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People Who Inject Drugs in Intimate Relationships: It Takes Two to Combat HIV

People Who Inject Drugs in Intimate Relationships: It Takes Two to Combat HIV. 20 th International AIDS Conference Melbourne, Australia July 20-25, 2014. Presentation Will Cover:. Global epidemiology of injection drug use and HIV

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People Who Inject Drugs in Intimate Relationships: It Takes Two to Combat HIV

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  1. People Who Inject Drugs in Intimate Relationships:It Takes Two to Combat HIV • 20th International AIDS Conference • Melbourne, Australia • July 20-25, 2014

  2. 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

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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)

  10. 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)

  11. 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.

  12. 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.

  13. Women Are in Charge 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). • Not all women are passive participants in injection contexts • Some women have more control of injection and condom use practices 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.

  14. 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. 

  15. 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)

  16. Review Paper Found Only 33 Couple-based HIV Intervention Studies (Jiwatram-Negrón and El-Bassel, 2014)

  17. Types of Couple-Based HIV Intervention Studies

  18. HIV Couple-Based Intervention Studies Globally (N=33)(Jiwatram-Negrón and El-Bassel, 2014)

  19. Couple-Based HIV Intervention Studies by Couple Definition (Jiwatram-Negrón and El-Bassel, 2014)

  20. 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: Bio-behavioral outcomes from a randomized clustered design in a Cape Town township (under review) (Wechsberg et. al.)

  21. 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.

  22. Central Asia Source: Russia-Ukraine-Travel.com

  23. 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.

  24. 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.

  25. 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.

  26. 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

  27. ProjectRenaissance 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

  28. 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.

  29. 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. Outcomes from Renaissance

  30. 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.

  31. 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.

  32. 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

  33. 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

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