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Nabila El-Bassel, Ph.D. Columbia University

Dual HIV Risks and Vulnerabilities among Women Who Use Drugs: No Single Prevention Strategy is the Answer. Nabila El-Bassel, Ph.D. Columbia University 37th National Conference November 7-9, 2013 Double Tree Hotel Bethesda, MD. Presentation Will Cover:.

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Nabila El-Bassel, Ph.D. Columbia University

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  1. Dual HIV Risks and Vulnerabilities among Women Who Use Drugs: No Single Prevention Strategy is the Answer Nabila El-Bassel, Ph.D. Columbia University 37th National ConferenceNovember 7-9, 2013Double Tree HotelBethesda, MD

  2. Presentation Will Cover: Global epidemiology of injection drug use and HIV among women Gender-specific drivers that increase vulnerabilities to HIV Multilevel behavioral HIV prevention strategies

  3. Epidemiology of HIV among Women Globally, over half of the people living with HIV/AIDS are female Around the world, HIV/AIDS is still the leading cause of death among women aged 15-49 Universally, women aged 15-24 are twice as likely as their male counterparts to become infected if exposed to HIV Sources: UNAIDS amfAR. Statistics: Women and HIV/AIDS, 2012: http://www.amfar.org/about-hiv-and-aids/facts-and-stats/statistics--women-and-hiv-aids/ The Henry J. Kaiser Family Foundation. The Global HIV/AIDS Epidemic, 2013: http://kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/

  4. Global Prevalence of People Who Inject Drugs in 2008 . Globally in 2008, there were 16 million people who injected drugs and 1.6 million were living with HIV (Mathers, et al., Lancet 2008).

  5. % of IDUs in Selected Regions/Countries who are Female Central Asia: China: Eastern Europe: India: Indonesia: Iran: Malaysia: North America/Europe: 15-26% 30-40% 15-45% 8.5% 10% 3.9% 10% 40% EuroHIV, 2007, 2008; UNAIDS report on the global AIDS epidemic. Geneva: Switzerland (2010)

  6. HIV Prevalence among IDUs in 2008 Source: Mathers, et al., Lancet 2008

  7. Prevalence Rates of HIV among Female IDUs Studies in 9 European countries show higher HIV prevalence rates among female IDUs than male IDUs (EMCDDA, 2006) A systematic review of 117 studies in 14 countries with HIV rates of 20% or greater found that female IDUs have higher HIV rates than their male counterparts (Des Jarlais, 2012 Drug and Alcohol Dependency)

  8. Gender-Specific Drivers that Increase Vulnerabilities to HIV

  9. Drivers that Increase Vulnerability to HIV Sex Trading Structural “risk environments” that drive the HIV epidemic among women who inject drugs: Partner Abuse Gender norms and gender imbalances in the drug culture Unemployment, homelessness, poverty Policies (e.g., registration of drug users, police harassment, incarceration) Lack of woman-specific drug treatment and services Strathdee, et al., Lancet , 2010. National Drug and Alcohol Research Center (NARC), University of New South Wales, 2010.

  10. Dual Risks: % of Female IDUs who Engage in Sex Work Central Asia: 15-30% China: 21-55% Eastern Europe: 20-50% Mexico: 20-30% US: 10-22.4% EuroHIV 2007, UNAIDS report on the global AIDS epidemic. Geneva: Switzerland, 2010

  11. Increased HIV Risks Among FSWs who are IDUs Higher syringe-sharing behavior Lower condom use Higher prevalence rate of STIs Higher prevalence rate of sexual abuse Strathdee, et al., Lancet, 2010 National Drug and Alcohol Research Center (NARC), University of New South Wales, 2010

  12. Ppa Partner Abuse

  13. Partner Abuse • Prevalence rates of Partner Abuse among drug-involved women range between 60-80% (El-Bassel et al., 2007, 2008) • WHO has identified Partner Abuse as a risk factor for HIV infection among women (WHO, 2006)

  14. Findings from Project WORTH in New York City among women who use drugs (N=307) Women on probation and in an alternative to incarceration program in NYC (2013) • 66 % Black or African American • 17% Hispanic or Latina • 61% reported that they had experienced sexual or physical PA in their lifetime and 18% reported it in the past 6 months Louisa Gilbert, et al. under review 2013.

  15. Women on probation in New York City (N=191) • –67% Black or African American –30% Hispanic or Latina • 75 % experienced PA in their lifetime • 47% reported experiencing sexual or physical PA in the past year • Louisa Gilbert, under review 2013.

  16. Project WINGS in Kyrgyzstan among FWID (N=59) • 93% (n=54) reported ever experiencing any physical, sexual or injurious abuse by a partner (PA) • 86% (n=50) reported ever experiencing any physical, sexual or injurious abuse as an adult by others • 50% (n=30) reported ever experiencing any abuse by police Louisa Gilbert et al. unpublished.

  17. Contexts Linking PA and HIV among FWID  Sexual Coercion Negotiation and refusal of condoms Fear of Violence Micro-social contexts in injection drug use

  18. Contexts Linking PA and HIV among FWID Sexual Coercion: FWID with a history of sexual coercion are less likely to use condoms than FWID with no history of sexual coercion Sexual coercion and rape increase the likelihood of vaginal lacerations which increases the risk of HIV transmission Sexual and physical PA increase when women: Ask their partners to use a condom Refuse sex without a condom Refuse vaginal and anal sex El-Bassel, et. al, AJPH, 2011, El-Bassel, et. al, Substance Use and Misuse, 2011.

  19. Contexts Linking PA and HIV Risks among FWID Negotiation of Condom Use Male partners often perceive requests for condom use as a: Lack of trust Sign of infidelity on her part Breach of gender role expectations As a result, some men may use sexual violence to exert control over the relationship El-Bassel, et. al, AJPH, 2011, El-Bassel, et al, Substance Use and Misuse, 2011.

  20. Contexts Linking PA and HIV Risks among FWID Fear of PA has been found to: Reduce a woman’s ability to ask her partner to use condoms Prevent a woman from refusing unprotected sex El-Bassel, et. al, AJPH, 2011, El-Bassel, et al, Substance Use and Misuse, 2011.

  21. Micro-Social Contexts and IDU Men often introduce their female partner to IDU FWID often use a syringe/needle after their partner Sharing injections is perceived as a sign of love, commitment, and faithfulness Refusal to share a syringe/needle can threaten the relationship If the woman shares injections with other men, it is perceived as infidelity and can lead to PA After experiencing PA, women may be hesitant to refuse to share syringes/needles El-Bassel, et. al, AJPH, 2011, El-Bassel, et al, Substance Use and Misuse, 2011.

  22. Structural Risk Environments Financial dependencies and unemployment have been found to compel women to: engage in unprotected sex stay in an abusive relationship (Zierler, 1997; El-Bassel et al., 2002, Lichtenstein, 2005; El-Bassel, 2005) Homelessness and unstable housing have been identified with increased risk of HIV among people who use drugs (Aidela et al, 2007, Shannom, 2009, Lazuru, 2011)

  23. Financial Dependencies and HIV Risks among Women on Methadone Never Request Condoms OR = 2.9; p = .04 Never Request Condoms OR = 1.9; p = .05 OR = 1.8; p = .04 IPV Dependent for Housing (Lease) Partner Paid forWoman’s Drugs Dependent for Household Expenses El-Bassel et al. Use and Misuse, 2011.

  24. Substitution Therapy HIV Prevention Needle Exchange Drug & Alcohol Treatment Systemic Barriers: Lack of Harm Reduction and Drug Treatment Programs Harm Reduction

  25. Systemic Barriers in Central Asia Outreach workers are male and do not reach out to women Female IDUs are stigmatized by service providers and medical staff in harm reduction & drug treatment programs Sex workers are excluded from harm reduction and HIV services There is no place for women to leave their children when they go for services Fear of stigma, IDU registration and police harassment prevent women from accessing services TECHNICAL REPORT: WOMEN AND HARM REDUCTION IN CENTRAL ASIA, JUNE 2011

  26. Systemic HIV Intervention Strategies • Provide access to services that address women’s needs (e.g., secure flexible hours, transportation, child care, partner involvement) • Increase the number of female outreach workers in harm reduction, HIV and drug treatment programs • Train medical and non-medical staff who work in harm reduction and HIV services on the unique needs of women • Reduce staff stigma against women who use drugs • Provide access to OST, NSP and ART in prisons UNAIDS, Technical Reports, Central ASIA Republics, 2011, El-Bassel, et al. Lancet, 2010, Beyrer et al. JAIDS, 2010.

  27. Couple-based Social Network Structural HIV Prevention Individual Group Community Advances in HIV Prevention: Our “Toolbox” Multilevel

  28. Individually-Focused Behavioral Prevention Negotiation of safer sex practices and condom use Serostatus knowledge and HIV testing Partner abuse, PTSD, and mental health Empowerment skills to help women access care, services, and employment Characteristic: The responsibility is placed on the woman El-Bassel, Wechsberg, & Shawn, Current AIDS Opinions (in press) ; Beyrer et al., JAIDS, 2011.

  29. Trauma-Informed HIV Prevention for Women • There are four empirically-tested HIV trauma-informed prevention intervention models: • Seeking Safety: Integrated model on trauma and substance-abuse, but not HIV (Hien, 2009) • Co-occurring Disorders and Violence Study: Sequential model in which trauma content was followed by HIV prevention sessions (Amaro, 2007) • Women’s Wellness Study: Integrated model of HIV, PA, and trauma (El-Bassel el al. 2008) • Project-WORTH: integration of HIV, drug abuse, and PA (El-Bassel, 2013)

  30. Multimedia Worth (307 Women ) • Group modality • Four sessions • Triple risks—sexual, drug and PA

  31. Project WORTH (Core Components) • PA screening, safety planning and referrals to PA services • Skills-building, problem solving, negotiation, help-seeking • HIV testing and linkages to HIV care and drug treatment • Identifying unmet service needs • Referrals to meet those needs and support to stay in treatment (retain) • Personal goal setting for HIV and IPV risk reduction and staying in care

  32. Multimedia WORTH Multimedia Mechanisms improve active learning: • Interactive games with high speed graphics to increase attention • Four characters (fictional role models) are used throughout the sessions to increase emotional engagement and facilitate positive peer norms • Use of storytelling by the four characters • Modeling of core skills by the fictional characters is followed by role play to increase intention and motivation to use skills • Individual activities are recorded in an electronic journal that participant may or may not share with group, which ensures confidentiality • Electronic journals allow participants to systematically track and document progress

  33. PROJECT WORTH

  34. Characteristics (n= 307)

  35. Findings Compared to the Wellness Promotion, women in the WORTH arms of the study: • Had a 30% more reduction in the incidence of unprotected sex • Were 3 times more likely to always use condoms with their sex partners • Were twice as likely to access drug treatment El-Bassel, et al. under review.

  36. Moving from an Individual to a Couple Approach Although globally, most HIV transmissions occur within serodiscordant intimate relationships, HIV prevention targets mainly individuals (UNAIDS, 2012) HIV prevention strategies rarely bring partners together to get tested for HIV or receive HIV prevention services (WHO, 2012; UNAIDS, 2012) Since the start of the HIV epidemic there have only been 29 couples HIV studies Only three of these studies with people who use or inject drugs: Project Connect Two – in New York City with 282 couples where one or both or inject drugs (El-Bassel, et al., 2011; JAIDS) (NIDA funded) Project Renaissance – in Almaty Kazakhstan with 300 couples where one or both inject drugs (El-Bassel, et al., 2013, under review) (NIDA funded) Couple-Based HIV Counseling and Testing– in New York City with 330 couples where one or both use or inject drugs (McMahon, et al., 2013; Advances in Preventive Medicine) (NIDA funded)

  37. HIV Couple-Based Intervention Studies Globally (N=29) (Jiwatran-Negron and El-Bassel, 2013)

  38. 282 drug-involved couples Seven sessions: Sexual risks, drug risks, PA, and reproductive health Aims: Reduction in sexual and drug risks Increase safety planning El-Bassel et al. JAIDS, 2011. Or your partner in or seeking drug treatment? Project Connect Two (NIDA Funded)

  39. Test Hypothesis To examine the efficacy of seven relationship-based HIV/STI prevention intervention compared to a Individual Risk Reduction control condition Couple Risk Reduction Individual Risk Reduction

  40. Core Components of the HIV/STI Risk Reduction Intervention Skills building to reduce sexual and drug risks: Problem-solving and communication skills related to sexual and drug risk behavior HIV, HCV, and STI testing detection, knowledge, prevention, and treatment Gender roles and expectations related to sexuality, drug risks, and reproductive health, sexual abuse, and building safer sex practices and healthy relationships, safety planning HIV testing, linkage, and navigation to HIV and STI care and harm reduction programs

  41. Core Components of the HIV/STI Risk Reduction Intervention Drug use and sharing syringes/needles and HIV Meaning of sharing syringes/needles in an intimate relationship (trust, love for each other) and risks associated with sharing Meaning of refusing to share needles or to be injected by the partner and communication skills on refusal to share syringes/needles, male’s dominance Relationship between PA and sharing needles/syringes El-Bassel et al., Substance Use and Misuse, 2011.

  42. 41% reduction in incidence rate of unprotected sex at 12 months in the couple modality, compared to the individual modality Significant reduction in injection drug use, and in sharing of needles/syringes with each other and other IDUs El-Bassel et al., JAIDS, 2011. Findings: Connect Two

  43. Central Asia Source: Russia-Ukraine-Travel.com

  44. Production of Opium by Afghans is Up Again (Asia Pacific, April 2013)

  45. Project Renaissance Project Renaissance is a randomized controlled trial conducted in Almaty, Kazakhstan testing the efficacy of a couple-based intervention to prevent HIV and HCV among heterosexual couples where one or both inject drugs (Funded by NIDA, completed 2013) Project Renaissance includes 5 sessions delivered to the couple together Project Renaissance was adapted from Project Connect Two and builds on extensive couple based research experience in the U.S. and internationally * * El-Bassel, N., Gilbert, L., Wu, E., Witte, S., Chang, M., Hill, J., Remien, R. (2011). Couple-based HIV prevention for low-income drug users from New York City: A randomized controlled trial to reduce dual risks. JAIDS. El

  46. Renaissance Test Hypothesis To examine the efficacy of five relationship-based HIV/STI prevention intervention compared to a Wellness Promotion control condition Couple Risk Reduction Wellness Promotion

  47. 42% reduction in incidence rate of unprotected sex at 12 months in the couple-based intervention arm, compared to the wellness promotion arm Couples in the HIV risk reduction arm were twice as likely to always use condoms with their study partner than couples in the wellness promotion arm Significant reduction in injection drug use and in sharing of needles/syringes with each other and other IDUs occurred in both arms Nabila El-Bassel, Louisa Gilbert et al., JAIDS, 2011. Outcomes from Renaissance

  48. Renaissance Outcomes HIV Incidence: Person-year incidence rate by condition: • 5.2% for Wellness Promotion • 2.7% for Risk Reduction • Over the one-year follow-up period, 51% reduction in HIV incidence in the RR arm when compared to the WP arm (IRR of 0.49; 95% CI=[0.17, 1.55]; p=0.2) HCV Incidence : Person-year incidence rates by condition: • 19.9% for Wellness Promotion • 7.4% for Risk Reduction • Over the one-year follow-up period, 69% reduction in HCV incidence among participants in the RR arm, compared to WP (IRR of 0.31; 95% CI=[0.10 – 0.90]; p=0.05) El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al., (under review). Effects of a couple-based intervention to reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A randomized controlled trial

  49. Advantages of Couple-Based Approach Provides an opportunity to assess HIV and PA risks, bringing the couple’s unique experiences Provides an opportunity for men to be included in PA and HIV prevention Responsibility for HIV risk reduction is placed on both members of the dyad El-Bassel et al., JAIDS (2012).

  50. Advantages of Couple-Based Approach Addresses barriers in individual level HIV interventions. Couple based creates safe environment for couples to disclose sensitive issues (e.g. sexual coercion, extra dyadic relationships, gender power imbalances, sexual risk, etc.) As a health-based intervention, draws on strengths through supporting intimate relationships and integrating HIV and reproductive health care Allows for the recruitment of hidden populations with unknown HIV status through their sex partners not engaged in services Can be integrated into the continuum of seek, treat, and retain to improve testing, linkage, and retention in care El-Bassel, N., Gilbert, L., Wu, E., Go, H., & Hill, J. (2005). Relationship between drug use and intimate partner violence among women onmethadone. American Journal of Public Health, 95(9). El-Bassel, N. Jemmott, J.B., Wingood, G.M., Pequegnat, W., Landis, J.R., Bellamy, S.L. (2010) NIMH Multisite Eban HIV/STD Prevention Intervention for African American HIV Serodiscordant Couples: A Cluster Randomized Trial. Archives of Internal Medicine, 170(17), 1594-1601.

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