Commentary on Thorne <i>et al</i>. (2012): HIV prevention and treatment in female injection drug users – a work in progress

In this issue of Addiction, Thorne et al. [1], demonstrate convincingly that pregnant HIV-infected injection drug users (IDUs) who underwent childbirth in Ukraine from 2000–2010 had more advanced HIV clinical status, less access to mother-to-child prevention (PMTCT) services, more adverse pregnancy outcomes, and a higher HIV vertical transmission rate than HIV-infected non-IDU women. More than three decades since the first description of an HIV outbreak among IDUs in New York City [2], these data reinforce the higher burden of HIV in this marginalized, impoverished and stigmatized population. This study's findings also offer an opportunity to reflect on the particular vulnerabilities and barriers to proven HIV prevention and treatment services confronting female IDUs. A previous study showed that the slow uptake of highly active antiretroviral therapy (HAART) in Ukraine's PMTCT programs contrasted with Western Europe where MTCT had nearly been eliminated [3]. Women in the Ukraine were also 83% less likely to receive an HIV diagnosis before pregnancy than Western European women [3]. As such, the data presented by Thorne et al. are particularly pertinent to resource-limited areas where IDU is the main epidemic driver: eastern, central and Southeast Asia and Eastern Europe. Their data show that PMTCT programs must be added to a list of HIV services with unequal access for IDUs—a list that includes general antiretroviral (ARVs) access. Indeed, in the five countries (including Ukraine) identified by Wolfe et al. [4] as IDU-driven mega-epidemics, IDUs represent 67% of HIV/AIDS cases, but only 25% of persons receiving ARVs [5]. Poor access to ARVs also occurs in resource-rich countries like the United States, partly attributable to health insurance disparities [6]. However, even in Canada, where all persons who clinically qualify have free access to ARVs, ARV utilization by female IDUs is suboptimal [7, 8]. As Thorne et al. indicate, one of the best ways to stop HIV vertical transmission is to prevent HIV infection in the mother. They and others [5, 9] have pointed to the current deficient availability of proven IDU HIV prevention strategies in the Ukraine and other areas of the world. Beyrer et al. [5] estimate that a 60% reduction in the unmet need for opioid substitution therapy, syringe exchange programs, and ARV therapy could reduce HIV transmission in Odessa by 41% between 2010–2015. These programs are urgently needed, but as this study demonstrates, the availability of free, state-run prevention programs does not always ensure equal access to IDUs. Women, in particular, may encounter individual, structural, and environmental level barriers that remain largely undefined. In fact, gender-specific research in IDU populations is sparse. A few studies have demonstrated that female IDUs are at elevated risk for HIV infection compared to men [10–12]. Several explanations have been proposed for these gender disparities, but further study is urgently needed to identify issues of particular importance in different cultural contexts. Studies in Canada suggest that women, compared to men, may be more engaged in street-survival activities that interfere with their access to HIV services [7]. It has also been suggested that women are more likely to experience serious depression [13], a potential mediator of risky behaviors and poor adherence to prevention and treatment programs. Several studies show that women's drug using networks are more frequently composed of friends and sex partners [14]. This places a woman at dual risk of HIV infection through risky injection and sexual practices. Furthermore, men frequently control access to drugs [15, 16] and as a result, transactional sex may become an important means of obtaining them. Unstable housing, economic insecurity, and fear of drug withdrawal symptoms may also increase dependence on men and compromise a woman's ability to negotiate safer sex and injection practices. This dependence may expose women to intimate partner violence, a key factor that further undermines a woman's ability to control injection and sexual risk [17]. Lastly, both IDU and female sex work increase a woman's risk of incarceration. Studies from Thailand and Iran reveal that IDUs who use drugs while incarcerated are at greatly elevated risk of HIV acquisition [18, 19]. Thorne et al. report some heartening secular trends in the Ukraine, including a significant increase in the proportion of IDUs aware of their HIV status at conception and the decline in MTCT rates among pregnant IDUs (17.6% in 2000–2001 to 3.8% in 2008–2009). However, for too many, PMTCT remains what the poet Langston Hughes called a ‘dream deferred’. Further study is imperative to identify the factors and issues that prevent female IDUs from utilizing prenatal care, PMTCT, and other HIV preventive and treatment services. Political will and financial commitment is needed to initiate proven harm reduction and HAART-driven PMTCT programs informed and customized by careful study of the particular challenges that affect female IDUs globally. None.

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