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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

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Women, Drug Abuse, HIV Vulnerability

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  1. Women, Drug Abuse, HIV Vulnerability Pratima Murthy Professor of Psychiatry and Chief, De-Addiction Centre National Institute of Mental Health and Neuro Sciences, Bangalore

  2. 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

  3. 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

  4. Transition • Especially in urban area • Greater participation in the economic workforce • Greater exposure to mass media • Multiple roles, multiple stressors

  5. 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

  6. 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 HIV-positive. While 14% of women used condoms consistently with clients, 91 % of them never used condoms during sex with their regular partners Reza-Paul (2005).

  7. Determinants of RTI/STI • 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

  8. Socio-Economic and Gender Impact of HIV/AIDS Survey covered 2068 HIV households and 6224 non-HIV 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

  9. 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.

  10. 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

  11. 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

  12. 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…

  13. Women’s vulnerability to HIV through male drug abuse: the Indirect evidence Across studies: • Multiple partners common • Low rates of condom use • Concomitant use of intoxicants prior to sex • Unsafe injecting practices • Injecting in groups not uncommon • Borrowing/lending needles/syringes common

  14. 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

  15. Burden of Drug Abuse • Health problems • Psychosocial problems • Economic problems • Violence

  16. Financial Difficulties faced by family members of drug users

  17. 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?’

  18. 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 • Single, educated, urban women • High rates of family substance use • Early onset substance use • Early initiation into sexual activity

  19. Common Substances Abused by Women - RSA • Heroin • Propoxyphene • Alcohol • Minor tranquilisers

  20. Interacting factors leading to drug use among women Social Disadvantage and Social isolation Predisposition, Modelling Role Transition and lifestyle changes Physical and emotional problems and ignorance about treatment Drug Availability Stigma, lack of support Lack of knowledge of harm Drug Use

  21. RSA women drug abuse • 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

  22. 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).

  23. 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)

  24. Study of female IDUs-Bangladesh 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).

  25. 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.

  26. 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

  27. Issues in follow-up with women • Lower cessation rates • Poor follow-up • Lack of support • Emotional difficulties

  28. Shortfalls of a Gender-Insensitive approach

  29. Comprehensive client based approaches • 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

  30. Other areas • 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.

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