Biomedical HIV Prevention Including Pre-exposure Prophylaxis and Opiate Agonist Therapy for Women Who Inject Drugs

Abstract

Women who inject drugs are at higher risk of HIV compared to their male counterparts as a result of multiple factors including biological, behavioral and socio-structural, yet comparatively little effort has been invested in testing and delivering prevention methods that directly target this group. In this paper, we discuss the need for expanded prevention interventions for women who inject drugs, focusing on two safe, effective, and approved, yet underutilized biomedical prevention methods: opiate agonist therapy (OAT) and oral pre-exposure prophylaxis (PrEP). While both interventions are well researched they have not been well examined in the context of gender. We discuss the drivers of women injectors’ higher HIV risk, review the effectiveness of OAT and PrEP interventions among women, and explain why these new HIV prevention tools should be prioritized for women who inject drugs. There is substantial potential for impact of OAT and PrEP programs for women who inject drugs in the context of broader gender-responsive HIV prevention initiatives. While awaiting efficacy data on other biomedical approaches in the HIV prevention research ‘pipeline’, we propose that the scale up and implementation of these proven, safe, and effective interventions are needed now.

Women Who Use or Inject Drugs

“…Page et al and Springer et al describe meager coverage of biomedical risk reduction treatments including Anti-Retroviral Therapy (ART), Opioid Substitution Therapy (OST), Opiate Agonist Therapy ( OAT) and Pre-Exposure Prophylaxis (PreP) for women. 8 Gilbert et al demonstrate that both injection and non-injection drug use among women are closely associated with a number of co-occurring disorders, including gender-based violence (GBV), trauma, and sexually transmitted infections (STIs), most notably HIV. 9 Additionally, Iversen et al demonstrate the extensive burden of HCV experienced by drug-using women: 60% of female injection drug users have been exposed to HCV, and 70 to 90% of HIV-positive women who inject drugs have co-morbid HCV infection.…”

“…In this issue, Page et al call for greater involvement of drug-using women in drug trials, Metsch et al call for increased research on their access to HIV care, and Auerbach et al call for greater consideration of gender theories in understanding risk environments. 8,11,16 …”

“…8,59 In this special issue, Springer et al describe the effectiveness of Medication Assisted Therapies (MAT) for opioid use (e.g., methadone; buprenorphine or buprenorphine/naloxone; oral naltrexone; extended-release naltrexone) in reducing frequency of injection and relapse to opioid use while improving health and social functioning and preventing transmission of HIV. 27 Yet the authors in this special issue emphasize that there has been little or no development of OAT specifically tailored for women, and that access to OAT for drug-using women is most constrained in the highest-need countries.…”

The effects of opioid-agonist treatments on HIV risk and social stability: A mixed methods study of women with opioid use disorder in Ukraine

“…Women who inject drugs are often overlooked and underrepresented in HIV treatment and OAT despite their increased risk of HIV infection (Greenfield et al, 2007; Page et al, 2015). Women who inject drugs may be characterized as a “difficult to reach population” because of the multifactorial nature of their drug dependence and accordingly, are less likely to enter OAT (Greenfield et al, 2007).…”

“…Another investigation of a HIV intervention in African American crack cocaine users demonstrated decreased sexual and injection risk behaviors in all women, but women in gender-specific groups also experienced improved employment and housing status (Wechsberg, Lam, Zule, & Bobashev, 2004). As women encounter greater barriers to treatment such as increased stigma/discrimination, fear of violence, higher rates of psychiatric disorders and loss of parental custody (El-Bassel, Gilbert, Witte, Wu, & Chang, 2011; Page et al, 2015), culturally-appropriate programs that take these barriers into account could improve enrollment, satisfaction and retention among women. Techniques such as women-only spaces, couple-enrollment, childcare and trauma-informed care are vital strategies to reach and improve outcomes among WWID who are disproportionately impacted by the Eastern European HIV epidemic.…”