HIV in women who use drugs: Double neglect, double risk

A Comment in The Lancet Series on HIV says that HIV infections continue to rise in drug-involved women,especially injecting drug users in Asia and eastern Europe, and in crack-cocaine users in the USA and other countries. Women who use drugs are doubly at risk for HIV infection via unprotected sex and unsafe injections. The Comment is by Dr Nabila El-Bassel, Columbia University School of Social Work, New York, USA, and colleagues.

Many women who use drugs lack the power to negotiate safer sex. Yet, most available HIV-prevention strategies put the onus on women to insist on safe sex, increasing their risk of physical and sexual abuse. The authors say: "Drug-involved women often rely on their partners to procure the drugs that they share, and because women are often injected by their partners, they are 'second on the needle', which increases their risk for infection by HIV and other pathogens. Refusing to share needles and syringes can also increase women's risk of physical and sexual intimate partner violence, further potentiating risks for HIV infection."

The authors propose a number of strategies to prevent HIV infection in women who use drugs:

1. Trauma-informed strategies that concurrently address co-occurring problems of intimate partner violence and drug use.
   
2. Couple-based HIV prevention, treatment, and care options for drug-involved women and their sex partners that include skills building for safe-sex negotiation within context of ongoing drug use.
   
3. Empowerment strategies, such as social network, community-based, community mobilisation, and peer-led interventions.
   
4. Income-generating interventions for women (including job training and microfinance, access to employment).
   
5. Public policies that: fight discrimination and gender-based violence; stop police mistreatment, arrest, and registration of female drug users; and increase access to drug treatment and care.
   
6. Increased funding to make drug treatment, harm reduction, and HIV-prevention services more available and friendly to women, by addressing the needs of pregnant women, mothers, and women with a history of intimate partner violence and trauma; and by protecting human rights of women who use drugs.
   
7. Increased research funding to improve and support women-specific evidence-based services, and to improve knowledge on global epidemiology of women who use drugs, especially in developing countries. Researchers must make greater attempts to include women, even if they are harder to recruit due to being fewer in number and hidden.

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