Bringing Female Substance Users to the Center of the Global HIV Response.

Abstract

Women aged 15 years and older bear half of the global HIV-infection burden.1 Women's risk for HIV infection varies by region, age, ethnicity, and socioeconomic status, yet one group is especially vulnerable: women and adolescent girls who use substances. The Global Burden of Disease Study Group estimates that one-third of the world's substance users are female, including approximately 3.8 million women who injected drugs in 2010.2 Prevalence and patterns of substance use vary widely by region and by drug type and administration route. In many countries with high-HIV prevalence among people who inject drugs, HIV prevalence is often higher among injecting females when compared with injecting males.3 Even noninjection drug use (ie, snorting, smoking, inhalation, and ingestion) has been linked to increased risk for HIV acquisition because of increases in unprotected sex, gender-based violence, and related-structural barriers (poverty, unemployment, stigma, aggressive policing, and human rights violations).4–6 Although the HIV epidemic has entered its third decade, research continues to largely ignore the role of gender in HIV prevention and treatment. As a result, HIV-intervention services are designed primarily for men, ignoring the needs of women and adolescent girls. Data collected on substance use, HIV, and service coverage (including harm reduction, drug treatment, and HIV care and treatment) is rarely sex disaggregated. This conceals the severity and scope of substance use and HIV among females, resulting in less investment by both governments and funders to address the distinctive needs of women and adolescent girls who use drugs. Moreover, certain populations of drug-using women and adolescent girls have been neglected by research, prevention, and treatment, including those who engage in sex trading, those involved in the criminal justice system, women who have sex with women, and transgendered women. This special issue attends to such groups and highlights their unique vulnerabilities to HIV. This special issue arose from the serious need to take stock of the existing literature on women and adolescent girls who use substances, including the epidemiology of HIV, drug use and comorbidities, risk environments, intervention approaches to prevent HIV, the continuum of HIV care and treatment, and the theoretical frameworks that have guided existing research. As guest editors, we sought out researchers and scholars working in this critical area and invited them to examine and reflect on the current state of the science, research gaps, and implications for HIV prevention, treatment, and policies, as well as future directions to overcome all identified gaps. We made a conscious effort for the first author on each article to be a female researcher. A total of 11 articles and 2 commentaries are included in this issue. Taken together, the authors make a compelling case for more research in all areas (epidemiology, behavioral, biomedical prevention and treatment, etc.) related to females who use substances and to scale up an integrated comprehensive package of interventions that address not only the HIV and drug use care continuum but also co-occurring underlying conditions. Future research must address the major root causes driving the HIV epidemic among this population, including stigma, discrimination, gender-based violence and structural violence, unemployment, lack of access to female-specific services, and drug policies. These articles underscore the message that without thoughtful attention from governments, funders, researchers, and society at large to the needs of women who use drugs, the burden of the HIV and drug use epidemics will continue to grow, affecting a new generation of women and adolescent girls worldwide. ACKNOWLEDGMENTS Dr. El-Bassel acknowledges partial support received from R01s (DA-033168) funded by the National Institute of Drug Abuse from the National Institute of Health and through HIV Prevention Trials Network (UM1 068619). Dr. Strathdee acknowledges partial support received from the National Institute on Drug Abuse (R37 DA019829) and from the National Institute of Health through HIV Prevention Trials Network (UM1 068619).