Transcript Women, Drug Abuse, HIV vulnerability

Women, Drug Abuse, HIV
Vulnerability
Pratima Murthy
Professor of Psychiatry and
Chief, De-Addiction Centre
National Institute of Mental Health and Neuro
Sciences, Bangalore
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
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
Transition
• Especially in urban area
• Greater participation in the economic
workforce
• Greater exposure to mass media
• Multiple roles, multiple stressors
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 13-24 years
Sexual initiation/condom use
• Age of sexual exposure 16-19 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 HIVpositive. While 14% of women used condoms
consistently with clients, 91 % of them never used
condoms during sex with their regular partners RezaPaul (2005).
Determinants of RTI/STI
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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
Socio-Economic and Gender
Impact of HIV/AIDS
Survey covered 2068 HIV households and 6224 nonHIV 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
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.
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
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
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…
Women’s vulnerability to HIV
through male drug abuse: the
Indirect evidence
Across studies:
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Multiple partners common
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Low rates of condom use
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Concomitant use of intoxicants prior to
sex
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Unsafe injecting practices
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Injecting in groups not uncommon
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Borrowing/lending needles/syringes
common
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
Burden of Drug Abuse
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Health problems
Psychosocial problems
Economic problems
Violence
Percentage
Financial Difficulties faced by family members of drug users
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45
40
35
30
25
20
15
10
5
0
40
43
26
Loss of
income
Less money
available
16
16
Loans
Debts
Expenditure
on treatment
24
Savings
spent
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?’
Drug Use- Preliminary
Experiences
• Difficult to capture in conventional studies
• 1-3% of treatment seekers female
• Among 4648 respondents in earlier RSA 2002
371 (7.9%) were women substance users
• Trends: Increasing in
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Single, educated, urban women
High rates of family substance use
Early onset substance use
Early initiation into sexual activity
Common Substances Abused by
Women - RSA
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Heroin
Propoxyphene
Alcohol
Minor tranquilisers
Interacting factors leading to drug use among
women
Social
Disadvantage
and Social
isolation
Predisposi
tion,
Modelling
Role
Transition
and
lifestyle
changes
Drug Availability
Stigma, lack
of support
Lack of knowledge of
harm
Drug Use
Physical and
emotional problems
and ignorance about
treatment
RSA women drug abuse
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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
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).
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)
Study of female IDUsBangladesh
130 female IDU
• 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).
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.
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
Issues in follow-up with
women
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Lower cessation rates
Poor follow-up
Lack of support
Emotional difficulties
Shortfalls of a Gender-Insensitive approach
Comprehensive client based
approaches
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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
Other areas
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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.