1. WOMEN, DRUGS AND HIV Science Addressing Drugs And Health: State of the Art 20 th International AIDS Conference 2014 21 July 2014, Melbourne Tasnim Azim, icddr,b, Dhaka, Bangladesh Irene Bontell, Karolinska Institutet, Stockholm, Sweden Steffanie Strathdee, University of California, San Diego, USA

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 Des Jarlais et al 2012 and 2013; Lambdin et al, 2013; Ghimire et al, 2013 HIV

4. WOMEN, DRUG USE AND SEX WORK: A DUAL RISK The combination of selling sex and using illicit drugs is common 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 FWID who sell sex FWID who do not sell sex

5. experience sexual violence high-risk sex sexual concurrency sharing needles and syringes Multiple vulnerabilities and risks faced by women who use drugs and sell sex result in a high risk of HIV street based sex work highly stigmatized lack of control HIV and STI risk

6. PWID ARE NOT AN ISOLATED POPULATION GROUP…..

7. PWID AS BRIDGE POPULATIONS FOR A GENERALIZED HIV EPIDEMIC Des Jarlais et al, 2012 Transitions from PWID concentrated epidemics to heterosexual epidemics are likely to have occurred in at least six countries: Argentina Brazil China Indonesia Netherlands Ukraine

8. 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

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

10. NON-DRUG USING PARTNERS OF MWID Condom use is uncommon with intimate partners and often MWID have high levels of risk behaviour Violence or threat of violence by intimate partners – a voice from Bangladesh “…..if I don’t give money to my husband for his drugs, he beats me and threatens to kill me” Marginalised by society – they call me “wife of a heroinchi....” Robertson et al, 2014; UNODC and icddr,b, 2010

11. 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

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

13. 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

14. VIOLENCE Experienced commonly - physical and sexual Perpetrators include: Law enforcement Intimate partners Clients 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 Otiashvili et al, 2013

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

16. CONCLUSIONS FWID often have higher rates of HIV than MWID. FWID who sell sex are more likely to share injection equipment, have unprotected sex with their clients and their intimate partners, have high rates of STIs and to experience sexual and physical violence and incarceration Women are often reliant on their male partners and may be controlled by their intimate male partners for drugs, clients, condom use

17. FWID have special needs e.g. pregnancy women and child care FWID are highly stigmatized by all strata of society and violence, both physical and sexual, is common Women who do not use illicit drugs but have MWID as their intimate partners are also stigmatised and vulnerable Behavioural, structural and biomedical interventions can work and should be made available CONCLUSIONS

18. 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

19. WE GRATEFULLY ACKNOWLEDGE ALL WOMEN WHO USE DRUGS AND WHO HAVE SHARED THEIR STORIES WITH US