HIV and hepatitis C prevalence, and related risk behaviours among people who inject drugs in three cities in Croatia: Findings from respondent-driven sampling surveys

Background

There are limited data on HIV and hepatitis C virus (HCV) epidemiology among people who inject drugs (PWID) in Croatia. This study aims to provide data on HIV and HCV prevalence and sexual and injecting risk behaviours among PWID in Zagreb, Split, and Rijeka.

Methods

Using respondent-driven sampling (RDS) we recruited from November 2014 to February 2015 a total of 176 PWID in Zagreb, 255 in Rijeka and 399 in Split. Participants provided biological specimens for HIV and HCV testing and completed a behavioural questionnaire.

Results

• The proportion of female PWID ranged from 19.5% in Zagreb to 26.0% in Split. 
• In the month before the survey, 2.5% of PWID in Split, 5.6% in Rijeka and 8.0% in Zagreb reported sharing non-sterile needles and syringes. 
• Many PWID injected opioid substitution therapy (OST) in the month before the survey (57.0% in Zagreb and 57.5% in Split and Rijeka, respectively). 
• Among PWID who had a casual sexual partner in the past 12 months (ranging from 39.2% in Split to 44.4% in Rijeka) condom use was low. 
• Although HIV prevalence was low (0.2% in Rijeka and Zagreb, 0.3% in Split), 
• HCV antibody prevalence was considerable (29.1% in Zagreb, 31.5% in Rijeka, 38.3% in Split). 
• HIV and HCV testing coverage in the past 12 months was insufficient (6.8% and 7.0% in Split; 13.2% and 13.5% in Zagreb; 20.2% and 21.5% in Rijeka, respectively).

Conclusion

We found a low-level HIV epidemic and a sizable HCV epidemic among PWID in Zagreb, Split and Rijeka. Presence of high-risk injecting and sexual behaviours together with inadequate HIV and HCV testing coverage call for development of a comprehensive approach to harm reduction and introduction of needle and syringe exchange programmes in prisons, as well as strengthening sexual health interventions.

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By:  Senad Handanagic, Ivana Bozicevic, Marta Civljak, Zoran Dominkovic, Sandra Sevic, Jelena Barbaric, Tatjana Nemeth Blazic, Oktavija Dakovic Rode, Josip Begovac

WHO Collaborating Centre for HIV Surveillance, Andrija Stampar School of Public Health, School of Medicine, University of Zagreb, Rockefellerova 4, 10000, Zagreb, Croatia

Correspondence

Corresponding author. Tel.: +385 1 4590 147; fax: +385 1 4684 212. 

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The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect

INTRODUCTION AND AIMS:

Needle and syringe automatic dispensing machines (ADM) aim to increase needle/syringe distribution to people who inject drugs. ADM implementation has been met with community concern about potential perceived increases in crime and drug use and that they will attract non-resident drug users-the 'honey-pot effect'. In April 2013, an ADM commenced operation in inner-city Sydney. We assessed the impact of the ADM on crime and examined its use by non-resident drug users (the honey-pot effect).

DESIGN AND METHODS:

Fixed-site needle and syringe program (n = 207) and ADM clients (n = 55) were surveyed to determine whether they lived within 1 km of the ADM. Police-recorded offences between January 2012 and March 2014 across six crime categories for the local and surrounding areas were assessed for trend to measure impact on crime.

RESULTS:

The majority (78%) of needle and syringe program clients reported residing within 1 km of the service. Most (95%) ADM users were fixed-site service clients. The 2 year trend for crime categories remained stable or decreased, except for fraud, which increased significantly (P < 0.05).

DISCUSSION AND CONCLUSION:

Automatic dispensing machine users were largely clients of the existing fixed-site service and lived locally. There was no apparent concurrent increase in crime or a honey-pot effect. It is important that services continue to be aware of community concerns and respond to them appropriate

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By:  Grau LE1, Zhan W1,2, Heimer R1.

• 1Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.
• 2Department of Children and Families, Hartford, USA. 
• Drug Alcohol Rev. 2016 Apr 13. doi: 10.1111/dar.12396

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Syringe Stockpiling by Persons Who Inject Drugs: An Evaluation of Current Measures for Needle and Syringe Program Coverage

Needle and syringe program (NSP) coverage is commonly used to assess NSP effectiveness. However, existing measures don't capture whether persons who inject drugs (PWIDs) stockpile syringes, an important and novel aspect of NSP coverage. 

In this study, we determine the extent of stockpiling in a sample of Australian PWIDs and assess whether including stockpiling enhances NSP coverage measures. As part of the Illicit Drug Reporting System study, PWIDs reported syringes procured and given away, total injections in the last month, and syringes currently stockpiled in 2014. We calculated NSP coverage with and without stockpiling to determine proportional change in adequate NSP coverage. We conducted receiver operating characteristic curve analysis to determine whether inclusion of stockpiled syringes in the measure improved sensitivity in discriminating cases and noncases of risky behaviors. 

Three-quarters of the sample reported syringe stockpiling, and stockpiling was positively associated with nonindigenous background, stable accommodation, no prison history, longer injecting careers, and more frequent injecting. Compared with previous measures, our measure was significantly better at discriminating cases of risky behaviors. 

Our results could inform NSP policy to loosen restricted-exchange practice, allowing PWIDs greater flexibility in syringe procurement practices, promoting greater NSP coverage, and reducing PWIDs' engagement in risky behaviors.

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By:  McCormack AR, Aitken CK, Burns LA, Cogger S, Dietze PM.

Correspondence to Professor Paul M. Dietze, Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia (e-mail:pauld@burnet.edu.au).

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Heterogeneity among Sex Workers in Overlapping HIV Risk Interactions with People Who Inject Drugs: A Cross-Sectional Study from 8 Major Cities in Pakistan

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing.

Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID.

The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad.Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. 

There is a need to closely to monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local subepidemics.

Below:  Unadjusted odds of injecting drugs in the past 6 months, by type of sex worker and sexual activity with people who inject drugs

Full article at:   http://goo.gl/PxD5ch

By:  Melesse DY1, Shafer LA, Shaw SY, Thompson LH, Achakzai BK, Furqan S, Reza T, Emmanuel F, Blanchard JF.

• 1From the Centre for Global Public Health, Department of Community Health Sciences (DYM, SYS, LHT, FE, JFB); Department of Internal Medicine (LAS), Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; and National AIDS Control Program (BKA, SF, TR), National Institute of Health, Islamabad, Pakistan. 
• Medicine (Baltimore). 2016 Mar;95(12):e3085. doi: 10.1097/MD.0000000000003085.

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Engagement in a National Naloxone Program among People Who Inject Drugs

HIGHLINGHTS

• Access to naloxone among PWID increased significantly from 8% in 2011–2012 to 32% in 2013–2014.
• Carriage of naloxone decreased significantly from 16% in 2011–2012 to 5% in 2013–2014.
• Community services and prisons were equally efficient at targeting their naloxone supplies.

BACKGROUND:

Availability of the opioid antagonist naloxone for lay administration has grown substantially since first proposed in 1996. Gaps remain, though, in our understanding of how people who inject drugs (PWID) engage with naloxone programmes over time.

AIMS:

This paper aimed to address three specific evidence gaps: the extent of naloxone supply to PWID; supply-source (community or prisons); and the carriage of naloxone among PWID.

MATERIALS AND METHODS:

Analysis of Scotland's Needle Exchange Surveillance Initiative (NESI) responses in 2011-2012 and 2013-2014 was undertaken with a specific focus on the extent of Scotland's naloxone supply to PWID; including by source (community or prisons); and on the carriage of naloxone. Differences in responses between the two surveys were measured using Chi-square tests together with 95% confidence intervals for rate-differences over time.

RESULTS:

The proportion of NESI participants who reported that they had been prescribed naloxone within the last year increased significantly from 8% (175/2146; 95% CI: 7-9%) in 2011-2012 to 32% (745/2331; 95% CI: 30% to 34%) in 2013-2014. In contrast, the proportion of NESI participants who carried naloxone with them on the day they were interviewed decreased significantly from 16% (27/169; 95% CI: 10% to 22%) in 2011-2012 to 5% (39/741; 95% CI: 4% to 7%) in 2013-2014.

CONCLUSIONS:

The supply of naloxone to PWID has increased significantly since the introduction of a National Naloxone Programme in Scotland in January 2011. In contrast, naloxone carriage is low and decreased between the two NESI surveys; this area requires further investigation.

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By:  McAuley A1, Munro A2, Bird SM3, Hutchinson SJ4, Goldberg DJ4, Taylor A2.

• 1Health Protection Scotland, Meridian Court, Cadogan Street, Glasgow G2 6QE, UK; Institute for Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK. Electronic address: andrew.mcauley@nhs.net.
• 2School of Media, Culture and Society, University of the West of Scotland, Paisley PA1 2BE, UK.
• 3MRC Biostatistics Unit, Cambridge CB2 0SR, UK; Department of Mathematics and Statistics, Strathclyde University, Glasgow G1 1XH, UK.
• 4Health Protection Scotland, Meridian Court, Cadogan Street, Glasgow G2 6QE, UK; Institute for Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK. 
• Drug Alcohol Depend. 2016 Mar 3. pii: S0376-8716(16)00106-X. doi: 10.1016/j.drugalcdep.2016.02.031. 

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High Prevalence of Assisted Injection among Street-Involved Youth in a Canadian Setting

Many people who inject illicit drugs receive manual assistance when injecting, and this practice has been linked to increased risk of HIV infection and other harms. Little is known, however, about this practice among youth. 

This study uses a multivariate generalized estimating equation to identify factors associated with receiving assistance with injecting among a cohort of street-involved youth aged 14-26 in Vancouver, Canada. 

A total of 253 participants reported injecting drugs during the study period, and 49 % (n = 125) of these youth reported receiving assistance with injecting in the past 6 months. In multivariate analysis, younger age, female gender, binge drug use, heroin injecting, cocaine injecting, crystal methamphetamine injecting, and syringe sharing were positively and independently associated with assisted injection (all p < 0.05). 

These findings underscore the need for expanding substance abuse treatment alongside HIV prevention and health promotion interventions to empower youth to enact safer injection practices.

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By:  Cheng T1,2, Kerr T1,3, Small W1,2, Dong H1, Montaner J1,3, Wood E1,3, DeBeck K4,5.

• 1Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
• 2Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
• 3Faculty of Medicine, University of British Columbia, Vancouver, Canada.
• 4Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-kd@cfenet.ubc.ca.
• 5School of Public Policy, Simon Fraser University, Burnaby, Canada. uhri-kd@cfenet.ubc.ca. 

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HIV Prevalence & Risk Behaviors among People Who Inject Drugs in Songkhla, Thailand

Background

Songkhla has one of the most serious provincial HIV epidemics among people who inject drugs (PWID). However, there remains a lack of systematic data on drug use patterns, HIV risk behaviors and access to interventions. To address the gap, we conducted an integrated bio-behavioral survey in 2010.

Methods

Respondent-driven sampling (RDS) was used to recruit PWID who reported injecting in the last six months. Participants were interviewed and tested for HIV and sexually transmitted infections (STIs). RDS Analysis Tool (RDSAT) was used to generate adjusted proportion estimates.

Results

Of 202 participants, almost all were men, 90% injected heroin, followed by methamphetamine (22%). One-third (37%) injected multiple drugs. HIV prevalence was high (22%). Seven percent reported needle sharing at last injection and 27% reported using a condom at last sex. Nearly half (42%) were currently on methadone treatment. Few participants received new needles (10%) and condoms (11%) from drop-in centers and/or peer outreach workers.

Conclusion

This RDS survey informs the understanding of the HIV epidemic and the programmatic response among PWID in Songkhla. It was effective at recruiting PWID who were currently out-of-treatment. Given the increasing trend of poly-drug injecting use documented, a comprehensive and integrated combination intervention approach for HIV services is recommended.

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By:  Prin Visavakum, Niramon Punsuwan, Chomnad Manopaiboon, Sarika Pattanasin, Panupit Thiengtham, Suvimon Tanpradech, Wichuda Sukwicha, Mitchell Wolfe, Dimitri Prybylski

Affiliations

Thailand MOPH – U.S. CDC Collaboration, Nonthaburi 11000, Thailand

Correspondence

Corresponding author at: Global AIDS Program, Thailand MOPH – U.S. CDC Collaboration, DDC7 Building, Ministry of Public Health, Nonthaburi 11000, Thailand. Tel.: +66 2580 0669; fax: +66 2591 2909.

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A Cross-National Analysis of the Effects of Methadone Maintenance & Needle & Syringe Program Implementation on Incidence Rates of HIV in Europe from 1995-2011

Highlights

• Greater years of needle and syringe program implementation were associated with lower incidence rates of HIV generally and among PWID.
• Greater years of methadone maintenance program implementation were associated with lower incidence rates of HIV generally and among PWID.
• Higher rates of clients enrolled in methadone maintenance therapy were associated with lower incidence rates of HIV generally and among PWID.
• Greater total expenditures on healthcare were associated with lower incidence rates of HIV generally and among PWID.

Abstract

Although many studies have found an association between harm reduction interventions and reductions in incidence rates of Human Immunodeficiency Virus (HIV) infection, scant research explores the effects of harm reduction cross-nationally. 

This study used a year- and country-level fixed effects model to estimate the potential effects of needle-and-syringe programs (NSPs) and methadone maintenance therapy (MMT) on incidence rates of HIV in the general population and among people who inject drugs (PWID), in a sample of 28 European nations. After adjusting for Gross Domestic Product (GDP) and total expenditures on healthcare, we identified significant associations between years of MMT and NSP implementation and lower incidence rates of HIV among PWID and the general population. In addition to years of implementation of NSP and MMT, the greater proportion of GDP spent on healthcare was associated with a decrease in logged incidence rates of HIV. The findings of this study suggest that MMT and NSP may reduce incidence rates of HIV among PWID cross-nationally. 

The current study opens a new avenue of exploration, which allows for a focus on countrywide policies and economic drivers of the epidemic. Moreover, it highlights the immense importance of the adoption of harm reduction programs as empirically-based health policy as well as the direct benefits that are accrued from public spending on healthcare on incidence rates of HIV within the general population and among subpopulations of PWID.

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By:  Phillip L. Marotta, Charlotte A. McCullagh

Affiliations

Columbia University

School of Social Work

Social Intervention Group

Global Research Center of Central Asia 1255 Amsterdam Avenue, New York NY 8^th Floor

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Prospects for Ending the HIV Epidemic among Persons Who Inject Drugs in Haiphong, Vietnam

Highlights

• We assessed prospects for ending the HIV epidemic among persons who inject drugs in Haiphong Vietnam.
• HIV prevalence declined from 68% in 2006 to 25% in 2014 among persons who inject drugs.
• Self-reported injecting “risk behavior” was quite low.
• Estimated HIV incidence among persons who recently (<5 years) began injecting drugs was 1/100 person-years at risk.
• The greatest gap in combined prevention and care services was in the low coverage of ART among HIV seropositive PWID. Scaling up ART for HIV seropositives should greatly accelerate the decline in the HIV epidemic. Ending the HIV epidemic among PWID in Haiphong is an achievable public health goal.

Abstract

Background

To examine the prospects for “ending the HIV epidemic” among persons who inject drugs (PWID) in Haiphong, Vietnam. Reaching an incidence of < 0.5/100 person-years at risk (PY) was used as an operational definition for “ending the epidemic.”

Methods

A respondent driven sampling study of 603 PWID was conducted from September to October 2014. Current heroin use (verified with urine testing and marks of injection) was an eligibility requirement. A structured questionnaire was administered by trained interviewers to obtain demographic, drug use, and risk behavior data; HIV counseling and testing and HCV testing was also conducted. Two methods (by assuming all new injectors were HIV negative at first injection and by slope of prevalence by years injecting) were used for estimating HIV among persons injecting for < 5 years (“new injectors”). Comparisons were made to the HIV epidemic among PWID in New York City and modeling of the HIV epidemic in Can Tho province.

Results

HIV prevalence was 25% in 2014, down from 68% in 2006 and 48% in 2009; overall HCV prevalence in the study was 67%. Among HIV seropositive PWID, 33% reported receiving antiretroviral treatment. The great majority (83%) of subjects reported pharmacies as their primary source of needles and syringes and self-reported receptive and distributive syringe sharing were quite low (< 6%). Estimating HIV incidence among non-MSM male new injectors with the assumption that all were HIV negative at first injection gave a rate of 1.2/100 person-years (95% CI -0.24, 3.4). Estimating HIV incidence by the slope of prevalence by years injecting gave a rate of 0.8/100 person-years at risk (95% CI -0.9, 2.5)

Conclusions

The current HIV epidemic among PWID in Haiphong is in a declining phase, but estimated incidence among non-MSM new injectors is approximately 1/100 person-years and there is a substantial gap in provision of ART for HIV seropositives. Scaling up interventions, particularly HIV counseling and testing and antiretroviral treatment for all seropositive PWID, should accelerate the decline. Ending the epidemic is an attainable public health goal.

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By:  Don C Des Jarlais, Huong Duong Thi, Oanh Khuat Thi Hai, Khuê Pham Minh, Giang Hoang Thi, Thanh Nham Thi Tuyet, Kamyar Arasteh, Jonathan Feelemyer, Theodore Hammett, Marianne Peries, Laurent Michel, Vinh Vu Hai, Marie Jauffret Roustide, Jean-Pierre Moles, Didier Laureillard, Nicolas Nagot. for the DRIVE Study Team

Affiliations

• Mount Sinai Beth Israel, New York City, USA

Correspondence

• Corresponding author at; The Baron Edmond de Rothschild Chemical Dependency Institute Mount Sinai Beth Israel 160 Water Street, 24th Floor New York, NY 10038 212.256.2548.

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Sharing of Needles and Syringes among Men Who Inject Drugs: HIV Risk in Northwest Bangladesh

INTRODUCTION:

Injection drug use is prevalent in northwestern Bangladesh. We sought to explore the context of needle/syringe sharing among persons who inject drugs (PWID), examining risk exposures to blood-borne infections like the human immunodeficiency virus (HIV) and hepatitis in a region where these dual epidemics are likely to expand.

METHODS:

We used a qualitative research approach to learn about injection practices, conducting 60 in-depth interviews among PWID. We then conducted 12 focus group discussions (FGDs) that generated a checklist of salient issues, and followed up with personal observations of typical days at the drug-use venues. Content and interpretative frameworks were used to analyze qualitative information and socio-demographic information, using SPSS software.

RESULTS:

We found that needle/syringe-sharing behaviours were integrated into the overall social and cultural lives of drug users. Sharing behaviours were an central component of PWID social organization. Sharing was perceived as an inherent element within reciprocal relationships, and sharing was tied to beliefs about drug effects, economic adversity, and harassment due to their drug user status. Carrying used needles/syringes to drug-use venues was deemed essential since user-unfriendly needle-syringe distribution schedules of harm reduction programmes made it difficult to access clean needles/syringes in off-hours. PWID had low self-esteem. Unequal power relationships were reported between the field workers of harm reduction programmes and PWID. Field workers expressed anti-PWID bias and judgmental attitudes, and also had had misconceptions about HIV and hepatitis transmission. PWID were especially disturbed that no assistance was forthcoming from risk reduction programme staff when drug users manifested withdrawal symptoms.

CONCLUSION:

Interventions must take social context into account when scaling up programmes in diverse settings. The social organization of PWID include values that foster needle-syringe sharing. Utilization and impact of risk reduction programmes might be improved with expanded clean needle/syringe distribution at times and venues convenient for PWID, better trained and non-judgmental staff, and medical assistance for health problems, including drug withdrawal symptoms.

Below:  Socio-demographic profile for 140 persons who inject drugs in Rajshani, Bangladesh

Full article at:   http://goo.gl/OBTdZE

By:  Pasa MK1, Alom KR1, Bashri Z2, Vermund SH3.

• 1Department of Anthropology, University of Rajshahi, Rajshani, Bangladesh.
• 2Institute of Environmental Science, University of Rajshahi, Rajshani, Bangladesh.
• 3Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America. 

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Community Pharmacy Services for People with Drug Problems Over Two Decades in Scotland: Implications for Future Development

BACKGROUND:

In Scotland community pharmacies are heavily involved in service delivery for people with drug problems (PWDP) as documented through surveys of all community pharmacies in 1995, 2000 and 2006. A further survey in 2014 enabled trends in service demand/provision to be analysed and provides insight into future development.

METHODS:

The lead pharmacist in every Scottish pharmacy (n=1246) was invited to complete a postal questionnaire covering attitudes towards PWDP and service provision and level of involvement in services (needle exchange, dispensing for PWDP and methadone supervision). Additional questions covered new services of take-home naloxone (THN) and pharmacist prescribing for opioid dependence. Telephone follow-up of non-responders covered key variables. A comparative analysis of four cross-sectional population surveys of the community pharmacy workforce (1995, 2000, 2006 and 2014) was undertaken.

RESULTS:

Completed questionnaires were returned by 709 (57%) pharmacists in 2014. Key variables (questionnaire or telephone follow-up) were available from 873 (70%). The proportion of pharmacies providing needle exchange significantly increased from 1995 to 2014 (8.6%, 9.5%, 12.2%, 17.8%) as did the proportion of pharmacies dispensing for the treatment of drug misuse (58.9%, 73.4%, 82.6% and 88%). Methadone was dispensed to 16,406 individuals and buprenorphine to 1777 individuals (increased from 12,400 and 192 respectively in 2006). Attitudes improved significantly from 1995 to 2014 (p<0.001). Being male and past training in drug misuse significantly predicted higher attitude scores (p<0.05) in all four years. Attitude score was a consistently significant predictor in all four years for dispensing for the treatment of drug misuse and providing needle exchange. In 2014, 53% of pharmacists felt part of the addiction team and 27.7% did not feel their role was valued by them. Nine pharmacists prescribed for opioid dependence.

CONCLUSION:

It is possible for pharmacy workforce attitudes and service engagement to improve over time. Training was key to these positive trends. Communication with the wider addiction team could be further developed.

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By:  Matheson C1, Thiruvothiyur M2, Robertson H3, Bond C3.

• 1Centre of Academic Primary Care, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, United Kingdom. Electronic address: c.i.math@abdn.ac.uk.
• 2Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, United Kingdom.
• 3Centre of Academic Primary Care, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, United Kingdom. 

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Impacts of Stigma on HIV Risk for Women Who Inject Drugs in Java: A Qualitative Study

Highlights

• Javanese women who inject drugs felt stigmatized by health professionals and others.
• This stigma contributed to feelings of shame.
• Drug use was hidden by avoiding those who do not inject and harm reduction services.
• Trust in their small group of injecting friends contributed to sharing needles.

Background

People who inject drugs have experienced stigma around the world. Stigma has been found to have negative consequences for individuals in relation to health-service use, psychological wellbeing and physical health; and for populations in terms of health inequalities. Indonesia has experienced a rapid growth in injecting drug use and HIV and little is known about drivers of HIV risk among Indonesian women who inject drugs. The purpose of this paper is to describe and consider the multiple impacts of stigmatization of injecting drug use on injecting behaviors among women who inject drugs in Java.

Methods

In-depth interviews were conducted with 19 women who inject drugs in Java. Mean age was 25 years, all but one was employed or at college. The interviewers were Indonesian women.

Results

Significant stigma around women's drug use was reported from multiple sources in Java including family, friends and health services, resulting in feelings of shame. To avoid this stigma, most of the study participants hid their drug use. They lived away from family and had few friends outside their drug-injecting circle, resulting in isolation from mainstream society and harm-reduction services. Sharing of injecting equipment was restricted to a small, closed circle of trusted friends, thus limiting possible HIV transmission to a small number of injectors.

Conclusions

The stigmatization of drug use, particularly of drug use by women, in Indonesia appears to have contributed to significant shame, isolation from mainstream society and high rates of sharing injecting equipment with a small group of trusted friends (particularly the partner).

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By:  Catherine Spooner^a, , , Antonia Morita Iswari Saktiawati^b, , Elan Lazuardi^b, , Heather Worth^a, ,Yanri Wijayanti Subronto^b, , Retna Siwi Padmawati^b, 

^a UNSW Australia, Sydney, NSW 2052, Australia

^b Center for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Bulaksumur, Yogyakarta 55281, Indonesia

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