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Lisa Messersmith, Jennifer Beard, Thomas Agyarko-Poku ,

Using a Gender Analysis to Understand HIV Vulnerability among Men and Women Who Inject Drugs in Kumasi, Ghana. Lisa Messersmith, Jennifer Beard, Thomas Agyarko-Poku , Rose Adjei , Ariel Falconer, Lora Sabin, Yaw Adu-Sarkodie.

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Lisa Messersmith, Jennifer Beard, Thomas Agyarko-Poku ,

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  1. Using a Gender Analysis to Understand HIV Vulnerability among Men and Women Who Inject Drugs in Kumasi, Ghana Lisa Messersmith, Jennifer Beard, Thomas Agyarko-Poku, Rose Adjei, Ariel Falconer, Lora Sabin, Yaw Adu-Sarkodie 2nd African Conference on Key Populations in the HIV Epidemic December 16 - 18, 2015, Dar es Salaam, Tanzania

  2. Research funded by PEPFAR, USAID,Project SEARCH This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH-I-00-07-00023-00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.

  3. Operations Research on HIV Risk among Key Populations in Kumasi, Ghana • 1 of 9 “short, sharp” qualitative studies conducted between 2010-2014 • Ghana Collaborators: School of Medical Sciences, Kwame Nkrumah University of Science & Technology (KNUST) • Sponsored by USAID & Ghana AIDS Commission • Objective: Provide detailed qualitative data to better tailor programming for key populations

  4. Rationale and Study Aims • Little is currently known about the behaviors and vulnerabilities of PWID in Ghana • To date, no programs have been implemented to reduce the vulnerability of PWID • Study Aims: • To understand the social, economic and behavioral vulnerability to HIV of PWID in Kumasi • To inform planned PWID HIV prevention interventions and other policies and programs

  5. Gender and Injecting Drug Use • Emerging problem in sub-Saharan Africa • 7.4% of intimate partners of SW in Ghana (8.9% in Accra) used heroin (WAPCAS 2010) and 8% of clients of SWs injected drugs in last 12 months (GAC/FHI360 2012) • PWID are noted in the National Strategy on Key Populations as highly vulnerable • Literature review of gender aspects of injecting drug use found: • Social stigma, marginalization, and lack of access to services, especially for women who inject • Women are often introduced to drug use by their sexual partners • Sharing injecting equipment is common in couples • Condom use is rare in relationships between PWID • Transactional sex is common

  6. Study Methods & Sample *RDS Sampling for PWID *Many more PWID were interested in participating in the study than we had the time and resources to include.

  7. Study Findings Related to Gender

  8. Study Population: Socio-Demographic Characteristics

  9. Drug Use • Most common injecting drugs: heroin and cocaine • Average length of drug use for men & women: 10 years • Cost of drugs: GHC3, 5, 10 per dose depending on quality (USD0.84, USD1.39, USD2.78) • Cost of needles and syringes: 3 for GHC1 (USD0.25) • Frequency of injection: 3-20 times/day

  10. Living Conditions • Nearly all men (14) and half the women (5) said they slept outside of kiosks or shops in places they called bases or “ghettos” R: I stay with my boyfriend in a ghetto at Amakom called the Base where drugs are sold I: Where exactly do you sleep? R: My boyfriend and I sleep in front of shops around the Base area (IDI-F-010)

  11. Initiation into drug use • Men are often initiated by friends, while women are most often initiated by sexual partners • R2: It’s our husbands who do it, so if the males are many, the females are so many. Because it’s our husbands who do that, they will introduce it to us if they are doing it. • R3: If you want money from them and you don’t want to inject the drug, they will not give it to you. So to avoid problems you have to also inject the drugs so that they give you the money. • R8: Usually, if your boyfriend injects, definitely you will also do the same one because if you tell your husband that you will not inject but wants a different one like the COCKTAIL, he will not give you the money to buy it. (FGD-F)

  12. Initiation into drug use • R2: Male IDU normally introduce their female counterparts. • R3: There are more male IDUs because injecting drugs is a hard life and a man’s job • R4: There are more male IDUs because the females only try to learn what their partners do • R 5: Females who date male IDUs feel cheated when their partners spend on drugs. Therefore they also start injecting. (FGD-M)

  13. Sharing, Reuse of Injecting Equipment • Sharing of N/S is common during initiation into injecting drug use • Half of men (10/20) and more than half of women (6/10) said they share and/or reuse needles and syringes I: Was the needle you used the last time brand new? R: No, it’s been used I: Was it used by you? R: No, it was used by someone else I: So would you say that you often use needles that have previously been used by someone else? R: Yes, I use needles that has been used by someone else I: Do you also pass the needle to someone else after using it? R: Yes, I give it to someone else (IDI-M-013)

  14. N/S sharing in PWID couples • N/S sharing is common within PWID couples I: Do you share a syringe and needle with others? R: No, I don’t share it with anybody. I: But do you share it with your boyfriend? R: Yes; as for him, I can share it with him. I: Why? R: Because I trust him (IDI-F-005) R: I have done it with my boyfriend before because I know that there is nothing that is going to happen because he is my boyfriend. (FGD-F) R7: Personally my girlfriend and I inject the drugs together using the same needle and syringe. R5: My girlfriend and I also inject together. I: Do they use the same needle and syringe? R7&5: Yes (in unison) (FGD-M)

  15. Using blood to mix with drugs • Q: Earlier you were saying that some people use blood to mix the drugs. If a couple is going to use the blood, whose blood do they use, is it the man or the woman’s blood? • R1: For me I trust my husband that he doesn’t have any diseases, so I let him use his blood. • R3: For me, I will not say because he is my husband so I trust him that he doesn’t have any diseases. Though he is my husband, I will not let him use his blood only. We will use the blood from the two of us. (FGD-F)

  16. Women’s economic dependence on men • R3: You can go out and work for money, but the man will warn you not to go so we always depend on them. • Q: Why do the men warn you not to go out to work? Do they have genuine reasons for that? • R1: The men cannot tell us not to go out and work. Some of the women are more criminal than the men so they cannot tell her not to go and work. But if you are not criminal and you always depend on the man, then he can control you. (FGD-F)

  17. Women depend on men for drugs • R6: … the men can go and do hard labor and get money to buy the drugs easily, unlike the woman who cannot do hard labor…. Some of the men can go and sell so many things to get money. Some can also go and unload trucks and get enough money. Some of them can also go and do pick-pocketing and other things. For that one, a woman cannot do it. That is why they [the men] always get money to buy the drugs more than the women. (FGD-F)

  18. Relationship dynamics – Women's perspective Men supply the drugs, mix them, and inject first • Q: So if you are injecting the drug with your husband, who will mix the drug first? • R5: It’s the husband, he will inject first and then give you whatever is left. If you complain, he will tell you that the money belongs to him and not you. • R4: As number 5 was saying, if he brings the drug, he will inject it first and give you what is left. You have no option then because you may be suffering due to the absence of the drugs in your system. And also, he is the one who owns the drug and so he gives you what he likes. (FGD-F) • R: Sometimes I do it, sometimes he does. He does it most of the times because he thinks that I will inject all, so he injects his portion and leaves the rest for me. (IDI-F-002)

  19. Relationship dynamics – Men's perspective Supplying drugs is man’s duty • I: Why doesn’t the lady also buy some of the drugs? • R9: It was my duty to provide the drugs as the man. • I: Who normally brings the drug? • R7: I normally bring the drug because my partner does not work • R5: I normally buy the drug • I: Who normally injects the drugs first? • R7: I am the one to inject first • R2: The one who buys the drugs injects first (FGD-M)

  20. Sexual behavior and relationships • 9/10 women and 12/20 men reported being sexually active R: I have only had sex with my girlfriend. Money is hard to come by so just one girl friend is enough. The women nowadays use the drugs even more than us so you the guy must have money to maintain her or else she may jump to another man.(IDI-M-001) • All stated that they inject drugs before having sex • Men who were not currently sexually active said that drugs diminished their desire for sex or they could not afford to support a woman When I take the drugs, I do not feel for sex. (IDI-M-009) I: So you have not been having affairs with girls? R: No; because if you go in for a girl, you have to pay that person, I also want much money to buy the drug so there is no way I can go in for girls. (IDI-M-019)

  21. Men feel pressure to meet financial and drug needs of their partners • R6: Most female IDUs have more than six sexual partners apart from their primary sexual partner • R8: Yes. Most females IDUs have more than ten sexual partners. Once you are unable to meet their financial needs they turn to such sexual partners to enable them have money for drugs. (FGD-M)

  22. But some women operated independently • R1: Some of the female partners work to be able to buy their own drugs • I: What work do they do to get money to buy the drugs? • R1: Some trade whiles others pick pockets. Others also work as head porters. • R8: Others engage in prostitution to get money • R5: Others pretend to be stranded travellers and seek for help form people passing by. (FGD-M)

  23. Transactional sex • Most participants said transactional sex is common I: Have you ever exchanged sex for money? R: Yes and even if that man is not careful, I can steal from him. (IDI-F-003) I: How many people have you had sex with in exchange of money in the last six months? R: About ten. (IDI-F-007) I: Do you have a girlfriend? R: No, but if I want sex, I can buy drugs for some of the junky ladies and get sex in return.(IDI-M-007)

  24. Transactional sex • I: Do female IDUs generally get involved in sex for money? • R: Yes (in unison) • I: Do some also get involved in sex for drugs? • R3: Some do have sex with pushers (drug vendor) for drugs but it does not often happen because most drug addicts are not attractive and neat while the pushers are. • R8: I agree with what R3 is saying but some pushers also agree to have sex with drug addicts to give them drugs • R1: Sometimes new female drug users look attractive. Therefore drug pushers lure them with drugs and have sex with them. (FGD-M) • R7 There are some ladies who give themselves for money or drugs. Some just take GH₵5 to have sex with a man so that they can get money to go and buy some of the drugs. Some even take GH₵2. (FGD-F)

  25. Condom use low in intimate relationships I: Do you use condoms when having sex with your boyfriend? R: No. We trust each other. (IDI-F-008) I: So do you use condom when you are with your current girlfriend? R: No, I don’t use condom when I am with her. I: Why do you use it with others but you don’t use it with your girlfriend? R: Those ones are just sexual acquaintances. (IDI-M-016) I: Do you remember to use condoms when having sex with someone else aside your boyfriend if you have taken the drugs? R: If you take the drug, it doesn’t even come to your mind to use condoms. (IDI-F-005)

  26. Condom use also low when trading sex for drugs • I: Do female IDUs who have sex for drugs and money use condoms? • R1: Some male refuse to use condoms and because the female IDUs need the money or drug they agree. (FGD-M) • R6: There are some people who are commercial sex workers and so they have condoms with them always. But there are some who are not commercial sex workers and to some extent if they take the drugs they forget to use condoms. (FGD-F)

  27. Intimate partner violence common • R2: When you come to see a male IDU beating a female IDU you will feel sorrowful. • R4: Most female IDUs do not have money for the drugs so the male IDUs maltreat them. (FGD-M)

  28. Summary: Our Findings through a Gender Lens • Demonstrate that gender norms and relations shape the HIV vulnerability of men and women. • Are similar to findings from studies in other countries. • Initiation into drug use, sharing of injecting equipment, lack of condom use, and women’s engagement in transactional sex • Sex is common currency used by women obtain drugs • Harm reduction programming critically needed • Interventions must be sensitive to differential vulnerabilities faced by women and men

  29. Questions/Comments?

  30. References • http://www.unodc.org/balticstates/en/topics/injecting-drug-use.html • http://www.aidsmap.com/Why-is-injecting-drug-use-a-risk-for-HIV-transmission/page/1324128/#ref1321285 • Abdala N et al. Survival of HIV-1 in syringes. J Acquir Immune Defic Syndr Hum Retrovirol 20(1):73-80, 1999 • Clay, SP et al. Survival of Human Immunodeficiency Virus (type-1) in Injection Syringes Int Conf AIDS, abstract Tu.C.2522, 1996 • WAPCAS. 2010. Draft Report. Integrated Bio-behavioral Surveillance Survey • Ghana AIDS Commission and FHI360. 2012. Behavioural Surveillance Survey of Female Sex Workers & Clients. PPT presentation. June 2012. • National Strategic Plan for Most At Risk Populations. 2011-2015 • Ross MW, McCurdy SA, Kilonzo GP, Williams ML, Leshabari MT. Drug use careers and blood-borne pathogen risk behavior in male and female Tanzanian heroin injectors. The American journal of tropical medicine and hygiene. 2008 Sep 1;79(3):338-43. • Roberts A, Mathers B, Degenhardt L. Women who inject drugs: A review of their risks, experiences and needs. A report prepared on behalf of the Reference Group to the United Nations on HIV and Injecting Drug Use. Australia Sydney: National Drug and Alcohol Research Centre (NDARC), University of New South Wales. 2010. • Beckerleg S, Telfer M, Hundt GL. The rise of injecting drug use in east Africa: a case study from Kenya. Harm Reduction Journal. 2005 Aug 25;2(1):12. • Gu J, Lau JT, Chen H, Tsui H, Ling W. Prevalence and factors related to syringe sharing behaviours among female injecting drug users who are also sex workers in China. International Journal of Drug Policy. 2011 Jan 31;22(1):26-33. • Platt L, Rhodes T, Lowndes CM, Madden P, Sarang A, Mikhailova L, Renton A, Pevzner Y, Sullivan K, Khutorskoy M. Impact of gender and sex work on sexual and injecting risk behaviors and their association with HIV positivity among injecting drug users in an HIV epidemic in Togliatti City, Russian Federation. Sexually transmitted diseases. 2005 Oct 1;32(10):605-12. • Davies AG, Dominy NJ, Peters AD, Richardson AM. Gender differences in HIV risk behaviour of injecting drug users in Edinburgh. AIDS care. 1996 Oct 1;8(5):517-28. • Williams ML, McCurdy SA, Atkinson JS, Kilonzo GP, Leshabari MT, Ross MW. Differences in HIV risk behaviors by gender in a sample of Tanzanian injection drug users. AIDS and Behavior. 2007 Jan 1;11(1):137-44. • Ross MW, McCurdy SA, Kilonzo GP, Williams ML, Leshabari MT. Drug use careers and blood-borne pathogen risk behavior in male and female Tanzanian heroin injectors. The American journal of tropical medicine and hygiene. 2008 Sep 1;79(3):338-43. • Cruz MF, Mantsios A, Ramos R, Case P, Brouwer KC, Ramos ME, Fraga WD, Latkin CA, Miller CL, Strathdee SA. A qualitative exploration of gender in the context of injection drug use in two US–Mexico border cities. AIDS and Behavior. 2007 Mar 1;11(2):253-62. • McCurdy SA, Williams ML, Kilonzo GP, Ross MW, Leshabari MT. Heroin and HIV risk in Dar es Salaam, Tanzania: youth hangouts, mageto and injecting practices. AIDS care. 2005 Jun 1;17(S1):65-76.

  31. Acknowledgements The brave women and men who were willing to tell us their stories Kumasi Research Team Ghana AIDS Commission—Kyeremeh Atuahene USAID Ghana—Peter Wondergem & Emmanuel Essandoh FHI360—Kimberly Green. Sam Wambugu, Nana Clement Fosua, Yussif Ahman Abdul Rahman, Debbie Kwablah, Henry Nnagai, Colette Nunekpeku WAPCAS Boston University Research Assistants

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