Women who inject drugs require gender-specific approaches to drug rehabilitation, modification of risk behaviors, and psychosocial adaptation. Improved outcomes have been demonstrated when the specific needs of women’s subpopulations have been addressed. Special services for women include prenatal care, child care, women-only programs, supplemental workshops on women-focused topics, mental health services, and comprehensive programs that include several of the above components. To address the special needs of women injecting drug user (IDU) subpopulations, such as HIV-positive pregnant women and women with young children, recently released female prisoners, and street-involved girls and young women, HealthRight International and its local partners in Russia and Ukraine have developed innovative service models. This paper presents each of these models and discusses their effectiveness and implementation challenges specific to local contexts in Russia and Ukraine. 1. Introduction The prevalence of injecting use of opioid substances among people 15–64 years of age is estimated at 0.9% in Ukraine and 2.29% in Russia [1]. There is no reliable data on gender distribution of IDUs in the region. Global trends suggest that drug use in general is more prevalent among boys and men than among girls and women [2]. Some data from the region demonstrate that women constitute between 20 and 30% of IDUs [3, 4]. The HIV epidemic in Russia has been closely linked with IDU: 56.2–61.3% of newly reported HIV infections in 2008–2011 were attributed to IDUs [5]. In Ukraine, heterosexual sex has been the predominant route of HIV transmission since 2008, but drug use is still a key force in the epidemic, with 38.4% of new infections occurring in IDUs in 2011 [6]. The midestimates of HIV prevalence in IDUs in the region are close to 40% [7]. Female sub-populations with the highest prevalence of injecting drug use and HIV in the region include commercial sex workers (CSWs) and those who engage in transactional sex, street-involved girls and young women, and prisoners. These groups are highly intertwined. Among CSWs, 18–70% inject drugs [8–10]; among IDUs, some 40% report transactional sex [11]. Among street children and youth, approximately one-third are female; 20–50% have experience of injecting drug use, and 5–10% report transactional sex [12–14]. Women constitute 5.3% and 8.2% of the prison populations in Russia and Ukraine, or 60 and 8 thousand women prisoners, respectively [15]. There are no reliable national data on the proportion of IDUs among prisoners in the region. In
References
[1]
UNODC, World Drug Report 2012, United Nations Publication, Sales No. E.12.XI.1, http://www.unodc.org/unodc/secured/wdr/Prev_All_2012.pdf.
[2]
L. Degenhardt and W. Hall, “Extent of illicit drug use and dependence, and their contribution to the global burden of disease,” The Lancet, vol. 379, pp. 55–70, 2012.
[3]
C. Aceijas, S. R. Friedman, H. L. F. Cooper, L. Wiessing, G. V. Stimson, and M. Hickman, “Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution,” Sexually Transmitted Infections, vol. 82, supplement 3, pp. iii10–iii17, 2006.
[4]
Analytical Report, Monitoring of Behavior of Injecting Drug Users as a Component of the Second Generation Epidemiological Surveillance, International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine, 2005, http://www.aidsalliance.org.ua/ru/library/our/monitoring_reports/pdf/idu.pdf.
[5]
Russian Federal AIDS Center, HIV Infection in the Russian Federation in 2012, http://www.hivrussia.ru/files/sprav_31032012.doc.
[6]
Ukrainian AIDS Center, Operational Information on Officially Registered HIV-infected Citizens of Ukraine for December 2011, http://ukraids.gov.ua/attachments/article/266/%D0%93%D1%80%D1%83%D0%B4%D0%B5%D0%BD%D1%8C%202011.pdf.
[7]
B. M. Mathers, L. Degenhardt, B. Phillips et al., “Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review,” The Lancet, vol. 372, no. 9651, pp. 1733–1745, 2008.
[8]
P. Kyrychenko and V. Polonets, “High HIV risk profile among female commercial sex workers in Vinnitsa, Ukraine,” Sexually Transmitted Infections, vol. 81, no. 2, pp. 187–188, 2005.
[9]
W. M. Wechsberg, E. Krupitsky, T. Romanova, et al., “Double jeopardy—drug and sex risks among Russian women who inject drugs: initial feasibility and efficacy results of a small randomized controlled trial,” Subst Abuse Treat Prev Policy, vol. 7, article 1, 2012.
[10]
L. Platt, T. Rhodes, C. M. Lowndes et al., “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, vol. 32, no. 10, pp. 605–612, 2005.
[11]
E. G. Benotsch, A. M. Somlai, S. D. Pinkerton et al., “Drug use and sexual risk behaviours among female Russian IDUs who exchange sex for money or drugs,” International Journal of STD and AIDS, vol. 15, no. 5, pp. 343–347, 2004.
[12]
D. M. Kissin, L. Zapata, R. Yorick et al., “HIV seroprevalence in street youth, St Petersburg, Russia,” AIDS, vol. 21, no. 17, pp. 2333–2340, 2007.
[13]
C. L. Robbins, L. Zapata, D. M. Kissin et al., “Multicity HIV seroprevalence in street youth, Ukraine,” International Journal of STD and AIDS, vol. 21, no. 7, pp. 489–496, 2010.
[14]
J. R. Busza, O. M. Balakireva, A. Teltschik et al., “Street-based adolescents at high risk of HIV in Ukraine,” Journal of Epidemiology and Community Health, vol. 65, no. 12, pp. 1166–1170, 2011.
[15]
International Center for Prison Studies, http://www.prisonstudies.org/.
[16]
K. Dolan, B. Kite, E. Black, C. Aceijas, and G. V. Stimson, “HIV in prison in low-income and middle-income countries,” The Lancet Infectious Diseases, vol. 7, no. 1, pp. 32–41, 2007.
[17]
UNODC, “Handbook for Prison Managers and Policymakers on Women and Imprisonment,” United Nations Publication, Sales No. E.08.IV.4, 2008, http://www.unodc.org/documents/justice-and-prison-reform/women-and-imprisonment.pdf.
[18]
R. Taylor, Women in Prison and Children of Imprisoned Mothers, Quaker United Nations Office, Geneva, Switzerland, 2004.
[19]
M. Bastick and L. Townhead, Women in Prison: A Commentary on the UN Standard Minimum Rules for the Treatment of Prisoners, Quaker United Nations Office, Geneva, Switzerland, 2008.
[20]
B. Bergh, A. Gatherer, A. Fraser, et al., “Imprisonment and women's health: concerns about gender sensitivity, human rights and public health,” Bulletin of the World Health Organization, vol. 89, no. 9, pp. 689–694, 2011.
[21]
S. F. Greenfield, A. J. Brooks, S. M. Gordon et al., “Substance abuse treatment entry, retention, and outcome in women: a review of the literature,” Drug and Alcohol Dependence, vol. 86, no. 1, pp. 1–21, 2007.
[22]
S. Wasilow-Mueller and C. K. Erickson, “Drug abuse and dependency: understanding gender differences in etiology and management,” Journal of the American Pharmaceutical Association, vol. 41, no. 1, pp. 78–90, 2001.
[23]
Center for Substance Abuse Treatment, “Substance abuse treatment: addressing the specific needs of women,” Tech. Rep. (SMA) 09-4426, Substance Abuse and Mental Health Services Administration (US), 2009.
[24]
K. T. Brady and C. L. Randall, “Gender differences in substance use disorders,” Psychiatric Clinics of North America, vol. 22, no. 2, pp. 241–252, 1999.
[25]
O. S. Ashley, M. E. Marsden, and T. M. Brady, “Effectiveness of substance abuse treatment programming for women: a review,” American Journal of Drug and Alcohol Abuse, vol. 29, no. 1, pp. 19–53, 2003.
[26]
List of narcotics, psychoactive substances and their precursors subject to control in the Russian Federation, Approved by the decision of the Government of the Russian Federation, 1998, http://fskn.gov.ru/pages/main/info/official_information/7947/index.shtml.
[27]
E. Krupitsky, E. Zvartau, E. Blokhina, et al., “Randomized trial of long-acting sustained-release naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence,” Archives of General Psychiatry, vol. 69, no. 9, pp. 973–981, 2012.
[28]
E. Krupitsky, E. V. Nunes, W. Ling, A. Illeperuma, D. R. Gastfriend, and B. L. Silverman, “Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial,” The Lancet, vol. 377, no. 9776, pp. 1506–1513, 2011.
[29]
E. Krupitsky, E. Zvartau, and G. Woody, “Use of naltrexone to treat opioid addiction in a country in which methadone and buprenorphine are not available,” Current Psychiatry Reports, vol. 12, no. 5, pp. 448–453, 2010.
[30]
E. M. Krupitsky, E. E. Zvartau, D. V. Masalov et al., “Naltrexone with or without fluoxetine for preventing relapse to heroin addiction in St. Petersburg, Russia,” Journal of Substance Abuse Treatment, vol. 31, no. 4, pp. 319–328, 2006.
[31]
E. M. Krupitsky, E. E. Zvartau, D. V. Masalov et al., “Naltrexone for heroin dependence treatment in St. Petersburg, Russia,” Journal of Substance Abuse Treatment, vol. 26, no. 4, pp. 285–294, 2004.
[32]
E. Holt, “Russian injected drug use soars in face of political inertia,” The Lancet, vol. 376, no. 9734, pp. 13–14, 2010.
[33]
Authors' communication with the St. Petersburg City Narcological Hospital.
[34]
S. Dvoriak, “Overview of opioid substitution treatment in Ukraine,” in National Conference on Harm Reduction, Kyiv, Ukraine, February 2006.
[35]
Order of the Ministry of Ukraine, “On approving the order of administering the substitution supportive treatment for patients with opioid dependency,” 2012, http://www.moz.gov.ua/ua/portal/dn_20120327_200.html.
[36]
D. M. Kissin, M. G. Mandel, N. Akatova, et al., “Five year trends in epidemiology and prevention of mother-to-child HIV transmission, S. Petersburg, Russia: results from perinatal HIV surveillance,” BMC Infectious Diseases, vol. 11, article 292, 2011.
[37]
Guidebook on Retaining Family Support for HIV-affected Children, St. Petersburg, Doctors to Children, 2008, http://doctors2children.ru/files/dtc_family__support__for__hiv-affected__children_.pdf.
[38]
Manual on Multidisciplinary Case Management, “The Project “Prevention of Abandonment of Children Born to HIV-positive Mothers (MAMA+)”,” Doctors of the World-USA, Kyiv, Ukraine, 2007.
[39]
R. Yorick, S. Suvorova, O. Sukovatova, et al., “Replication of the MAMA+ model to prevent child abandonment by HIV-positive women in Yekaterinburg, Russia,” in Proceedings of the 19th International AIDS Conference, Washington, DC, USA, July 2012.
[40]
D. Wolfe, M. P. Carrieri, and D. Shepard, “Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward,” The Lancet, vol. 376, no. 9738, pp. 355–366, 2010.
[41]
Golichenko, “Russia: district court upholds legal ban on opioid substitution treatment,” HIV/AIDS Policy & Law Review, vol. 15, no. 3, pp. 57–58, 2011.
[42]
A. Shapoval, “Socioeconomic profile of HIV+ mothers including those who abandon their infants in Ukraine,” in Proceedings of the 17th International AIDS Conference, Mexico City, Mexico, August 2008.
[43]
H. Bailey, I. Semenenko, T. Pilipenko, R. Malyuta, and C. Thorne, “Factors associated with abandonment of infants born to HIV-positive women: results from a Ukrainian birth cohort,” AIDS Care, vol. 22, no. 12, pp. 1439–1448, 2010.
[44]
E. Finnerty, H. Skipalska, O. Libanov, et al., “MAMA+ for injecting drug users: a pilot programme in Ukraine,” in Proceedings of the 20th International Harm Reduction Conference (IHRC '09), Bangkok, Thailand, 2009.
[45]
J. Beard, G. Biemba, M. Brooks, et al., “Children of female sex workers and drug users: a review of vulnerability, resilience and family-centred models of care,” Journal of the International AIDS Society, vol. 13, supplement 2, p. S6, 2010.
[46]
“MAMA+ for Drug Using Pregnant Women and New Mothers Project in Ukraine,” HealthRight International, 2010, http://www.healthright.org.ua/en/leafletmama.
[47]
Women and HIV in prison settings, UNODC, 2008, http://www.unodc.org/documents/hiv-aids/Women%20and%20HIV%20in%20prison%20settings.pdf.
[48]
Comprehensive Support to Women Released from Penitentiary Institutions. St. Petersburg, Doctors to Children, 2011, http://doctors2children.ru/publications/methodological%20materials/.
[49]
J. Baillargeon, T. P. Giordano, J. D. Rich et al., “Accessing antiretroviral therapy following release from prison,” Journal of the American Medical Association, vol. 301, no. 8, pp. 848–857, 2009.
[50]
J. G. Baillargeon, T. P. Giordano, A. J. Harzke, G. Baillargeon, J. D. Rich, and D. P. Paar, “Enrollment in outpatient care among newly released prison inmates with HIV infection,” Public Health Reports, vol. 125, supplement 1, pp. 64–71, 2010.
[51]
R. Yorick, K. Zakharov, A. Shaboltas, et al., “HIV prevention and access to care for HIV-positive street youth in St. Petersburg, Russia,” in Proceedings of the 17th International AIDS Conference, Mexico City, Mexico, August 2008.
[52]
R. Yorick, J. Batluk, A. Shaboltas, et al., “HIV prevention for street youth in St. Petersburg, Russia,” in Proceedings of the 18th International AIDS Conference, Vienna, Austria, July 2010.
[53]
“STEPS Prevention Training Program for Adolescents,” Trainer's Guide. St. Petersburg, Doctors to Children, 2009, http://doctors2children.ru/files/DTC_STEPS_Trainer%E2%80%99s_%20Guide%20.pdf.
[54]
“STEPS Educational Training for Adolescents,” Kalita, Kyiv, Ukraine, 2010, http://www.healthright.org.ua/sites/default/files/ourbook3.pdf.
[55]
Guidebook on Integrated Assistance to Street Youth. St. Petersburg, Doctors to Children, 2009, http://doctors2children.ru/files/dtc_guidebook__assistance_to__street_youth_.pdf.
[56]
Guidebook on HIV prevention and Assistance to HIV-positive Street Children and Youth. St. Petersburg, Doctors to Children, 2009, http://doctors2children.ru/publications/methodological%20materials/.
[57]
Comprehensive Care and Assistance to Homeless and Neglected Children: Methodological Recommendations, Kalita, Kyiv, Ukraine, 2010.
[58]
“Guidebook on Multidisciplinary Case Management in Working with Homeless Minors,” HealthRight International, Kyiv, Ukraine, 2010, http://www.healthright.org.ua/sites/default/files/ourbook2.pdf.
[59]
H. Skipalska, N. Grytsaienko, R. Yorick, et al., “Targeted, gender-sensitive support for street girls: linking the most vulnerable to care,” in Proceedings of the 19th International AIDS Conference, Washington, DC, USA, July 2012.
