Substance Use & HIV among Female Sex Workers & Female Prisoners: Risk Environments & Implications for Prevention, Treatment & Policies

Female sex workers (FSWs) and female prisoners experience elevated HIV prevalence relative to the general population because of unprotected sex and unsafe drug use practices, but the antecedents of these behaviors are often structural in nature. We review the literature on HIV risk environments for FSWs and female prisoners, highlighting similarities and differences in the physical, social, economic, and policy/legal environments that need to be understood to optimize HIV prevention, treatment, and policy responses. Sex work venues, mobility, gender norms, stigma, debt, and the laws and policies governing sex work are important influences in the HIV risk environment among FSWs, affecting their exposure to violence and ability to practice safer sex and safer drug use behaviors. Female prisoners are much more likely to have a drug problem than do male prisoners and have higher HIV prevalence, yet are much less likely to have access to HIV prevention and treatment and access to drug treatment in prison. Women who trade sex or are imprisoned and engage in substance use should not be considered in separate silos because sex workers have high rates of incarceration and many female prisoners have a history of sex work. Repeated cycles of arrest, incarceration, and release can be socially and economically destabilizing for women, exacerbating their HIV risk. This dynamic interplay requires a multisectoral approach to HIV prevention and treatment that appreciates and respects that not all women are willing, able, or want to stop sex work or drug use. Women who engage in sex work, use drugs, or are imprisoned come from all communities and deserve sustained access to HIV prevention and treatment for substance use and HIV, helping them and their families to lead healthy and satisfying lives...

Although female prisoners are much more likely than male prisoners to have a drug problem, they are much less likely than men to have access to drug treatment in prison. For example, in Iran, methadone maintenance was available in men’s prisons long before it was available in women’s prisons. At a minimum, full access to free evidence-based drug and alcohol treatment should be offered to all women who need it, both inside and outside prison. Alternatives to incarceration for drug-involved women are also needed. Because most women are in prison for nonviolent offenses and pose no risk to the public, we call on all governments to grant amnesty to women imprisoned on drug possession offenses. Serious attention should be paid to development and implementation of noncustodial sentences for women, particularly during pregnancy and when they have young children.

Given the complex HIV/STI prevention needs of drug-involved FSWs and incarcerated women, a broad set of gender-specific HIV/STI prevention tools for this population need to be identified, developed, and implemented, as Figure 1 suggests. Although some interventions for FSWs who are drug or alcohol dependent have been developed,^60,61 there are few evidence-based HIV/STI prevention interventions for incarcerated women or those under community supervision. An example is Project POWER, which is a behavioral intervention aimed to reduce risk of acquiring or transmitting HIV and STIs among incarcerated women returning to their communities.⁶² POWER was adapted based on formative research with prison staff and administration, incarcerated and previously incarcerated women, and community advisory boards. A randomized trial using this adaptation with 521 women in 2 North Carolina correctional facilities showed that POWER participants had significantly less occasions of unprotected sex with both main and casual male partners. POWER participants also reported significantly fewer barriers to using condoms and greater HIV knowledge, health-protective communication, and tangible social support. However, the intervention had no significant effects on incident STIs.⁶³

Because of the high rates of serious mental illness along with substance use disorders in incarcerated women⁴⁹ who rarely receive treatment for these conditions, there is a need for targeted attention to the chronic medical, psychiatric, and drug treatment needs of women at risk for incarceration, in jail and after release. Lessons can be learned from a successful pilot project treating major depressive disorders in prison settings conducted in Rhode Island, USA, where of the 25 study participants, 72% were free of all depressive disorders after treatment...⁶⁴ 

Below:  HIV risk environment and opportunities for intervention and prevention among FSWs and prisoners.

Full article at: http://goo.gl/DJGn66

By: Steffanie A. Strathdee, PhD,* Brooke S. West, PhD,* Elizabeth Reed, ScD,* Babak Moazan, BSc,† Tasnim Azim, MBBS, PhD,‡ and Kate Dolan, PhD§

^*Department of Medicine, University of California San Diego, La Jolla, CA

^†Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

^‡Centre for HIV/AIDS, ICDDR, B, Dhaka, Bangladesh

^§Program of International Research and Training, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

Correspondence to: Steffanie A. Strathdee, PhD, Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mailstop 0507, La Jolla, CA 92093, ude.dscu@eedhtartss

   

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