users’ privacy discourages contact with institutions and disclosure of drug use. Even the organisation of hospital wards may reveal a patient’s drug use. For example, if babies born to active drug users are kept in a separate ward, visitors know immediately that mothers used drugs during pregnancy.⁷¹

Barriers to access to drug treatment

Women drug users are less likely to have the financial resources and social support networks to allow them to leave their children or household responsibilities during a period of prolonged treatment. Yet few drug treatment or harm reduction programmes have the child care services, flexible hours and regulations, short waiting periods and mobile delivery of medications that would make it easier for women to fit visits into their schedules. In Eastern Europe, Central Asia, South and Southeast Asia, China, and Africa, effective outpatient drug treatment – notably medication-assisted treatment – is available to only a tiny proportion of those in need. In Russia, home to two million IDUs, methadone and buprenorphine are unavailable. Worldwide, only a handful of drug treatment programmes have childcare facilities or a child-friendly environment that would allow women to bring their children with them on visits.² Inpatient treatment with childcare would help some women, but some women do not want their children to spend long periods in a treatment centre, and others do not wish to undergo treatment in the presence of their children. In general, women require programmes that take into account domestic responsibilities. In an Australian survey, women were less likely to drop out of drug treatment programmes that were flexible, had few rules and offered individualised care.⁸⁰

Designing services for women who use drugs

Increasing women drug users’ access to needed services, including drug treatment, harm reduction and sexual and reproductive health care services, is crucial. Achieving this goal requires:

• policies that encourage women to seek drug treatment and harm reduction rather than punishing or stigmatising them for drug use during pregnancy or motherhood;

• increased availability of medication-assisted treatment;

• incorporation of sexual and reproductive health and other women’s services into harm reduction programmes;

• flexible, low-threshold services that are more convenient for women with children; and

• links between harm reduction, drug treatment, women’s shelters and violence prevention services.

The following recommendations will help to create gender-sensitive services that respond effectively to women’s needs.

Involve women drug users in services and policymaking

Meaningful involvement of women who use drugs in service design and delivery can improve the effectiveness and efficiency of health and social services. The presence of other women drug users as staff members and volunteers will make women drug users feel more comfortable and improve the quality of care. People who use drugs have “inside knowledge” that is essential to an informed approach to service provision and policymaking. For both ethical and practical reasons, the involvement of women who use drugs must be the basis of any response to this population’s needs.

The overarching goal should be to empower women to contribute ideas and to hold real decision-making authority. Agencies serving women who use drugs should, for example, be required to establish service-user advisory committees and elect women who use drugs to their boards of directors. In the hiring and promotion of staff, including for management positions, direct experience of injecting drug use should be considered a positive credential in evaluating a candidate. Similarly, research projects that include drug users as subjects have a responsibility to involve drug user representatives on ethical review boards, to seek consultation with drug users throughout all phases of research and to share results. Researchers should pursue participatory research as a means of both enhancing quality and supporting social justice, particularly when focusing on marginalised or otherwise hard-to-reach populations such as women who use drugs. Finally, government and other policymaking bodies should strive to include women drug users on relevant committees, involve them in hearings and otherwise support substantive participation.

Create a woman-friendly environment

Since women drug users are inordinately likely to have experienced violence and often feel marginalised by other drug users, services must strive to create a woman-friendly environment. Female staff members and volunteers may make women feel more at ease, and are essential for those who are not comfortable receiving care or treatment from men. Women’s support groups provide a forum for women to discuss their concerns and

Young woman, long-term drug user, abandoned by her parents in Greece, sells cigarettes to tourists, 2004

experiences in a safe space. Staff members need clear policies, training and supervision to prevent sexual harassment or sexual relationships between staff and clients or patients, and to ensure that women can receive care in an atmosphere free of any perceived threat.

Help women to become more independent

A growing body of evidence suggests that in order to be effective, HIV prevention interventions must address risk factors beyond the level of the individual. Couples counselling can help women to negotiate a reduction in sexual and injection-related risk behaviour with their partners, and address the power dynamics that underlie these risks. Women’s support groups, specialised counselling and women outreach workers can help women drug users to negotiate safer injecting, while gender-sensitive syringe exchange and outreach can provide women with injection supplies and reduce their reliance on men. Strong connections between harm reduction programmes and women’s shelters, services for survivors of domestic violence, and rape and domestic violence prevention programmes can reduce women’s vulnerability to their partners. Job training and placement assistance can help women become financially independent and avoid damaging economic dependence on abusive partners. Legal aid programmes can help women access legal remedies for abuse, exploitation, unjust incarceration and loss of custody of their children, while sending the message that women drug users cannot be abused with impunity. Self-defense classes can help women protect themselves from assault.

For many women drug users, poverty lies at the heart of risk. Many successful harm reduction programmes help fulfill basic needs, showing women that they care about their immediate well-being by providing food, shelter, transitional housing, clothing and showers. Tampons, sanitary pads and other useful women’s products can be provided along with standard safe injecting kits to attract and retain women and show them that programmes are aware of their needs and recognise that women use drugs, too. For pregnant and parenting women, some programmes have provided antenatal vitamins and nutritional counselling, children’s clothing and other items, childhood immunisation, baby food, paediatric consultations, parenting support and help dealing with social services.^*

Make programmes available for mothers

Since lack of childcare is the greatest obstacle to women’s access to drug treatment, providing childcare and allowing children to stay with their mothers in inpatient drug treatment facilities can increase women’s willingness and ability to enter treatment. The many women who do not need or want inpatient treatment, or who cannot or will not bring children with them to treatment, need access to effective outpatient treatment that interferes as little as possible with their childcare, work and household responsibilities. If possible, drug treatment and harm reduction programmes should create safe, clean, age-appropriate spaces where children can stay while their mothers receive care. However, this may be difficult for programmes with limited resources, the presence of children may be unwelcome to other clients or to the mothers themselves and the presence of children at some service sites may pose a prohibitive safety risk. Finally, mothers may not want their children to know they are drug users. These limitations make it especially important that programmes work with women to provide services that do not interfere with their family responsibilities.

Provide low-threshold access and services

Some women may be unable to visit harm reduction sites because of childcare and other domestic responsibilities, because their partners oppose it, because they cannot afford the cost of transportation to a site, because they are unwilling to be identified as a drug user or for other reasons.

The frequency of syringe exchange visits can be reduced by eliminating limits on the number of syringes that can be exchanged at any one time. Visits of all types can be made more convenient by extending working hours or making them more appropriate to women’s schedules and minimising waiting times. Making syringes available over the counter in pharmacies, without the threat of police harassment or a pharmacist’s breach of confidentiality, can also make syringes more accessible to women by providing a discreet source in their neighbourhood. Providing harm reduction and drug user-oriented sexual and reproductive health services through other women-centred services (for instance, women’s shelters or domestic violence prevention services) can provide access for those unwilling or unable to visit a harm reduction or drug treatment site. Particularly in small communities, services should be positioned in such a way that entry is not tantamount to disclosure of drug use.

Secondary syringe exchange, whereby a woman obtains and returns syringes through another person who visits a syringe exchange site, can also increase access for women unable to use syringe exchanges directly. Home delivery of clean injection equipment can help programmes reach women and give outreach workers an opportunity to assess a woman’s circumstances in person and offer her additional services and support. Mobile harm reduction and drug treatment services can improve access for those unable to leave their own neighborhoods. Hotlines can provide anonymous, convenient information to women reluctant to visit harm reduction sites or disclose their identity.

Incorporate sexual and reproductive health into harm reduction services

Incorporation of sexual health services into harm reduction programmes can attract women to services and help them protect themselves from HIV, STIs and unwanted pregnancy. Programmes can educate women and their partners about the continued importance of using contraception even while using drugs, and of using both condoms and sterile injection equipment with sexual partners. They can provide high-quality male and female condoms and other forms of contraception. Rather than viewing sexual and injection-related HIV transmission as separate risks in need of individual interventions, services should recognise the synergistic relationship between the two and support women as they work to reduce such risks.

Gynaecological consultations or appropriate referrals at harm reduction sites can also provide women with low-threshold access to care from a doctor who is accustomed to working with women drug users and will not stigmatise or reject them. Many programmes also provide staff to accompany women to their doctor’s appointments for support.

Provide gender-sensitive drug treatment

Effective drug treatment can help women manage, reduce or cease drug use, and can reduce sexual risk by making women less likely to be high or in withdrawal when making sexual choices. But in order to be effective, treatment cannot have inflexible rules that promote drop-out by punishing relapse or refusing to work around concerns such as dependent family members or abusive partners. Low-threshold, medication-assisted treatment with mobile delivery units or take-home doses is particularly valuable for women, whose household responsibilities may make it difficult to visit a clinic every day at a fixed time, and whose attendance at a methadone or buprenorphine clinic may be especially stigmatising.

By helping women to avoid withdrawal and overdose, reduce or cease injection and illicit drug use, stabilise their lives and improve their health, methadone maintenance treatment (MMT), which is safe for use during pregnancy, is an essential tool in helping opiate users to have healthy babies. It is widely recognised as the treatment of choice for opiate-dependent pregnant women.² After birth, the stabilising effect of medication-assisted treatment can make mothering easier. Drug treatment providers and obstetrician–gynaecologists should be trained in methadone maintenance for pregnant and parenting women, including adjusting doses during pregnancy as required, management of neonatal abstinence syndrome and breastfeeding during methadone treatment.² When women are hospitalised during pregnancy, they should be given their methadone discreetly and according to their usual schedule.

Though there have not yet been large-scale trials, it appears that buprenorphine is also safe for use during pregnancy.⁸¹⁸² Buprenorphine providers and obstetrician–gynaecologists should be educated on its use during pregnancy. Oral slow-release morphine has also been used safely and successfully during pregnancy.⁸³ Where no form of maintenance treatment is available, advocates should press for its introduction.

Provide integrated harm reduction programmes for sex workers who use drugs

IDU sex workers need services that do not treat sexual and injection-related risk in isolation, but address the ways in which they interact. Programmes should provide sterile injection equipment, safe injecting information, condoms and other harm reduction and sexual health interventions, but must also work to alleviate the underlying causes of risk behaviour. Services to reduce drug-related risk can also reduce sexual risk. For example, effective drug treatment to help sex workers avoid being high or in withdrawal during a transaction, or to reduce their need to generate income to support an illicit drug addiction, will help them avoid sexual risk-taking. Programmes should employ staff members and outreach workers who are familiar with the community of sex workers who use drugs, and who are comfortable addressing the intersection of sex work and drug use.

Connect with domestic violence and rape prevention services

In order to be truly accessible, services (as well as policies and advocacy) must address the prevalence of violence in women drug users’ lives. At the moment, few drug-related services are linked with women’s shelters and services for battered women and rape survivors, if either type of service exists at all. In some Russian cities, for example, women’s shelters refuse to accept drug users (Personal communication, Nadezhda Fedoseeva, Anti-AIDS Foundation Penza, 2007). Existing programmes should collaborate to develop strong links to one another, and to ensure that each has staff with the skills, resources and experience needed to work with women drug users who have experienced violence. Harm reduction programmes should train all staff members to recognise and respond to signs that a woman is experiencing violence or suffering from post-traumatic stress. Women’s shelters should welcome drug users and offer strong connections to harm reduction and drug treatment services and education, or provide them on-site.

Educate mainstream service providers

Mainstream medical services are generally uninformed and unaccommodating where drug use is concerned, and as long as drug users remain stigmatised and marginalised, specialised services will be necessary. Specialised programmes serving women drug users should make an effort to provide as many services as possible on-site. But there is a limit to how many medical services can be provided at a specialised programme, and some women will make contact first with mainstream providers. It is essential, therefore, that curricula for primary care providers, adolescent care providers, obstetrician–gynaecologists, psychiatrists, psychologists and social workers include training in the signs and risks of problem drug use and how to offer effective drug treatment, accurate information and referrals to harm reduction services.

With the growing number of women drug users across the world, there is an urgent need for policy reform and gender-sensitive services to protect the health and human rights of women drug users and their children. Policy reforms that promote women’s access to health services; that promote evidence-based, low-threshold drug treatment; and that reduce police abuse and eliminate unnecessary hospitalisation and incarceration can offer immediate improvements in women’s ability to protect their health and that of their children. There is a broad spectrum of gender-sensitive services that health care providers can adopt to attract more women drug users and better address their needs. No harm reduction, drug treatment or women’s programmes have unlimited resources, but fortunately, many of the changes needed cost little or nothing. For example, services can make an effort to ensure gender balance among staff, to have a dedicated “ladies’ night” and to be vigilant in preventing sexual harassment. In order to provide the most effective care for drug-using women, however, governments and donors need to fund and encourage gender-sensitive harm reduction programmes. With their support, women drug users can create healthier, safer lives for themselves and their families.

Acknowledgements

This paper is an abridged version of Pinkham S, Malinowska-Sempruch K. Women, Harm Reduction, and HIV. New York: International Harm Reduction Development Program, Open Society Institute, 2007. It is printed here with the kind permission of the Open Society Institute. Katya Burns, Hannah Byrnes-Enoch, Nancy Goldstein, Lesia Lozowy, Nandini Pillai and Cécile Kazatchkine helped research this paper. Matt Curtis, Daniel Wolfe, Camille Abrahams, Wyndi Anderson, Mary Barr, Anna Benyo, Faranak Chamanyzadeh, Françoise Girard, Daliah Heller, Tiloma Jayasinghe, Lynn Paltrow, Karen Plafker, Penelope Saunders, Phoebe Schreiner, Anna Shakarishvili, Susan Sherman, Sue Simon, Rona Taylor, Christina Voight and Wendee Wechsberg commented on drafts of the original report.

Notes

* For an example of such a programme, see the website of Sheway, a programme for pregnant and parenting drug users in Vancouver. At: <www.vch.ca/women/sheway.htm>.