Female injecting drug users are at a much higher risk of acquiring HIV than other women and their male counterparts.
Few programmes recognise their needs or reach women. SASO is an organisation working in Manipur in north-east India which has considerable experience and success in working with these particularly vulnerable women.
Manipur state shares a border with Myanmar on the East, directly linked to the ‘Golden Triangle’ where an estimated 20% of the world’s opium is produced, so drugs are widely available.
Why take drugs?
Women start drug taking for a number of different reasons but the two main ones SASO have identified is peer or partner pressure and the desire to overcome feelings of depression.
“I tried my level best to make my boyfriend quit drug injection but failed. I was so frustrated and angry with him that I also started taking orally. Now, I inject with him.” 22 year old female injecting drug user, from Imphal East.
Many of the women re-use needles and syringes because they can’t access clean or new needles whenever they need them.
Fear of the police leads drug users to seek isolated spaces such as river banks, funeral places or public toilets to inject, thereby making them even more vulnerable to violence.
Their risk of HIV is further increased because condom use is very low. Often the women are unable to insist on condoms with either their partners or their clients. Sex is a very common way of earning money for drugs and this combination means conflict is very much a part of these women’s lives.
Social marginalisation forces them underground, their vulnerability further accompanied by unsafe practices such as sharing needles and syringes and not using condoms. All these can jointly contribute to an increase in STIs, HIV and Hepatitis C. A lack of proper access to treatment further compounds the situation.
SASO’s research has shown that most women who inject drugs know about HIV transmission so their vulnerability is not only about their knowledge. It is also about power.
Backgrounds play a role
Many of the women have had unstable or difficult childhoods and are overwhelmingly from poor backgrounds who struggle to get a regular income. “My mother left me when I was only 2 years old. I hate my stepmother. My father doesn’t love me. I was unwanted and unloved at home…” 21 year old female injecting drug user from Senapati district, Manipur.
Barriers to healthcare
Because women are more likely to feel stigma associated with their drug taking, they are more likely to conceal their drug use, so while health services are available they tend not to use them. Government health centres are avoided because of a lack of accessibility and poor quality care. Confidentiality is not assured and the cost of treatment is expensive.
Peer education is a very effective way of promoting behaviour change. Support groups can empower women to negotiate safe sex and safe injecting but it requires women outreach workers if these approaches are going to be successful.
There is an urgent need to address the situation through comprehensive interventions such as a harm reduction approach and HIV prevention, care, support and treatment.
SASO has been implementing and providing harm reduction projects and a package of services to support IDUs and their partners since 1994.
They provide drop in centres in the community that give services such as HIV education, STI treatment, HIV prevention and counselling, needle-syringe exchange programmes and training members of the community to do outreach work. Female doctors mean that the women are more likely to use the available health services.
At drop in centres women are also offered a safe place to relax and get some respite from life on the street. Women can use the centre to bathe and use the make up kits provided by the centre. To reduce the stigma the centre encourages women from the community to use its facilities so it is not only for female injecting drug users. Loans are provided so that the women can start earning an income.
One woman’s experience
“I am 34 and have studied up to class ten. After the birth of my second child I found my husband was an injecting drug user. We would quarrel if I asked him to stop using drugs. He sold most of the household items. I too started injecting drugs along with him and soon my in-laws got to know and isolated me.
“I contacted a rehabilitation centre through a friend and stayed there for treatment… My husband refused to join me in the treatment despite my attempts to persuade him. We divorced. I was then tested HIV positive. After three years I left and went to stay with my sister and worked with an NGO working with sex workers. During this time I had an affair and planned to get married but our families disapproved. Having left drugs the depression got me back into them again.
“The drugs pushed me into drug peddling and sex work. I earned good money but at the same time felt guilty. I was harassed by clients who didn’t want to use condoms. I came into contact with a SASO outreach worker who encouraged me to use the health services at SASO. I was initially reluctant to visit the drop in centre and clinic but I received needles, syringes, medicine and counselling. I got involved in the activities and joined SASO as a peer educator.
“I then got pregnant and they helped me register at a hospital for delivery and arranged my treatment. I stayed with my baby. While I had stopped using drugs my baby died after six months.
“Depression gripped me again and I left the treatment centre and was very tempted to use alcohol and drugs but on contacting SASO staff, they encouraged me and employed me as an outreach worker. I have made many friends who are facing similar problems. I know that I won’t live long but I’m conscious of my health and I motivate people like me to live positively.”
I was initially reluctant to visit the drop in centre and clinic but I received needles, syringes, medicine and counselling