Introduction to Module 5

By the end of this module you will be able to:

• Offer suggestions for mainstreaming gender into existing services for PWUD.
• Expand access to women who use drugs (WUD) through appropriate gender-sensitive and gender-specific services.
• Address gender issues within existing services and/or to develop gender-specific services.
• Setting targets for scale-up to improve access to comprehensive HIV and care services, expanding coverage among WUD.

There are marked differences between the genders in almost all aspects of the drug phenomenon, and there are many sound public health and human rights recommendations that indicate the need for Harm Reduction (HR) and other HIV related services to specifically address the needs and preferences women who use drugs. Such reasons are evidence-based and are supported by relevant international agencies and institutions. Nevertheless, HR services are generally primarily target men and women who use drugs often feel that their specific needs are unacknowledged and that the sites they need to access to are not “women-friendly.” HR programs and projects often do not succeed in guaranteeing women’s personal safety and confidentiality; in providing sexual and reproductive health (SRH) services; prevention of mother-to-child transmission (PMTCT) services; and providing child care. In many cases, staff are not trained to offer gender-specific services, support for sex workers or for the victims of gender-based violence (GBV).

The failure to address the needs of women who use drugs (WUD) contributes to the spread of blood borne infections and other infections. In fact, first of all, WUD are actually at higher risk of acquiring HIV, viral hepatitis and other sexually transmitted infections (STIs) than their male counterparts. Specific risk factors include the fact that women are more likely than men to be “second on the needle”—i.e., they inject after, and often are injected by, a male partner. Data by gender shows that women who inject drugs (WID) are more vulnerable to HIV infections and STIs than are males who inject drugs. The likely reasons for such a gender difference include both social factors, e.g. WID are much more likely to be involved in sex work than males are, and biological factors, such as women’s higher risk of contracting genital infections. WUD are likely to be more often in a vulnerable position when attempting to protect themselves from infection within partnerships and networks.

Those of them engaged in sex work increase their vulnerability to HIV and other blood-borne infections. When involved in sex work, they often experience physical and sexual violence from clients and other intimate partners, as well as from the police; abuses can also occur while they are detained in prison.

Gender-based violence prevents WUD from accessing services and the criminalization of sex work heavily affects their willingness and possibility to access HIV-related services and to negotiate condom use.

Other factors which prevent WUD from accessing health services include policies or laws suggesting that drug use can be a reason for loss of child custody, coerced sterilization and abortion. Such practices are examples of gender-related stigma and discrimination that is still widespread in some countries.

WUD are often diagnosed with HIV late in pregnancy or when they are already in labor. Mother-to-child transmission rates among WUD living with HIV are significantly higher than for other HIV positive women. Many maternity clinics do not provide opioid substitution treatment (OST), a situation that may compel drug-dependent women or those on OST to leave appropriate care in order to seek drugs or medication.

The following are some of the most frequent problems experienced by WUD:

• Many countries have organized their health systems in a way that requires separate access for HIV, TB, viral hepatitis, HR and SRH services. This makes it difficult for WUD to take good care of their health needs.
• WUD reported many times that SRH services are very important but that they feel stigmatized when accessing them; stigma and discrimination constitute a huge barrier. Negative experiences with health services include judgmental attitudes and/or disrespectful treatment on the part of healthcare staff and perceived lack of privacy and confidentiality. WUD are afraid to seek advice and care.
• Pregnant WUD access antenatal care and PMTCT services less frequently than the other pregnant women and consequently face an increased risk of passing HIV to their babies.
• In some countries, a conservative social climate makes it harder for WUD, especially girls and young women, to access SRH services.