Download Plenary Presentation – El-Bassel 2013

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:
•
Global epidemiology of injection drug
use and HIV among women
•
Gender-specific drivers that increase
vulnerabilities to HIV
•
Multilevel behavioral HIV prevention
strategies
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/
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).
% of IDUs in Selected Regions/
Countries who are Female
Central Asia:
15-26%
China:
30-40%
Eastern Europe:
15-45%
India:
8.5%
Indonesia:
10%
Iran:
3.9%
Malaysia:
10%
North America/Europe:
40%
EuroHIV, 2007, 2008; UNAIDS report on the global AIDS epidemic. Geneva: Switzerland (2010)
HIV Prevalence among IDUs in 2008
Source: Mathers, et al., Lancet 2008
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)
Gender-Specific Drivers
that Increase
Vulnerabilities to HIV
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.
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
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
Ppa
Partner Abuse
Partner Abuse
• Prevalence rates of Partner Abuse among druginvolved 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)
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.
•
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.
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.
Contexts Linking PA and HIV among FWID
• Sexual Coercion
• Negotiation and refusal of condoms
• Fear of Violence
• Micro-social contexts in injection drug use
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.
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.
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.
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.
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)
Financial Dependencies and HIV Risks among
Women on Methadone
Dependent for
Housing (Lease)
OR = 2.9; p = .04
Never Request
Condoms
Partner Paid for
Woman’s Drugs
OR = 1.9; p = .05
Never Request
Condoms
Dependent for
Household
Expenses
El-Bassel et al. Use and Misuse, 2011.
OR = 1.8; p = .04
IPV
Systemic Barriers: Lack of Harm Reduction and Drug
Treatment Programs
Harm Reduction
Needle
Exchange
Substitution
Therapy
Drug & Alcohol
Treatment
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
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.
Advances in HIV Prevention: Our “Toolbox”
Multilevel
Individual
Couple-based
Group
Community
Social Network
Structural
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.
Trauma-Informed HIV Prevention for Women
There are four empirically-tested HIV trauma-informed
prevention intervention models:
1. Seeking Safety: Integrated model on trauma
and substance-abuse, but not HIV (Hien, 2009)
2. Co-occurring Disorders and Violence Study: Sequential model
in which trauma content was followed by HIV prevention
sessions (Amaro, 2007)
3. Women’s Wellness Study: Integrated model of HIV, PA, and
trauma (El-Bassel el al. 2008)
4. Project-WORTH: integration of HIV, drug abuse, and PA (ElBassel, 2013)
Multimedia Worth (307 Women )
• Group modality
• Four sessions
• Triple risks—sexual, drug and PA
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
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
PROJECT WORTH
Characteristics (n= 307)
Variable
Age (mean and SD)
Percentage
41.3% (10.5)
Black
Latina
66%
17%
Injection drug use past 90 days
7%
Crack use past 90 days
31%
Cocaine use past 90 days
39%
HIV positive at baseline
13%
Any STIs
30%
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.
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)
HIV Couple-Based Intervention Studies Globally (N=29)
(Jiwatran-Negron and El-Bassel, 2013)
Project Connect Two (NIDA Funded)
• 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?
Test Hypothesis
To examine the efficacy of seven relationshipbased HIV/STI prevention intervention compared
to a Individual Risk Reduction control condition
Couple Risk
Reduction
Individual Risk
Reduction
Core Components of the
HIV/STI Risk Reduction Intervention
• Skills building to reduce sexual and drug risks: Problemsolving 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
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.
Findings: Connect Two
• 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.
Central Asia
Source: Russia-Ukraine-Travel.com
Production of Opium by Afghans is Up Again
(Asia Pacific, April 2013)
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.
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
Outcomes from Renaissance
• 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.
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
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).
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.
Structural HIV Prevention
Economic Development
• Micro-Finance
• Asset-Building
HIV Prevention and Microfinance
• Microfinance has been found to be a potentially powerful
structural intervention tool in HIV prevention (Pronyk et al., 2005;
Parker et al., 2000)
• Several studies have shown microfinance to be an effective
structural HIV prevention strategy for women working in sex
work (Odek et al., 2009; Pronyk et al., 2008; Pronyk et al., 2006; Erulkar et al., 2006;
Sherman et al., 2006).
Undarga pilot (2010) –
Microfinance Intervention
Financial Literacy
Education
Business Development
Training
Vocational Mentorship
Groups
12 sessions (3/week)
12 sessions (3/week)
10 sessions (2/week)
Matched Savings (2:1 up to 576,000₮/425US$)
From second week of financial literacy education through end of the intervention
Cordisco-Tsai, L., Witte, S.S., Aira, T., Riedel, M., Altantsetseg, B. (2011). Piloting a savings led microfinance intervention with sex
workers in Mongolia: Implications for HIV risk reduction. Open Women’s Health Journal, 5, 11-17.
Undarga Trial (2010-2013) (Witte et al.,
unpublished, 2013)
HIVSRR
n=50
Baseline
Assessment
n=204
IPT Followup
Assessment
n=95
Random
Assignment
n=107
HIVSRR + MF
n=57
3 Month
Follow-Up
Assessment
N=93
6 Month
Follow-Up
Assessment
N=93
Undarga Preliminary Findings
Table 1. Estimates of the impact of assignment to HIVRR+MF vs. RR at 3 month post intervention
(n=78, 39 in each condition)
Condom-protected vaginal sex
*Unprotected vaginal sex
Percentage income
Financial literacy
(percentage of acts, past 90 days)
(# acts in past 90 days)
from sex work
(Sum of scale score)
11.2
.444
-18.9
2.935
[3.003, .228]
[.385, .511]
[-.367, -0.10]
[1.67, 4.20]
(p=0.057)
(p<.001)
(p=0.039)
(p<0.001)
*Poisson regressions; others are linear, adjusting for baseline value and condition; b, confidence intervals and p are reported
Susan Witte et al., unpublished, 2013.
Undarga Preliminary Findings
•HIV&MF participants were more likely to have saved money
compared with HIVRR only (19 MF vs. 8 HIVRR only, p<.01)
•Follow-up rates are 92% and 90% at 3 and 6 months
respectively, with approximately half of interviews remaining
Witte et al., unpublished, 2013
Advances in HIV Prevention:
Our “Toolbox”
Biomedical
ARV Treatment
Microbicides
PrEP
Biomedical Studies Have Not Fully
Addressed:
• Level of adherence to ARV, PREP, or microbicide
protocols among FWID
• Role of co-morbidities: mental illness, trauma,
partner abuse
• Structural barriers for FWID that affect participation
and adherence
Implications for Women-Specific
HIV Prevention
One HIV intervention model does not fit all women!
• HIV prevention interventions should provide women
with a range of HIV protection strategies and the risk
of each option should be assessed with them
• Men should be included in HIV and IPV prevention,
when it can be done in a manner that protects the
woman’s safety
Conclusion
• No single HIV prevention is sufficient to curtail the epidemic
• A combination of HIV prevention strategies and services are required
Structural Interventions should include:
• Economic development and empowerment
• Systemic/organizational change
• Policy changes – fight discrimination and gender-based violence, stop
police mistreatment, arrests, and required registration of female drug
users and sex workers
Next Steps Needed in Research:
• Population-based epidemiologic studies on HIV and IDU
• Implementation science to scale-up structural and systemic HIV
prevention
Thanks To:
Social Intervention Group (SIG)
Global Health Research Center of
Central Asia (GHRCCA)
NIDA for supporting the Research
And to the women and men who
participated in the studies