Download People Who Inject Drugs in Intimate Relationships

People Who Inject Drugs
in Intimate Relationships:
It Takes Two to Combat HIV
20th International
AIDS Conference
Melbourne, Australia
July 20-25, 2014
Presentation Will Cover:
• Global epidemiology of injection drug use and HIV
• Gender roles in intimate relationships in drug-using cultures
(micro social contexts)
• A couple-based behavioral HIV prevention modality that addresses
the micro social context of unsafe injection and sexual practices
source: globe.gov
Epidemiology of IDU
• Outside sub-Saharan Africa, IDU accounts for approximately one in
three cases of HIV, particularly in low and middle income countries
(UNAIDS Global Report 2012; Wood et al, 2010)
• Globally, the number of people who inject drugs (PWID) is
approximately 16 million (Mathers et al, 2008; UNAIDS Global AIDS
Report, 2012)
• Of PWID globally, about 3 million are female (Des Jarlais, 2012 Drug
and Alcohol Dependency; UNAIDS Global AIDS Report, 2012)
• The proportion of females who inject drugs (FWID) among all PWID
ranges from 4% (Iran) to 45% (North America, Eastern Europe)
(EuroHIV, 2007; UNAIDS Global Report, 2010)
source: globe.gov
FWID Vulnerabilities for HIV
•
Gender inequalities
•
Social exclusion, stigma,
discrimination
•
Poverty—unemployment and
financial dependencies lead
to sex work
•
Lack of access to harm
reduction and gender specific
services
•
Gender roles and a male
oriented drug culture (micro
social contexts)
El-Bassel, N., Shaw, S.A., Dasgupta, A., Strathdee, S. (2014). Drug use as a driver of HIV risks re-emerging and emerging issues. Current
Opinion in HIV & AIDS.
Strathdee, S.A., Hallett, T.B., Bobrova, N., Rhodes, T., et. al (2010). HIV and risk environment for injecting drug users: The past, present,
and future. Lancet.
Micro Social Contexts of Injection Sharing
• Men often introduce their female partners to IDU
• Females are often injected by their male partner not only at
initiation of use, but over their injection career
• Females often inject second, using their male partner’s equipment
• Non self-injection among FWID has been linked to HIV infection and
marginalization and abuse in the relationship
Epel, M. (2002). Scars, harm and pain about being injected among drug using Latina women. Journal of Ethnicity in Substance
Abuse.
Lloyd-Smith, E., Rachlis, B.S., Tobin, D., Stone, D., Li, K., Small, W., et. al (2010). Assisted injection in outdoor venues: An
observational study of risks and implications for service delivery and harm reduction programming. Harm Reduction Journal.
El-Bassel, N. Shaw, S A.; Dasgupta, A, Strathdee, S. (2014). People who inject drugs in intimate relationships: It takes two to
combat HIV. Current HIV/AIDS Report.
Micro Social Contexts of Injection Sharing
Common reasons reported by FWID for assisted injection:
• Sex partner’s controlling behaviors and gender role expectations
around drug and sex practices
• FWID may be uncomfortable injecting themselves, lack skills or
have difficulty finding veins
• FWID avoid intramuscular injection to reduce the chance of lesions
and scars especially among those who sell sex for survival
• Police threats restrict time to locate and inject in vein
Epel, M. (2002). Scars, harm, and pain: About being injected among drug using Latina women. Journal of Ethnicity in Substance Abuse.
Lloyd-Smith, E., Rachlis, B.S., Tobin, D., Stone, D., Li, K., Small, W., et. al (2010). Assisted injection in outdoor venues: An observational
study of risks and implications for service delivery and harm reduction programming. Harm Reduction Journal.
El-Bassel, N. Shaw, S A.; Dasgupta, A, Strathdee, S. (2014). People who inject drugs in intimate relationships: It takes two to combat
HIV. Current HIV/AIDS Report.
Micro Social Contexts of Injection Sharing
•
Sharing injections is perceived by the
couple as a sign of love and
commitment
•
If the woman shares injections with
other men, it is perceived as infidelity
and can lead to IPV, IPV can also
prevent refusal to inject
•
FWID often see the cost of putting
themselves at HIV risk as less than the
cost of jeopardizing their relationship
El-Bassel, N., Gilbert, L., Wu, E., Chang, M., & Fontdevila, J. (2007). Perpetration of intimate partner violence among men in
methadone treatment programs in New York City. AJPH.
El-Bassel, N. Shaw, S A.; Dasgupta, A, Strathdee, S. (2014). People who inject drugs in intimate relationships: It takes two to
combat HIV. Current HIV/AIDS Report.
Micro Social Contexts of Unsafe Sexual Behavior
Among Couples Who Inject Drugs
•
Condom use remains low in
intimate, established relationships
compared to casual and
commercial sexual encounters
•
Condom use symbolizes a lack of
love, trust and commitment in
some established relationships
•
FWID often avoid using and
introducing condoms to preserve
the relationship and to evade IPV
source: streethypenewspaper.com
El-Bassel, N., Gilbert, L., Wu, E., Chang, M., & Fontdevila, J. Perpetration of intimate partner violence among men in methadone
treatment programs in New York City. AJPH (2007).
El-Bassel, N. Shaw, S A.; Dasgupta, A, Strathdee, S. (2014). People who inject drugs in intimate relationships: It takes two to combat
HIV. Current HIV/AIDS Report.
IPV and HIV
• HIV & IPV are two overlapping public health problems that affect a
significant number of women who use or inject drugs (WHO,
2012)
• WHO has identified IPV as a risk factor for HIV infection among
women (WHO, 2006)
• Lifetime prevalence rates of IPV among women who use or inject
drugs range between 60-80%, which is more than 3 times higher
than these rates in the general population (El-Bassel et al., 2005;
Gilbert, 2013; Hien, 2007; Bennet et al., 2001)
Intimate Partner Violence
Women on probation and in an alternative to incarceration program in NYC
(300 women)
•61% reported that they had experienced sexual or physical IPV in their
lifetime and 18% reported it in the past 6 months (El-Bassel, et al., 2014)
FWID in Kyrgyzstan (n= 78 women)
•91% reported ever experiencing any physical, sexual or injurious IPV, (Gilbert
et al., 2014)
HIV positive women n in Kazakhstan (250 HIV positive women)
•65% reported ever experiencing any physical, sexual or injurious IPV
(Jiwatram-Negrón & El-Bassel, 2014, in progress)
Contexts Linking IPV and HIV
Sexual Coercion:
• FWID with a history of sexual coercion are less likely to use condoms
than those who use drugs 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 IPV increase when women:
•
Ask their partners to use a condom
•
Refuse sex without a condom
•
Refuse vaginal and anal sex
El-Bassel, N., Gilbert, L., Wu, E., Go, H. & Hill, J. (2005). HIV and intimate partner violence among women on methadone. Social Science and Medicine.
El-Bassel, N., Gilbert, L., Wu, E., Chang, M., & Fontdevila, J. (2007). Perpetration of intimate partner violence among men in methadone treatment
programs in New York City. AJPH.
Micro Social Contexts of IDU, IPV, and HIV
• Disputes over sharing/splitting drugs leads to physical and
sexual IPV
• Forced unprotected sex while high
• Male partners often take advantage of a woman’s state of
drug withdrawal to coerce sex
El-Bassel, N., Gilbert, L., Witte, S. et al. (2011). Intimate Partner Violence and HIV among drug-involved women: Contexts
linking these two epidemics - challenges and implications for prevention and treatment. Substance Use and Misuse.
Gilbert, L., El-Bassel, N., Chang, M., Shaw, S., Wu, E., Roy, L. (2013). Risk and protective factors for drug use and partner
violence among women in emergency care. Journal of Community Psychology.
Women Are in Charge
• Not all women
are passive
participants in
injection
contexts
• Some women
have more
control of
injection and
condom use
practices
In a study with 181
PWID in Australia,
among 25% of the
couples, the female
partners were
primarily
responsible for
acquiring and
preparing drugs
and obtaining
needles (Bryant, et.
al 2010).
Bryant, J., Brener, L., Hull, P., Treloar, C. (2010). Needle sharing in regular sexual relationships: An examination
of serodiscordance, drug using practices, and the gendered character of injecting.
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
Characteristics:
• Responsibility is placed on the woman
El-Bassel, N., Wechsberg, W., & Shaw, S.A. (2012). Dual HIV risk and vulnerabilities among women who
use or inject drugs: No single prevention strategy is the answer. Current AIDS Opinions.
Moving from an Individual to a Couple Approach
HIV prevention strategies rarely
bring partners together to get
tested for HIV or receive HIV
prevention services (WHO,
2012; UNAIDS, 2012)
Review Paper Found Only 33 Couple-based HIV
Intervention Studies (Jiwatram-Negrón and El-Bassel, 2014)
Types of Couple-Based HIV Intervention Studies
HIV Couple-Based Intervention Studies Globally (N=33)
(Jiwatram-Negrón and El-Bassel, 2014)
Couple-Based HIV Intervention Studies by Couple Definition
(Jiwatram-Negrón and El-Bassel, 2014)
Couple-Based Studies With PWID
• 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., 2014, JAIDS) (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)
• Intersecting risk after an HIV couple-based intervention: Biobehavioral outcomes from a randomized clustered design in a Cape
Town township (under review) (Wechsberg et. al.)
Couple-Based HIV Prevention
Two systematic reviews found that couple-based HIV prevention with IDUs and
non-injection drug users have the potential to:
•Increase condom use with main and casual partners
•Reduce needle sharing and unsafe injection, prevent overdose death
•Improve access to HIV testing, treatment, harm reduction, drug treatment,
and promote ART adherence
•Improve communication, negotiations skills, and relationship satisfaction and
address micro social contexts
•Reduce HIV, HCV, and STI incidence ( Few studies)
Jiwatram-Negron, T. & El-Bassel, N. (2014). Systematic review of couples-based HIV intervention and prevention studies: Advantages,
gaps, and future directions. AIDS Behav.
Burton, J., Darbes, L.A. & Operario, D. (2010). Couples-focused behavioral interventions for prevention of HIV: systematic review of
the state of evidence. AIDS Behav.
Central Asia
Source: Russia-Ukraine-Travel.com
Project Renaissance (NIDA Funded)
•
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)
•
Includes 5 sessions delivered
to the couple together
•
Adapted from Project Connect
II and builds on extensive
couple-based research
experience in the U.S. and
internationally
source: magazine.columbia.edu
El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al., (in press). Effects of a couple-based intervention to reduce
risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A randomized controlled trial. JAIDS.
Project Renaissance (NIDA Funded)
• Problem-solving and communication skills related to sexual
and drug risk behaviors
• HIV, HCV, and STI testing detection, knowledge
• Gender roles and expectations related to sexuality, drug risks,
and reproductive health, experience and fear of sexual abuse,
and building safer sex practices and healthy relationships,
safety planning
El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al., (in press). Effects of a couple-based
intervention to reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A
randomized controlled trial. JAIDS.
Project Renaissance (NIDA Funded)
• The meaning of refusing to share needles or to be injected by partner,
and IPV. Communication skills on refusing to share syringes/needles,
dealing with male dominance in drug culture
• Meaning of assisted injection and empowering women to self-inject
• HIV testing, linkage, and navigation to HIV and STI care and harm
reduction programs
• Overdose prevention for the partner and their social network,
educating family and friends on addressing overdose
• Access to naloxone to reduce overdose and death from overdose
El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al. (in press). Effects of a couple-based intervention to
reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A randomized controlled trial. JAIDS.
Test Hypothesis
• To examine the efficacy of the relationship-based
HIV/STI prevention intervention compared to a
Wellness Promotion control condition
Couple Risk
Reduction
Wellness
Promotion
Project
Renaissance
Screened
966 Individuals
Baseline
728 Individuals
(364 Couples)
Randomization
300 Couples
(600 Individuals)
Couple HIV Risk Reduction and Overdose
5 Sessions (151 Couples)
Couple Wellness Promotion and Overdose
5 Sessions (149 Couples)
Intervention Attendance (Couples)
Mean of sessions attended= 4.58 (SD=1.04)
249 participants completed 5 sessions (82.5%)
Intervention Attendance (Couples)
Mean of sessions attended= 4.78 (SD=0.77)
268 participants completed 5 sessions (89.9%)
Follow-up
12-month=229 (81.2%)
Participant deaths=20
Follow-up
12-month=234 (86.0%)
Participant deaths=26
Baseline Data - Project Renaissance
Age
35. 2 (SD =7.7)
Ethnicity
Russian
395 ( 64%)
Kazakh
67 ( 11%)
Marital Status
Legal or Common-Law
521 (87%)
Marriage
HIV Status
HIV positive:
26%
HCV positive
77%
El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al., (in press). Effects of a couple-based intervention to
reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A randomized controlled trial. JAIDS.
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 (IRR=0.58, 95% CI=0.36 – 0.93,
p=.024)
• 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 (OR=2.30, 95%
CI=1.33 – 4.00, p=.003)
El-Bassel, N., Gilbert, L., Terlikbayeva, A., Beyrer, C., Wu, E., Chang, M., et al., (in press). Effects of a couple-based
intervention to reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A
randomized controlled trial. JAIDS.
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 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., (in press). Effects of a couple-based intervention to
reduce risks for HIV and HCV among drug-involved heterosexual couples in Kazakhstan: A randomized controlled trial. JAIDS.
Advantages of Couple-Based Approach
•
Couple-based approach 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
•
Integrates micro social contexts of IDU
El-Bassel, N., Gilbert, L., Wu, E., Go, H., & Hill, J. (2005). Relationship between drug use and intimate partner violence among women on
methadone. American Journal of Public Health.
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.
Summary: Couple-Based HIV Prevention
•
One HIV prevention strategy does not fit
all
•
FWID and their partners need to have
access to various multi level and combined
HIV prevention strategies
•
Couple-based HIV prevention is a strategy
that addresses micro social contexts
•
The use of couple-based HIV prevention
requires an ideological shift by service
providers and administrators
•
Must grasp that some women and men
prefer to receive services together
•
Service providers need to be trained in use
of this modality
•
Funding must be available to address the
dyad rather than the individual
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