1. Women, Drug Abuse, HIV Vulnerability
Pratima Murthy
Professor of Psychiatry and
Chief, De-Addiction Centre
National Institute of Mental Health and Neuro Sciences, Bangalore

2. Format Contextualising gender and vulnerability
The interface of women and drugs
HIV vulnerability in the context of drug use
Women oriented approaches
Pragmatics
Barriers to care

4. Status
In many states, women do not have any autonomy in decision making in their personal lives
In Madhya Pradesh and Rajasthan, less than 50% of women had access to money in household (IIPS 2000)
In some states between 62.7 and 85.5% of married women suffer from anaemia (IIPS 2000)
The average Indian woman bears her first child before she is 22 and has little control over her own fertility and reproductive health

5. Transition Especially in urban area
Greater participation in the economic workforce
Greater exposure to mass media
Multiple roles, multiple stressors

6. Sexual behaviours, vulnerabilities
CHARCA Baseline Survey 2004:
Baseline survey of knowledge, attitude, behaviour in 5 selected districts through a systematic, multistage sampling design
450 eligible females from each district between years

7. Sexual initiation/condom use
Age of sexual exposure years
35-47% of women in 3 sites: first sex before age 15
Use of condoms for family planning: under 1% in Bellary, 7% in Guntur, 19% in Aizawl, 26% in Kishanganj, 41% in Kanpur.
For dual protection (family planning and protection against HIV/AIDS) the figures were even lower (CHARCA)
26% of sex workers in the city of Mysore were HIV-positive. While 14% of women used condoms consistently with clients, 91 % of them never used condoms during sex with their regular partners Reza-Paul (2005).

8. Determinants of RTI/STI
Poverty-driven sex
Poor economic background
Alcoholic husbands
Domestic and sexual violence
Pre-marital sex
Repeated abortions
Low age at first birth, short birth intervals
Unhygenic practices during menstruation
Poor ability to deny sex
Lack of early diagnosis and treatment by trained medical practitioners

9. Socio-Economic and Gender Impact of HIV/AIDS
Survey covered 2068 HIV households and 6224 non-HIV households spread over the rural and urban areas of six HIV high-prevalence states(UNDP 2006)
More than 40% of PLWHA were housewives. More than one-third of the sample female PLWHA were widows.
Heavy burden of care in terms of cost, domestic work, economic responsibilities
Gender differences in health seeking behaviour
School dropouts higher among female children

10. Condom Use
The Charca Study (IIPS 2004) reveals some startling facts regarding the use of condoms. For family planning, was under 1% in Bellary, 7% in Guntur, 19% in Aizawl, 26% in Kishanganj, 41% in Kanpur. For dual protection (family planning and protection against HIV/AIDS) the figures were even lower.
Reza-Paul (2005) found that 26% of sex workers in the city of Mysore were HIV-positive. While 14% of women used condoms consistently with clients, 91 % of them never used condoms during sex with their regular partners.

11. Decision Making
While 41% of respondents in Bellary think that utilisation of health facility decision should be jointly made in practice, only 3% are actually involved in deciding health services (IIPS 2004). However, a majority of women seek their husbands’ permission to seek health care services, and to use the contraceptive method of her choice

12. Knowledge/Stigma
UNIFEM-SARO (2000) undertook community based research on Gender and HIV/AIDS in four regions of India representing both high and low prevalence regions.
Most women respondents lacked elementary knowledge of reproduction, health issues and safe sex practices.
Major discrimination
Partners of infected men and women themselves infected did not get the same kind of support and care that positive men got

13. Enter drugs…. Women as partners of drug users Women using drugs
Women involved in selling drug
Women have traditionally not been part of the statistics when it comes to drugs…

14. Women’s vulnerability to HIV through male drug abuse: the Indirect evidence
Across studies:
Multiple partners common
Low rates of condom use
Concomitant use of intoxicants prior to sex
Unsafe injecting practices
Injecting in groups not uncommon
Borrowing/lending needles/syringes common

15. Emerging evidence about women
Women and substance Use in India (UNDCP 2002) collated the impact on women family members of male drug users and impact on them (179 women and 143 key informants)
RSA (UNDCP 2002) 361 of the 4648 drug users interviewed across 14 sites throughout the country were women

16. Burden of Drug Abuse Health problems Psychosocial problems
Economic problems
Violence

17. Financial Difficulties faced by family members of drug users

18. Reactions
I feel like committing suicide when I come home and find that the little money I have saved and hidden for my daughters has been stolen by my husband. He doesn’t care even a bit for them. What will happen when both of us die soon?’

19. Drug Use- Preliminary Experiences
Difficult to capture in conventional studies
1-3% of treatment seekers female
Among 4648 respondents in earlier RSA (7.9%) were women substance users
Trends: Increasing in
Single, educated, urban women
High rates of family substance use
Early onset substance use
Early initiation into sexual activity

20. Common Substances Abused by Women - RSA
Heroin
Propoxyphene
Alcohol
Minor tranquilisers

21. Interacting factors leading to drug use among women
Social Disadvantage and Social isolation
Predisposition, Modelling
Role Transition and lifestyle changes
Physical and emotional problems and ignorance about treatment
Drug Availability
Stigma, lack of support
Lack of knowledge of harm
Drug Use

22. RSA women drug abuse 40% were IDUs.
Mostly single, educated and employed
Early onset of substance use.
Early initiation into sex and sharing injecting equipment.
Almost half the women had engaged in sex work to support the habit
Nearly a third sold drugs

23. IDU
A study from Manipur showed that 20% of commercial sex workers were also injecting drugs (BSS 2001).
Drug injectors report higher levels of regular and casual partnerships and as a rule, condom use in these partnerships is even lower than in commercial sex (MAP 2005, UNDCP 2002a).

24. Sharing
Women are also likely to share injecting equipment with more people in their social network compared with men (Sherman et al 2001)
Women often the last to use, increaing health risks (European Monitoring Centre 2003)
Being female is one of the risks for sero conversion (Estanbez et al 2000)

25. Study of female IDUs-Bangladesh
82 were sex workers and 48 were non-sex workers.
More sex workers reported lending needles/syringes (29.3% and 14.6% respectively) and sharing other injection paraphernalia (74.4% and 56.3% respectively)
More sex workers used condoms during last sex than non-sex workers (74.4% and 43.3% respectively)
More sex workers reported anal sex (15.9% and 2.1% respectively) and serial sex with multiple partners (70.7% and 0% respectively).
Lifetime sexual violence and being jailed in the last year was more common in sex workers (Azim et al 2006).

26. Women in treatment
There is little data on the characteristics and needs of women drug users in treatment.
A retrospective characterization of 35 women seeking help at a de-addiction centre in North India (Grover et al 2005) revealed that the typical subject was urban, married, with opiods being the commonest drug of abuse. Common reasons cited for use were medical. Comorbidity was common, as well as impairment in functioning, especially social.

27. Reticence to Treatment
Overwhelming family responsibilities often make their own needs a lesser priority and consequently their drug dependence remains untreated. Societal disapproval, fear of exposure, lack of support

28. Issues in follow-up with women
Lower cessation rates
Poor follow-up
Lack of support
Emotional difficulties

29. Shortfalls of a Gender-Insensitive approach

30. Comprehensive client based approaches
Client-centred treatment plan, flexible
Focus on issues concerning partners and family relationships and responsibilities
Pregnancy
High risk behaviours
Trauma history and mental health problems.
Address possible obstacles involved in participating in treatment
Some women require residential services,
Community –based outpatients or day services needed
Aftercare and social integration components, particularly skill development
Employment training
Help with stay especially for women on the streets

31. Other areas Child care Relapse prevention Extra-treatment support
Attention to training and capacity building in order to reduce drug use
Programmes that address HIV risk prevention for partners of substance users as also for women substance users engaged in high risk sexual behaviour
Increase in the participation of women in demand reduction programmes.