There are concerns that heroin use is growing but also concern over the high HIV infection rates of users, particularly among women. Injection drug behaviours are recognised as key facilitators of HIV transmission.
Research conducted four years ago among people who inject drugs in Nairobi found that 18.3% of them were HIV positive. Of these, 16% of men were HIV positive and 44.5% of women were HIV positive. Women who inject drugs are therefore more than two times more likely to have HIV than men.
Our research sought to understand why and how young girls and women progressed from using legal drugs – like alcohol and cigarettes – into illicit narcotics, like heroin.
We found that most women were introduced into drug use by male sexual partners in their teenage years, between the ages of 11 and 17 years. A key factor in their continued drug use were these, often volatile, relationships.
Our findings also gave us insights into why women were more at risk of HIV infections: they often faced significant stigma which meant they were less likely to participate in drug treatment or needle exchange programmes and they usually depended on male partners for drugs and needles. This meant that they shared equipment. In addition, many of the women participated in commercial sex work to fund their drug habit and often didn’t use condoms.
Our findings could help identify which girls and women are at risk. The hope is that this could better inform strategies to stop them from becoming drug users.
Women at risk
We spoke to 306 women from low-income settlements in Nairobi who were attending a community harm reduction programme ran by a non-govermental organisation. The women were injecting drugs – mainly heroin, in combination with other drugs like bhang, valium, rohypnol and artane. The women were between 18 and 42 years old.
Most of the women were born in low-income settlements and did not have much of a formal education. About 60% were educated to primary school level and 32% reported going to secondary school or higher. About 7% of the respondents never went to school.
The vast majority, over 90%, were living with a partner.
Most of the women started to use drugs when they were about 17 years old. About 74% said that sex partners, including spouses and casual sex partners, introduced them to drugs.
Women who started to use drugs early (between the ages of 11 and 19) tended to be those who had dropped out of school or those who didn’t graduate from secondary school. They also tended to have had sex at a younger age, usually with male partners who were already using drugs. The women usually started with licit drugs such as alcohol and Miraa (Khat).
The men were usually older, able to support the women financially and controlling and abusive. Relationships would frequently break up and the stress of this meant they would use more licit and illicit drugs. The women would also start new relationships, which would sometimes introduce new drugs, like heroin.
To get money to buy the heroin women would engage in sex work or be in a relationship with male users so that they could share it with them.
These insights are important to inform the design of effective HIV prevention interventions. They show that HIV programmes for adolescent girls and young women must also address substance abuse, gender based violence and the stigma towards women who take drugs.
Strategies moving forward
Health policies and programmes for women who inject drugs must identify and target potential users early. Lessons can be learned from a US government programme called “Teens Linked to Care” which successfully targeted high-risk teenagers with education programmes on substance use and sexual health education. These could help young women to avoid, or positively manage the risk of substance use in sexual relationships.
In Kenya, the ministry of health, through the National Aids and Sexually Transmitted Infection Control Program, has been implementing the nine WHO recommended interventions for prevention of HIV among people who inject drugs. These interventions include needle and syringe programmes, drug dependence treatment, HIV testing and counselling, antiretroviral therapy, prevention and treatment of sexually transmitted infections and targeted information, education and communication.
The interventions have been successful in reducing the sharing of needles and syringes among people who inject drugs, reducing the risk of HIV transmission.
But, the programme has its limitations. The main one is that it only reaches a few women because it doesn’t have targeted mobilisation strategies. Various surveys show that the people who engage most with drug reduction programmes are men.
Going forward HIV prevention programmes must target girls in their adolescent phase with a package composed of identifying girls at risk, substance use interventions, sexual health education and improved educational attainment.
Catherine Mwangi, PhD candidate, Jomo Kenyatta University of Agriculture and Technology and John Gachohi, Postdoctoral Fellow, Washington State University