1. G. Tawakol 1, O. Abaza 1, M. Abdel Malak 1, C. Khoury 1, S. Elkamhawi 1, W. Elbeih 2, H. Youssef 3, N. Elkot 4, N. Sanan 5, E. Elkharrat 6, H. Ramy 7, C. Soliman 1 1 FHI 360/Egypt, 2 Drosos Foundation, 3 Ford Foundation, 4 Hayat, 5 Befrienders, 6 Freedom, 7 Ain Shams University Female Injecting Drug Users in Egypt: A Hard to Reach Population

2. Background Egypt’s population is about 90 Million 37.1% are between 15 – 34 years old (CAPMAS,2014) GDP Per Capita is 3198.7 (US $) Females comprise 49.5% of total population 29.3% of females are unemployed (World Bank, 2014) HIV Prevalence in Egypt is less that 0.1% (UNAIDS, 2014)

3. Female Injecting Drug Users (IDUs) have limited access to Harm Reduction (HR) services due to: ‒Cultural constraints; high level of Stigma and Discrimination ‒Weak network ‒Low social status ‒Lack of motivation ‒Restrictions against drug injection and sex outside marriage ‒Political instability Lack of information hinders designing proper interventions tailored to their needs Background

4. Methods Established in 2013 A network for HR projects, ensuring standardized, high quality, and stigma-free services for Key Populations (KPs) and related communities in Egypt Emphasis is placed on HR strategies that include “Safe Sex and Safe Injection” practices All services offered are anonymous, confidential, and free of charge The Network of Associations for Harm Reduction (NAHR)

5. NAHR Comprehensive Care Center (CCC)

6. Between March 2013 and July 2015, socio demographic, behavioral and biological data were collected and analyzed from six of NAHR CCCs located in Cairo, Giza, and Alexandria Governorates: ‒ Hayat ‒ Befrienders ‒ YAPD KPs are street based outreached and referred to CCCs Methods ‒New Waay ‒Freedom Terra ‒Freedom Shobra

7. Results

8. Background Characteristics of Female IDUs March 2013 – July 2015 ResultsPercentN Age Group (25-35 yrs.) *49.3%144 Married26.1%142 University Education59.7%144 Employed20%145 Alcohol Consumption Last Month22.9%144 * Higher among Male IDUs 61.4% (59.9 - 62.9%) than Female IDUs 49.3% (40.9 - 57.8%) 145 Female IDUs visited NAHR CCCs

9. Female vs Male IDUs, Outreached, Visited, & Received VCT in NAHR CCCs (March 2013 – July 2015)

10. Female vs Male IDUs, Outreached, Visited, & Received VCT in NAHR CCCs (March 2013 – July 2015) - 2.1% of Male IDUs (N=4156) and 2.9% of Female IDUs were detected HIV Positive (N=138) 105.0% 58.8% 91.1% 95.2% 87% 39.9% Male Female

11. Injecting Behaviors of Female IDUs March 2013 – July 2015 ResultsPercentN Age at First Drug Injection (16-24 yrs.)68.9%145 Ever Shared Paraphernalia79.0%143 Ever Shared Needles or Syringes *63.9%133 Heroin Injection in the Past Month58.3%144 Shared Syringe or Needle in the Past Month **48.6%74 * Higher among Male IDUs 71.3% (69.7 – 72.5%) than Female IDUs 63.9% (51.3 – 68.0%) ** Higher among Male IDUs 64.8% (62.9 – 66.6%) than Female IDUs 48.6% (24.1 – 42.3%)

12. Sexual Behaviors of Female IDUS March 2013 – July 2015 ResultsPercentN Ever had Sex 93.1%145 Had Sex in the Past Year 95.6%137 Had Sex in the Past Month 65.1%129 Not willing to use Condoms 36.8%125 Exchanged Sex for Drugs in the Past Year * 29.6%125 * Higher among Female IDUs 29.6% (20.6 – 36.5%) than Male IDUs 14.5% (12.4 – 17.0%)

13. Condom Use in Last Six Months March 2013 – July 2015 N= 130 N = 129

14. Conclusion Low Female participation in Harm Reduction services HIV Prevalence in Females IDUs is higher than in Male IDUs High risk injection and sexual behavior were a common finding among female IDUs Low condom use with steady and non-steady partners was detected

15. Recommendations NAHR CCC model should be replicated, using a combined approach of “Safe Sex and Safe Injection” to provide services to Female IDUs Conducting an in depth qualitative research to address the low condom use and the low participation of Female IDUs A third round of the Biological Behavioral Surveillance Survey should be conducted among Female IDUs and other KPs to maintain Egypt low HIV prevalence

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