The Gender Project: for women who use drugs

This International Women’s Day, in the run up to the UN’s General Assembly on the ‘World Drug Problem’ we’re focusing on women who use drugs who are often overlooked in HIV and harm reduction programmes, despite being increasingly affected.

Women are especially vulnerable to HIV and hepatitis C transmission. HIV rates are generally higher among women who use drugs, compared with men who use drugs. Women who use drugs often suffer the consequences of harmful drug policy more intensively than men. Women are incarcerated for drug offences, mostly non-violent, more than for any other crime.

In Ukraine, where the Alliance’s largest HIV and harm reduction programme operates, women account for almost half of all HIV cases among adults. 

The sharing of injecting equipment is the main driver of HIV transmission in Ukraine, though increasing numbers of new infections are attributed to unprotected sex. Despite this, very few HIV programmes have integrated harm reduction and sexual and reproductive health and rights (SRHR) services.

“There is a general idea that people who use opiates are not capable of having sex,” believes Liudmyla Shulga, head of the technical support team at the Alliance for Public Health.

In Kenya, where an estimated 18,000 people inject drugs, research showed that only around 15% of people who inject drugs receive SRHR services, which means women are missing out on vital interventions including condoms and family planning, access to safe abortion, and maternal health services including prevention of mother to child transmission (PMTCT) services.

In Kenya and Ukraine there are also two examples of Alliance Linking Organisations addressing this imbalance by combining harm reduction and SRHR services.

Innovation project – Kenya

In Kenya, KANCO works in partnership with Marie Stopes International to address the huge gaps in services for women who use drugs, and also sex workers. They use a ‘blended outreach’ approach to reach their target clients. It is ‘blended’ because they involve government SRHR officers who have been trained in harm reduction, working alongside harm reduction specialists. This helps address the stigma and long queues that drug users and sex workers were used to facing at government clinics, which deterred them from seeking essential services. Often women who use drugs report that they are reluctant to use mainstream services because they require drug users to be ‘drug free’.

The project found that the majority of women taking drugs are sexually active, whether with a regular partner or involved in sex work and/or transactional sex, including accounts of dealers pushing for sex when women don’t have money for drugs.

The project also found that while women who use drugs take control over their family planning, unintended pregnancies inevitably occur, as with all women. However the risks occurring through abortion may be higher with women who use drugs. A lack of willingness to access services in a country where both using drugs and abortion are stigmatised, leads to ‘less conventional’ methods being used to abort a pregnancy and accounts of women who have died as a result.

The need for services for women who use drugs is clear, but the uptake of this ‘blended’ harm reduction and SRHR service has dramatically exceeded expectations. In just two years it has reached 2,262 women who use drugs, from an initial target of 500.

Harm reduction and sexual and reproductive health and rights should not be separately organised.

Greater integration helps the most vulnerable, including women, to access the services they require, and helps reduce HIV transmission.

Gender project - Ukraine

In Ukraine the Alliance for Public Health were concerned that women were not being proportionately reflected in their services. To reach more women the Alliance for Public Health embarked on the ‘Gender Project’.

It included ‘The Women’s Club’ a female only safe space. Staff at Our Help in Slovyansk in Eastern Ukraine reported significant results: “[Clients] began thinking about their own safety and health. 90% of our clients no longer reuse syringes, while 70% have reported they have started using condoms. Especially popular are female condoms.”

women ukraine

Couple counselling

Project staff from the community-based organisations (CBOs) had made a point of asking male clients about female partners who use drugs as a means to reaching more women, which had the desired result of more female clients coming along with their partners.

This provided an opportunity for social workers to reinforce safer sex and drug use messages with both partners, which sparked a new idea: couple counselling.

This service, which began in 2012 and is still continuing, enables men and women in
relationships to receive counselling together. It is based on the belief that couples need opportunities to talk together in safe environments about their health, relationships and drug use, and so they can support each other’s healthy behaviour.

“It takes a long time for adults to feel comfortable talking about sex. Instead of doing general training and embarrassing everyone, I thought that maybe it would be quicker and more helpful if we talked to the couples, to people who are quite close to each other.... [Also] If you don’t talk to people simultaneously, they won’t talk to each other about it,” says Liudmyla Shulga.

Most clients reached through the Gender Project had one regular sexual partner, and much of the information and support was designed for women in long-term relationships. However, a significant number of women also reported having casual sexual partners and transactional sex.

To meet the needs of these and other women, the Alliance for Public Health is now supporting CBOs to provide HIV and SRHR services for women with diverse backgrounds including women who use drugs, women who sell sex, have multiple casual sexual partners, or who are living with HIV.

While the initial ‘recruitment’ was via male partners, now that the female client base has built up a natural ripple effect is happening via word of mouth, and services are adapting to cater for all women.

Our Gender Framework

The Alliance’s ‘Gender Framework’ recognises that gender includes multiple identities and reflects the complexities of people’s lives. Alliance programmes recognise these overlaps and the resulting stigma or barriers to accessing services, in order to address the needs of women, in all their diversity.

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