Out of the Shadows: Female Drug Users and HIV/AIDS

Although global action against HIV/AIDS is more than three decades old, certain populations have stayed on the margins of prevention efforts, medical care, and access to antiretroviral medication. While stigma surrounding HIV continues to frustrate progress against the epidemic for many vulnerable groups, few have been less visible than female drug users.

On October 30, the Columbia University School of Social Work and the Mailman School of Public Health co-sponsored a conference focused entirely on this population. “Rethinking the Global Response to the HIV Epidemic Among Women Who Use Drugs” explored the long-standing challenges of understanding and reaching women who use drugs. Despite evidence that more women are using drugs than ever before, this population still experiences a disproportionate share of the disease burden. Meanwhile, few interventions target their specific needs.

Planned in tandem with a special issue of the Journal of Acquired Immune Deficiency Syndromes (JAIDS), the conference was organized by Nabila El-Bassel, the Wilma and Albert Musher Professor of Social Work, and Steffanie Strathdee of the University of California San Diego School of Medicine, and funded with support from the National Institute on Drug Abuse, which has been keenly aware that women have been differentially affected by HIV and AIDS in the United States and globally.

El-Bassel introduced the day-long conversation by asserting the need for more research and a greater understanding for HIV prevention, treatment, and care among this population. Of the 35 million people worldwide living with HIV, more than half are women, El-Bassel reminded more than 100 researchers, governmental employees, students, and members of the community. Though women represent only one-third of the 246 million worldwide who use illicit drugs, their sheer numbers—82 million—suggest the urgency of addressing their needs.

The Problem of History

In her opening plenary, El-Bassel highlighted that women who use drugs have never been at the center of the response to HIV. In the epidemic’s earliest years, the most visible populations were gay men living in urban areas. Though HIV and AIDS have always affected other groups, research, funding, and advocacy continue to connect HIV with gay men despite a global disease burden in which more women are infected than men.

Similarly, measures to address HIV among drug users have been male-focused. While heroin users have benefitted from the distribution of safe injecting equipment, women are more likely to use prescription painkillers, which have seldom been a prominent category for HIV prevention interventions. In 2012, the U.S. Centers for Disease Control reported that women are more likely to be prescribed painkillers, receive higher doses, and become dependent more quickly than men. Such drugs do increase HIV risk, with injectable opioids blamed for the recent HIV outbreak in rural Indiana where the CDC detected a direct connection between the surge in infections and the painkiller Opana. The risk of infection is compounded for women who use drugs by multiple factors, including sex work, transgender discrimination, and incarceration.

In the United States: Systems and Structures

“There is a history in this country of excluding substance users from key studies,” said Lisa Metsch, Stephen Smith Professor and Chair of Sociomedial Sciences at the Mailman School, whose remarks centered on the United States, a country, she said, that has been far from a leader in addressing substance using women and HIV.

Metsch indicated that substance users in the United States have benefitted less from all effective interventions, from prevention to treatment access to adherence, designed to target other groups. She also acknowledged that this discrepancy is not explained by physiology, and that when substance users have access to the same continuum of care as non-drug users, and if they adhere to treatment, their progress against HIV can be equally effective.

“Systems and structures matter,” Metsch said. Pointing to the correlation between drug use and poverty, unstable housing, and incarceration, Metsch observed that drug users not only suffer from higher viral loads but also face multiple other hardships that complicate access to medical care.

“That Other Ten Percent”

In July, the United Nations Programme on AIDS (UNAIDS) declared new targets in the global fight against HIV and AIDS. The “90-90-90” goal for 2020 sets its sights on 90 percent of people living with HIV knowing their HIV status, 90 percent with an HIV diagnosis on antiretroviral medication, and 90 percent having undetectable viral loads. But in an epidemic response characterized by unequal access to diagnostic testing, care, and treatment, these targets have led some to ponder the proportions.

For Judy Auerbach, professor at the University of California San Francisco School of Medicine, the UNAIDS goal raises questions hugely relevant to this conversation. “When I see 90-90-90, I want to know about that other ten percent,” said Auerbach. “Are they going to be the very people we are focused on today—that intersection of women and people who use drugs?”

Lisa Metsch, whose research addresses substance users in the U.S. and Caribbean, sees 90-90-90 on the distant horizon, a goal we will reach only if we begin to acknowledge women who use drugs in all facets of the global response to HIV and AIDS.