Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India.

0.2 MB·English

by  Kermode, Michelle

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RESEARCH ARTICLE Open Access
Falling through the cracks: a qualitative study of
HIV risks among women who use drugs and
alcohol in Northeast India
Michelle Kermode1*, Collins Z Sono2, Chingzaning Hangzo Songput3 and Alexandra Devine1
Abstract
Background: HIVrisks for women who injectdrugs and those who engage insex work are well documented.
Women who are dependent onnon-injecting drugs and alcohol are also likelyto have increased vulnerabilityto
HIVinfection, but until they actually inject drugs or engage in sex work, are unlikely to cometo theattention of HIV
prevention programs.
Methods: We undertooka qualitative study involving ninefocus group discussions (FGDs) and 27 key informant
interviews to investigate thecontext offemaledrug and alcohol use intwo highHIV prevalence statesof India
(Manipur and Nagaland) and to describe their HIVrisks. The FGD and interview transcripts were thematically
analyzed
Results: The women were relatively young (mean age 31 years inManipur and 28 years in Nagaland), but 64% in
Manipur and 35% inNagaland were widowed or divorced.Both heroin and alcohol were commonly used by the
women from Manipur, while alcohol was primarily used by the women from Nagaland, especially in the context of
‘booze joints’(illicit bars). Reasons for drug and alcohol use included: to avoid symptoms of withdrawal, to suppress
emotional pain, to overcome theshame of sex work, pleasure, and widowhood. HIV vulnerability was clearly
described, not onlyin relation to injecting drug use and sex work,but also alcohol consumption.
Conclusions: The contribution of alcohol use to theHIV vulnerability of women is not currently considered when
HIVprevention programs are being designedand implemented leaving a group of high-risk womenuncoveredby
much needed services such as treatment for a range ofhealth problems including alcohol dependence.
Keywords: Alcohol, HIV, India, Substance use, Women
Background SubstanceusebywomeninIndia
Drug and alcohol use is a highly gendered behaviour in Substanceuse hasa long historyinIndia.Druguse, espe-
most parts of the world [1]. Gender differences have ciallyinjectingdruguse,occurs mainly in large cities, and
been observed in relation to the prevalence of substance isparticularlyprevalentintheNortheaststatesofManipur
use, initiation into use, patterns of use, reasons for use, and,toalesserextent,Nagaland.Alongsiderapideconomic
and health and social consequences of substance use and growthinIndia,alcoholconsumptionhasincreasedrapidly,
dependence [1-7]. Women are more likely than men to: although several states still prohibit the production, sale
use drugs and alcohol as a consequence of difficult life and consumption of alcohol [9-11]. Alcohol (such as rice
circumstancesandeconomichardship;becomedependent beer/wine and spirits) is consumed mostly by men, and is
on substances; experience worse health consequences widely available even in states where alcohol consumption
related to substance use; and engage in more HIV risk- isillicit.
behavioursinassociationwithsubstanceuse[2,7,8]. TheprevalenceofsubstanceuseamongwomeninIndia
is not well documented, but an increase in female sub-
*Correspondence:[email protected]
stanceusehasbeenanecdotallyreported[2,12,13].Alarge
1NossalInstituteforGlobalHealth,UniversityofMelbourne,Level4,161Barry
St,Carlton,VIC3010,Australia rapid assessment of substance users in fourteen Indian
Fulllistofauthorinformationisavailableattheendofthearticle
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cities in 2000–01 found that 8% were women, and the fromeachother,notonlysocially,culturallyandlinguistic-
substances they were using included heroin, alcohol and ally, but also in terms of the patterns of drug and alcohol
pharmaceutical products [2,3,8]. As is the case with men, consumption, and the nature of the HIV epidemic. Inject-
women substance users tend to use more than one sub- ing drug use of heroin is far more common in Manipur,
stance. In a large 2008 survey of 1258 women substance while the oral use and occasional injecting of pharma-
users from several states of India (including Manipur), ceutical agents, especially Spasmoproxyvon (containing
67%werecurrentalcohol users(butonly6%usedalcohol dextropropoxyphene), is more common in Nagaland. Her-
astheironlysubstance),25%wereheroinusers,18%were oin produced in the Golden Triangle region (Myanmar,
dextropropoxypheneusers,and16%usedsleepingpills[14]. Laos,Thailand)issmuggledintoIndiaandbeyondthrough
Manipur, with the result that the drug is readily available,
SubstanceuseandHIVrisks which contributes to the high prevalence of injecting in
The HIV risks for women who inject drugs and those this state. An estimated 1-2% of the adult population
who engage in sex work are well documented. Women has injected drugs [36], with the result that injecting
who are dependent on non-injecting drugs and alcohol drug users (IDUs) have been the primary focus of HIV
are also likely to have increased vulnerability to sexually prevention interventions to date, and most IDUs are
transmittedinfections(STIs)andHIVinfection[3,15],but male. However, there is increasing recognition of the
until they actually inject drugs or engage in sex work, importantcontributionthat sexualtransmissionis mak-
are unlikely to come to the attention of HIV prevention ing to the spread of HIV in the region, especially in
programs. Nagaland, where HIV prevalence among IDUs in 2008
Alcohol consumption potentially contributes to sexual wasonly3%(comparedto29%inneighbouringManipur)
disinhibition, sexual risk-taking, and compromised ability (HIV Sentinel Surveillance 2008–09, personal communi-
to negotiate and use condoms. There are links between cation,July2010).Inthesameyear,theprevalenceamong
alcohol use and sexual risk-taking [16-22], and between FSWsinNagalandwas11%,andreportedratesofsyphilis
alcohol use and STIs and HIV infection [15,18,23-25]. among both IDUs and FSWs in Nagaland are also ex-
Alcohol is often consumed by both sex workers and tremely high [37], indicating low levels of condom use,
their clients for a variety of reasons including to heighten potential presence of an ulcerative STI, and increased
enjoyment, overcome shame, and gather courage to en- riskforHIVtransmission.
gageincommercialsex[21,26-28]. The sale and consumption of alcohol is illicit in both
Although there is growing research interest in the states, but relatively commonplace nevertheless. On the
links between alcohol use and HIV risks, including in one hand there is strongly voiced moral disapproval of
India [10], many of the studies examine alcohol use by alcohol (as reflected in the state laws), but on the other
men [29-32], with the exception of a few studies that re- handalcoholisreadilyavailableandcommonlyconsumed
portontheselinksamongFSWs[33,34].A surveyamong in an unregulated, illicit market. Many ‘booze joints’, that
211 HIV positive FSWs in Mumbai found that 32% were are essentially illicitbars, are visibleacross both states. As
heavy drinkers and 17% usually or always drank before Benegal argues, these co-existing contradictory attitudes
having sex with a client. Although 90% of the women to alcohol predispose to ‘asocial behaviour, as well as
reported inconsistent condom use, this was not found to chronic disabling alcoholism’ (p.1052) because there are
beassociatedwithalcoholuse.Aqualitativestudyexamin- no prescribed social norms to regulate people’s drinking
ing the use of alcohol in association with commercial sex behaviours[9].
in South India found that half of the FSWs avoided alco- TheoverallgoalofthepresentstudyistoassesstheHIV
hol when having sex with a client because they wanted to risks and health service needs of female (injecting and
stay in control in order to avoid difficult situations. Very non-injecting) drug and alcohol users in two Northeast
little investigation has been done on alcohol use and HIV Indian states (Manipur and Nagaland) in order to pro-
risksintheNortheasternpartofthecountry. mote improved access to services. This paper reports on
findings in relation to the following objectives: 1. Under-
ThecontextofNortheastIndia standing the local context of female drug and alcohol use
Manipur and Nagaland are two Northeast Indian states inManipurandNagaland;and2.DescribingtheHIVrisks
that consistently report a high HIV prevalence, and in amongthefemaledrugandalcoholusers.Findingsrelated
the case of Manipur, the highest in the country (adult tootherstudyobjectivesarereportedelsewhere[38].
HIV prevalence in 2009 was 1.4% in Manipur and 0.8%
in Nagaland) [35]. The Northeast region is characterised Methods
by political unrest, deeply felt social conservatism, and Studydesign
substantial under-development. However, the states of This qualitative study involved semi-structured, in-depth
ManipurandNagalandareinmanyrespectsquitedifferent interviews with key informants (KIs) and focus group
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discussions (FGDs) with female drug and alcohol users in (cid:1) Reasonsfordrugandalcohol use
Manipur and Nagaland. The data collection took place in (cid:1) Commonlyexperienced problems
2009–10. The study was facilitated by partnerships with (cid:1) Mainhealth problems
local NGOs working in both urban and rural settings. (cid:1) HIVriskbehaviours
These NGOs have existing relationships with female drug (cid:1) Differencesbetweenwomenand mendrugand
and alcohol users through their networks of outreach alcohol users
workers and peer educators. Local research officers (ROs) (cid:1) Types ofservices required
were trained and supervised by the study investigators to (cid:1) Barriersand facilitators toserviceaccess.
coordinateandconductthedatacollectionineachstate.
A female drug or alcohol userwasdefined as awoman The interview guides were developed with the litera-
who judged herself to be a regular (injecting or non- ture and the study objectives in mind, then refined and
injecting) user of one or more of the following drugs piloted in collaboration with the Indian partner NGOs
in the past six months: alcohol, heroin/brown sugar, and local research team members. They were translated
propoxyphene/Spasmoproxyvon,cannabisoramphetamine into the local languages (Paite, Manipuri and Nagamese)
typesubstances.Allparticipantswereaged≥18years. after detailed discussion of the intended meanings and
appropriate language for each thematic area. All inter-
Datacollection views andFGDswere digitallyrecorded, transcribed,and
In-depthinterviewswithkeyinformants(KIs) translatedintoEnglishforsubsequent analysis.
A total of 27 KIs were purposively recruited and inter-
viewed (15 in Manipur and 12 in Nagaland). The KIs
Dataanalysis
were from a range of government, private and NGO ser-
The interview and FGD transcripts were thematically
vices, and included: directors, program managers and
analyzed [39].This involved systematicallyidentifying and
field workers from organizations that work with sex
manually coding themes based on those covered in the
workers, drug users, and vulnerable women; workers
interview guides. Following this initial coding of themes,
from drug detoxification and rehabilitation centres; HIV
sub-themes were inductively identified for each theme,
testing counselors; nurses working with HIV patients; a
journalist; and a‘booze joint’ owner. Each interview took andpatternsandcontradictionswithinandbetweenthemes
andsub-themeselucidatedusinganiterativeprocess.When
approximately one hour.
undertaking the data analysis and reporting the findings,
the subjective perspectives of the female drug and alcohol
FGDswithdrugandalcoholusers
users were privileged over those of the KIs. However, the
Five focus groups discussions (FGDs) were conducted
perspectives of the KIs tended to support and augment
with women alcohol and drug users in Manipur (2 in
what the FGD participants had to say, and are also pre-
Imphal, 3 in Churachandpur), and four in Nagaland
(3 in Dimapur, 1 in Wokha). There were 7–8 participants sentedhere.
in each group, with a total of 39 participants in Manipur
and 32 in Nagaland. Some groups included alcohol users
Ethicalissues
exclusively, while others were a mixture of alcohol users,
All potential participants were informed about the nature
opiateusersandthosewhousedbothsubstances.AllFGDs
andpurposeofthestudywhentheywereinvitedtopartici-
wereconductedbythelocalROs,andeachFGDlastedap-
pate. Those who agreed to participate gave informed con-
proximately two hours. FGD participants were identified
sent, and were assured of confidentiality. Ethics approval
through NGO outreach worker networks, and subsequent
was obtained from the University of Melbourne Human
snowball sampling. Some of the participants were NGO
Research Ethics Committee and the Institutional Review
service users and others were not, and while some were
Board of the Emmanuel Hospital Association, New Delhi,
engaged in sex work, the majority were not. FGD partici-
India.
pantswereprovidedwithpaymenttocompensateforchild
careandtravelcosts.
Both the KI interviews and FGDs were conducted in Results
the local language by the ROs using semi-structured Backgroundinformationonparticipants
interview guides that covered a range of thematic areas Demographic information of all FGD participants are
pertaining to female drug and alcohol users as listed summarized in Table 1. The proportion of widowed and
below: divorced women was very high considering the relatively
young age of the participants (64% in Manipur and 35%
(cid:1) Patternsofdrugand alcohol use in Nagaland), highlighting the particular vulnerability of
(cid:1) Learningtousedrugsand alcohol thesewomenacrossIndia,includingtheNortheast.
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Table1DemographicinformationforFGDparticipants joint...Theytellusthatwedon’thavegood
Variable Manipur Nagaland communicationskills,orwehavenotaccompaniedour
n=39 n=32 customerswell,andthereforetoavoidthisconfrontation
Meanage(range) 31yrs(20–45) 28yrs(18–38) weforceourcustomerstodrinkmoreandmoreby
-<25yrs 26% 28% accompanyingthem,andwegetdrunk.(FocusGroup
-25–29yrs 15% 28% Discussion(FGD)3Dimapur,Nagaland)
-30–34yrs 21% 28%
Whiletheboozejointswerethemostfrequentlydescribed
-35–39yrs 33% 16%
context for alcohol consumption by women, some partici-
-≥40yrs 5% 0 pantssaidthatsmallgroupsofwomencongregateindrink-
Schooling ing ‘hotspots’orinthehomeofoneofthewomeninorder
-None 18% 22% to drink. Additionally, some women, especially those who
are married, drink alone at home where privacy can be
-Notcompleted 61% 62%
maintained and social opprobrium avoided. However, this
-Completed 21% 16%
is only possible for women who have enough money to
Maritalstatus
purchase a supply of alcohol to take home; many others
-Single 15% 34% aredependentonmeninboozejointswhopurchasealco-
-Married 21% 31% holforthem.
-Widowed 31% 13% AlcoholusewassimilarlypopularamongtheManipuri
women, but almost two-thirds were using heroin (No.4)
-Divorced 33% 22%
and one-quarter Spasmoproxyvon. The women who used
Drug/alcoholuse
heroin tended to do so alone in quiet places, or at the
-Alcohol 90% 91% peddler’s place. Mostofthe women usingheroin injected
-Heroin 64% 0% it,butsomewere‘chasing’(inhaling)heroin.
-Spasmoproxyvon 26% 16% There was widespread acknowledgement that women
Children 64% 63% begin and continue to drink and take drugs for a com-
plex range of reasons including poverty, family conflict,
divorce or widowhood, pleasure, to deal with stress and
Drugandalcoholuseamongthewomen suppress emotional pain, to overcome shyness and shame
The patterns of drug and alcohol use were different in associated with sex work, and finally to avoid the symp-
each of the states. Most of the women from Nagaland tomsofwithdrawal.
were alcohol users, a small number used Spasmoproxy-
von, and none were using heroin. The Nagaland study P:Wedrinkanddodrugsfordifferentreasons.Some
participants consistently reported that injecting drug use dosobecauseoflotsofstressintheirlives,whilesome
among women in their state was previously observed haveafriendwhodrinks,andsoshegivesintopeer
but is now very uncommon, and although women used pressureandgoesastray...Somebreakoffaserious
Spasmoproxyvon orally, the most problematic substance relationshipwiththeirboyfriendandtoeasethe
forwomeninNagalandwasalcohol. heartache,theygetintodrinkingordodrugs.Iama
According to the study participants, even though marriedwomanwholooksafteraboozejoint,andso
Nagaland is a dry state, alcohol is widely available. Young thinkingofmy[absent]children,Idrinkaway,getdrunk
women (as young as mid-teens) are employed in numer- andthengotosleep.Iwakeupfresh[sober]andwash
ous booze joints that are commonplace, particularly in myselfandthenstartdrinkingandgotosleepdrunk.
Dimapur (the commercial capital). These women are (FGD3Dimapur,Nagaland)
employedtoattractmalecustomerswhoarethenencour-
aged to purchase alcohol not only for themselves but also Table 2 provides examples of quotes that highlight the
for the young women, thereby increasing sales. Women main reasons why women in Manipur and Nagaland use
drink mostly manufactured beer, locally brewed rice beer, drugsandalcohol(asidentified bythe participants).
and spirits. Over time some women become dependant
on alcohol as indicated by the fact that they are drinking HIVvulnerability
all dayeveryday,and describe symptomsof alcohol with- The women in this study were vulnerable to HIV infec-
drawalifnotabletoaccessalcohol. tion in a range of ways that differed somewhat by state.
For some of the participants, especially for those from
P:(participant):Sometimeseven ifwesell 8–9cases Manipur who were heroin dependent, involvement in
ofdrinks,westillgetascoldingfromtheownerofthe sex work was an obvious risk for sexual transmission of
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Table2QuotesreflectingsomeofthereasonswomeninManipurandNagalandusedrugsandalcohol
Reason Quote
Widowhood Mainly,accordingtomyexperienceswomenwhobecomewidowsataveryyoungageturnintoalcoholic
andfemaleinjectingdrugusers.Iknow20–30ofthem.Womenwhoareverypooralsobecomesexworkers
andstartdrinkingalcohol...Mainlyyoungwidows,iftheydon’thavesupportfromfamily,theystartlooking
forwaysofearning.Iftheydosexworkthentheycompulsorilyusealcoholoranytypeofdrugsinorderto
avoidshynessandshame.(KI6Manipur,Nurse)
Tosuppressemotionalpain Myfirsthusbandelopedwithmeandlaterranawaywithanothergirl.Igotmarriedagain,andmysecond
husbandusedtobeatmeupeverydayandmyfacewasalwaysswollen.Sometimes,Icouldn’tevenopenmy
eyesbecauseofbeingbeatenup.Ileftmysecondhusbandtoo.IdrinkbecauseIcannotstopmytearsfrom
falling.IdrinkbecauseIalwayscry(brokedown).Ifeelsosad.WhereverIgo,Igoanddrinklotsofrum.Even
beforefood,Idrinkabottleofrum.Pleasedon’tfeelangryatme.(FGD3Dimapur,Nagaland)
Forpleasure Formemyfriendtaughtmedrinkingalcoholwhileattendingparties.LateronIstartedinjectingheroin
withoutbeingtaughtbyanybodybecauseIlovetotakedrugsverymuch.It’sbeenalmostsevenyearsthatI
aminjectingdrugs.Iwasalsoindetoxificationtwotimesinbetween,butstillIdon’twanttostop,andsoI
continue.ThemomentIseethepeddler’shouseIwanttotakeit.(FGD1Imphal,Manipur)
Toavoidsymptomsofwithdrawal NowIamanaddict.WhenIdon’ttakemydailydose,Ifeellethargicandsickandstayinbedthewholeday
butwheneverIhavemydailydose,Ifeellightandactive.(FGD1Dimapur,Nagaland)
Iwassellingdrinksandintheprocess,customersaskedmetodrinkwiththemandslowlyIstarteddrinking,
andtodayIamanaddict.IfIdon’tdrink,Iexperienceturkey[withdrawal].FromthetimeIgetup,beforeI
drinkmymorningtea,ItakeMC[rum]forbreakfast(laughs).(FGD5Wokha,Nagaland)
Toovercomeshameassociated Formethereisnothinglikesadnessasthereason,butwithoutdrugsIcannotearnmoney,withoutthisI
withsexwork cannotbetogether[havesex]withaman.WiththedrugIdon’tfeelshame.LikethatIstarteddrinking
[alcohol].(FGD2Imphal,Manipur)
STIs including HIV. However, identifying as a sex worker P:ThesedaysaswecangetfreesyringesfromNGOs
also meant that they were able to access HIV prevention weuseourown,andsharingofsyringesismuchless.
services that provided needles & syringes, condoms, and However when we have severe withdrawal, as we do
STI treatment. While some of the women indicated that not always carry our own syringes we do not mind
theyneededtoengageinsexworkinordertosupporttheir sharing, even if we know the HIVstatus of that
drugandalcoholuse,itwasalsothecasethatsomeneeded person. This way it is easier for drug users [to be
tousedrugsandalcoholinordertoengageinsexwork. infected]. (FGD3 Churachandpur, Manipur)
The FGD participants from both states said that con-
doms were used some of the time, but not all the time. In both states, but particularly in Nagaland, the HIV
The failure to use condoms was sometimes because the risks for women dependent on alcohol were very evi-
men insisted on sex without a condom or paid extra dent. Many participants described situations that placed
money for it (in relation to sex work), but the intoxi- women alcohol users at high risk for infection with HIV.
cated state of the woman was also commonly identified The consumption of alcohol by women was frequently
as a reason for condom-free sex, both in the context of linked to sex, mostly unprotected sex. Sometimes the
sexworkandoutsideofit. women were raped when very drunk, sometimes by
groupsofmen,andhadlimitedrecallfortheevent.
P1:Sometimes,mentellusthattheywillnotuse
condomseventhoughweinsist,andsosometimeswe P: AsformeIstarteddrinkingaftermyhusbanddied.I
giveinanddohavesexwithoutcondoms.Wealso stayedwithmybrotherwhousedtorunaboozejoint.
don’tknowwhethertheyareinfectedornot-they Thenwhiskywasknownasbagpiper-it’ssostrong-it
mightbeortheymightnotbe...Mengiveuswhatever wasmyfirsttime.Idrankthisandgotalldrunk.Ifound
amountofmoneyweaskbutonthegroundsthatwe myselfnakedinthemorningafterdrinking.Ididn’t
havesexwithoutcondoms.Wedosaynotothem,but rememberanythingaboutwhathadhappened.Mysister
theygetangryandtellusthattheywillnotpay...We inlawclothedmewithmekhela[skirt].Shetoldmenot
usesometimes,andsometimeswedon’t.(FGD1 todrinkit[whisky]everagain...Istarteddrinkingbeer
Dimapur,Nagaland) andMC[rum].Weevengooutwithmenwithout
knowinghowtoputonacondom.Manyofuswomen
The risk of HIV infection secondary to injecting drug arelikethis.Wearenotevenawareofwhetherweare
usetendedtobeafocusoftheKIsmorethanthewomen, goingaroundnakedorclothed.Mostofthetimeswe
althoughsomeofthewomenwhoinjecteddrugsacknowl- womendrinkbecauseofproblemsfacedwithhusbands.
edgedthispossibility,andafewmentionedthattheywere Weevengolookingforcustomersandhavesexwithout
HIVinfected. condoms.(FGD3Dimapur,Nagaland)
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alcohol-dependentwomen.Tothe bestofourknowledge,
P1:Ithappens always. Afterwearedrunkwedon’t alcohol detoxification treatment for women is not avail-
evencare whether theguyswearewith aresickor ableineitherofthesetwostates,andevenifitwere,many
not. Sometimeswealsofindourselvesnot properly of the women would not have the money or family sup-
clothed.Isleep atthebooze joints. portrequired toaccesssucha program. Similarly,there is
no chapter of Alcoholics Anonymous for women in these
P2:Sometimesmalefriendsgrouptogetherand states. Consequently, these women are effectively trapped
performgroupsexwiththegirl.(FGD2Dimapur, in a cycle of alcohol dependence, which is challenging
Nagaland). enough to recover from even when appropriate resources
are available and accessible. Somewhat in contrast, those
Discussion womenwhoweredependentoninjectableopioidssuchas
This qualitative study among women drug and alcohol heroinandSpasmoproxyvonhavetheoptionofregistering
users in two Northeast Indian states highlights the prob- to receive opioid substitution therapy (OST) as treatment
lemof bothdrugandalcohol useand dependenceamong for their opioid dependence, and there is at least one
women,andtheveryclearwaysinwhichthisplacesthem drug detoxification and rehabilitation centre that caters
at risk of HIV infection. While descriptions of HIV risks forwomenspecifically.Theliteratureindicatesthatwomen
associated with drug use are not an unexpected finding, dependent on substances are less likely, over their lifetime,
the strong focus given to the link between sexual risk to enter treatment compared to men, but gender does
behaviours and alcohol consumption in the context of not predict treatment retention, completion, or outcome
relativelyhighHIVprevalenceisanimportantfindingthat if given the opportunity of treatment [41]. The partici-
hasimplicationsforHIVpreventionprograms. pants in this study frequently emphasized the desperate
The findings also highlight the extent to which the need for women-only and women-friendly drug and alco-
women’ssituationsandissuesvariedbystate.Thewomen hol detoxification and rehabilitation centres that are low
inNagalandweremainlystrugglingwiththeconsequences costandcanaccommodatechildren[38].
of alcohol use anddependence, and anabsence of access-
ibleservices.TheirHIVvulnerabilitywasmostlyrelatedto HIVrisksforfemaledrugandalcoholusers
thelackofcontroltheyhadduringsexualencountersdue TherelationshipbetweenHIVriskbehavioursandalcohol
to their intoxicated state (and no doubt the intoxicated use has not received as much attention as the risks asso-
stateofthemeninvolvedaswell).ThewomeninManipur ciated with injecting drug use and sex work [42], even
were also struggling somewhat with the consequences of though sex and alcohol use are frequently co-occurring
alcohol use, but the most problematic substance in this behaviours all over the world. In a large study of women
statewasheroin.TheirHIVvulnerabilitywasmainlyasso- and substance use in India, Murthy noted that 60% of
ciated with the need to frequently engage in sex work in female substanceusersbelieved that substance usemakes
order to raise money to purchase heroin. The observed sex moreenjoyable and less painful[14].A survey among
differences between the two states could arguably be migrant FSWs in fourteen districts of four high HIV
attributed to the non-representative sampling, but these prevalencestates(AndhraPradesh,Karnataka,TamilNadu
differences are consistent with the experience of staff and Maharashtra) found that 54% consumed alcohol prior
working in local HIV prevention and care services, and to sex, and that alcohol use was associated with incon-
withotherresearch[40]. sistent condom use [21]. Many of the FSW participants
The stated reasons for using drugs and alcohol over- inourstudysaidthattheyusedalcoholinordertoover-
lappedwithwhathasbeenreportedelsewhereinthelitera- come the shame of engaging in sex work, and to cope
ture [14] and included widowhood, suppressing emotional with having sex with their clients. Thus it may be
pain, pleasure, avoiding the symptoms of withdrawal, and difficult for FSWs to reduce their alcohol use in the
overcoming the shame of sex work. Even though the absence of alternative sources of income, and this has
Northeast region of India is culturally, linguistically and consequences for their ability to negotiate safe sex, and
ethnicallydistinctfromtherestofthecountry,widowhood thereforetheirriskofHIVinfection.
and divorce place women in situations of personal, social Alinkbetweenalcoholuseandunsafesexisanimport-
and financial hardship, similar to other parts of India. ant one, particularly in the state of Nagaland where the
While some of these women may have been divorced due evidencesuggeststhatsexualtransmissionofHIVisprob-
to their substance use, others were using substances to ably the major driver of the epidemic, which is somewhat
copewithbeingwidowedordivorced. different from the neighbouring state of Manipur where
Someofthewomenreporteddrinkingalcoholprimarily HIV transmission through unsafe injecting is still making
toavoidthesymptomsofwithdrawal.Unfortunatelythere a major contribution to the epidemic. Women who are
arelimitedviabletreatmentoptionscurrentlyavailablefor injectingdruguserscanaccessarangeofservicesthrough
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HIVpreventionNGOsincludingSTImanagement,needle deliberately recruited participants who were not recipi-
& syringe and condom distribution, abscess manage- ents of their services. It is also possible that the women
mentandbasichealthcare.Incontrast,womenwhoare participating in the study are at the more chronic end of
dependent on alcohol are not eligible for services pro- the drug and alcohol dependence spectrum, and there-
vided by these NGOs unless they are engaging in sex fore more conspicuous for recruitment into the study.
work, as the NGOs are mostly funded to target HIV Giventhesensitive nature ofthequestionsabout socially
prevention services to specific high-risk groups (IDUs, taboo behaviours of women, some participants may have
FSWs, or men who have sex with men). It is likely that been inclined to provide more socially acceptable
fear of discrimination because of their alcohol depend- responses, attheexpenseof validresponses,resultingin
ence would inhibit these women from accessing any bias. It is a qualitative investigation so findings cannot
mainstream health care services, even though many of be generalized to all women drug and alcohol users in
themexperiencearangeofhealthproblems[38]. Manipur and Nagaland. A follow-up survey with a repre-
AsalcoholisanillicitsubstanceinManipurandNagaland, sentatively sampled group of women would strengthen the
its consumption is inherently risky. The quality and serving findings.
ofalcoholistotallyunregulated,andvenuesthatsellalcohol,
while commonplace, are nevertheless trading outside of Conclusion
the law. Young women entering this world are vulnerable
The findings from this study add to the growing body of
to a range of hazards including STIs, HIV, substance de-
literature linking risks for HIV infection with alcohol use,
pendence, and violence [38]. While the (female) partici- especiallyinthecontextofdevelopingcountriesgenerally,
pants in this study provided vivid descriptions of unsafe
andthesetwostatesofNortheastIndiainparticular.Both
sex linked to their own alcohol use, it is probable that al-
the Manipur and Nagaland governments have embraced
cohol use by men is also making a substantial and direct and successfully implemented a harm reduction approach
contribution to the occurrence of unsafe sex and sexual
to injecting drug use, and a similar approach to alcohol
violence,andthereforeacontributiontotheprevalenceof
use and dependence is warranted. In particular, there is a
HIVand other STIs in these two states. Therefore, inter- real need for services to assist and provide treatment for
ventions to minimise the harms caused by alcohol use
women who are alcohol dependent. Many of the women
shouldtargetbothwomenandmen.
inthisstudywereatriskofSTIsincludingHIV,andthisis
These study findings raise a number of key questions occurring in a context of relatively high HIV prevalence.
that need to be answered if the situation of women drug
HIV prevention efforts need to consider the vulnerability
and alcohol users in Manipur and Nagaland is to be
ofwomenalcoholusers,whoarecurrentlynotcoveredby
improved:HowcanHIVpreventionNGOprogramsreach the HIV prevention services, if the HIV epidemic is to be
vulnerable women (non-injecting) drug users and alcohol
comprehensivelyaddressed.
users when they are only funded to target key population
groups that do not generally include such women? If the Competinginterests
NGO programs are not able to reach these women, who Theauthorsdeclarethattheyhavenocompetinginterests.
can/will? Women drug and alcohol users in India gener-
Authors’contributions
ally prefer to receive health care services through NGOs
Allauthorscontributedtotheconceptionanddesignofthestudy,CZSand
[14],soitwouldbebeneficialiftheHIVpreventionNGO CHSmanagedthedatacollection,MKandADanalysedthedata,MKdrafted
services currently offered to female IDUs and FSWs themanuscript,allauthorshavereviewedthefinalmanuscript.
were extended to include other vulnerable women such
Acknowledgements
as (non-injecting) drug users and alcohol users. This
WewouldliketoacknowledgethecontributionsofTemjenNungsangJamir,
especially applies to safe sex promotion (including the NeiphrulouLasuh,PurnimaDeviandBiakLunwhosoablyassistedwiththe
distribution of condoms) and STI clinic services. Some of datacollectionandtranslation,andthefollowingNGOswhofacilitatedthe
FGDs:CommunityAwarenessDevelopment(CAD)Foundation,Guardian
the participants mentioned that they were HIV infected, Angel,Prodigal’sHome,AkimboSociety,andAgapeYouthWelfare
and it is highly likely that others are unknowingly OrganizationinNagaland;andSocialAwarenessServiceOrganization(SASO),
HIV infected. The negative effects of alcohol on the pro- SocietyforHIV/AIDSandLifelineOperation(SHALOM),andLamka
RehabilitationandResearchCentre(LRRC)inManipur.Weareespecially
gression of HIV disease are well recognised [43], so
gratefultoallthekeyinformantsandFGDparticipants.
infected women need to be identified, offered treatment,
andprovidedwithrelevanthealthpromotinginformation. Authordetails
1NossalInstituteforGlobalHealth,UniversityofMelbourne,Level4,161Barry
This study has a number of limitations that should be
St,Carlton,VIC3010,Australia.2ProjectORCHID,EmmanuelHospital
considered when interpreting the findings. There could Association,Dimapur,Nagaland,India.3ProjectORCHID,EmmanuelHospital
be some selection bias because the FGD participants Association,Imphal,Manipur,India.
were recruited through the NGO networks, but this is
Received:29August2012Accepted:24January2013
somewhat offset by the fact that the NGO workers Published:29January2013
Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page8of8
http://www.biomedcentral.com/1472-698X/13/9
References 26. KumarMS:Arapidsituationassessmentofsexualriskbehaviourand
1. PinkhamS,Malinowska-SempruchK:Women,harmreductionandHIV. substanceuseamongsexworkersandtheirclientsinChennai(Madras),South
ReprodHealthMatters2008,16:168–181. India.Geneva,Switzerland:WorldHealthOrganization;2003.
2. UnitedNationsOfficeonDrugsandCrime:Substanceabusetreatmentand 27. LiY,DetelsR,LinP,FuX,DengZ,LiuY,TanY,LiJ,WuZ:Prevalenceof
careforwomen:casestudiesandlessonslearned.NewYork:UnitedNations; HIVandSTIsandassociatedriskfactorsamongfemalesexworkersin
2004. GuangdongProvince,China.JAcquirImmuneDeficSyndr2010,
3. KumarMS,SharmaM:WomenandsubstanceuseinIndiaand 53(Suppl1):S48–S53.
Bangladesh.SubstUseMisuse2008,43:1062–1077. 28. WHO:AlcoholUseandSexualRiskBehaviour:ACross-CulturalStudyinEight
4. AshleyOS,MarsdenME,BradyMT:Effectivenessofsubstanceabuse Countries.Geneva:WorldHealthOrganization;2005.
treatmentprogrammingforwomen:areview.AmJDrugAlcoholAbuse 29. SinghSK,SchensulJJ,GuptaK,MaharanaB:Determinantsofalcoholuse,
2003,29:19–53. riskysexualbehaviourandsexualhealthproblemsamongmeninlow
5. Kerr-CorrêaF,IgamiTZ,HiroceV,TucciAM:Patternsofalcoholuse incomecommunitiesofMumbai,India.AIDSBehav2010,14:S48–S60.
betweengenders:across-culturalevaluation.JAffectDisord2007, 30. GuptaK,VaidehiY,MajumderN:Spatialmobility,alcoholuse,sexual
102:265–275. behaviourandsexualhealthamongmalesinIndia.AIDSBehav2010,
6. ShermanS,KamarulzamanA,SpittalO:Womenanddrugsacrossthe 14:S18–S30.
globe:acalltoaction.IntJDrugPolicy2008,19:97–98. 31. SaggurtiN,SchensulSL,SinghR:Alcoholuse,sexualriskbehaviourand
7. RobertsA,MathersB,DegenhardtL:Womenwhoinjectdrugs:Areviewof STIsamongmarriedmeninMumbai,India.AIDSBehav2010,14:S40–S47.
theirrisks,experiencesandneeds.Sydney:SecretariatoftheReferenceGroup 32. NayakMB,KorchaRA,BenegalV:Alcoholuse,mentalhealth,andHIV-
toUnitedNationsonHIVandInjectingDrugUse;2010. relatedriskbehavioursamongadultmeninKarnataka.AIDSBehav2010,
8. UnitedNationsInternationalDrugControlProgrammeandMinistryof 14:S61–S73.
SocialJusticeandEmpowerment,GovernmentofIndia:WomenandDrug 33. SametJH,PaceCA,ChengDM,ColemanS:Alcoholuseandsexrisk
Abuse:TheProbleminIndia.NewDelhi:UNODCROSA;2002. behavioursamongHIVinfectedfemalesexworkers(FSWs)andHIV-
9. BenegalV:India:alcoholandpublichealth.Addiction2005,100:1051–1056. infectedmaleclientsofFSWsinIndia.AIDSBehav2010,14:S74–S83.
34. RodriguezDC,KrishnanAK,KumarasamyN,KrishnanG:Twosidesofthe
10. SchensulJJ,SinghSK,GuptaK,BryantK,VermaR:AlcoholandHIVinIndia:
Areviewofcurrentresearchandintervention.AIDSBehaviour2010, samestory:AlcoholuseandHIVriskinSouthIndia.AIDSBehav2010,
14:S1–S7. 14:S136–S146.
35. NationalAIDSControlOrganization:HIVdeclininginIndia;newinfections
11. SharmaHK,TripathiBM,PeltoPJ:TheevolutionofalcoholuseinIndia.
AIDSBehav2010,14:S8–S17. reducedby50%from2000–2009;sustainedfocusonpreventionrequired.Press
ReleaseDecember2010.http://www.nacoonline.org.
12. PinkhamS,Malinowska-SemprunchK:Women,HarmReduction,andHIV.
36. ChandrasekaranP,DallabettaG,LooV,RaoS,GayleH,AlexanderA:
NewYork:InternationalHarmReductionDevelopmentProgramofthe
ContainingHIV/AIDSinIndia:theunfinishedagenda.LancetInfectDis
OpenSocietyInstitute;2007.
2006,6:508–521.
13. UnitedNationsOfficeonDrugsandCrime,RegionalOfficeforSouthAsia:
37. NationalSummaryReport–India:IntegratedBiologicalandBehavioural
DrugUseintheNortheasternStatesofIndia.NewDelhi:UNODCROSA;2006.
Assessment(IBBA)Round2(2009–2010).NewDelhi:IndianCouncilof
14. MurthyP:WomenandDrugUseinIndia:Substance,WomenandHigh-Risk
MedicalResearchandFHI360;2011.
AssessmentStudy.NewDelhi:UNODCROSA;2008.
38. KermodeM,SongputCH,SonoCZ,JamirTN,DevineA:Meetingtheneeds
15. CookR,ClarkDB:Isthereanassociationbetweenalcoholconsumption ofwomenwhousedrugsandalcoholinNorth-eastIndia–achallenge
andsexuallytransmitteddiseases?Asystematicreview.SexTransmDis
2005,32:156–164. forHIVpreventionservices.BMCPublicHealth2012,12:825.
39. PattonMQ:QualitativeResearch&Evaluationmethods.3rdedition.London,
16. SteinM,HermanDS,TrisvanE,PirragliaP,EnglerP,AndersonBJ:Alcohol
NewDelhi:SagePublications,ThousandOaks;2002.
useandsexualriskbehavioramonghumanimmunodeficiencyvirus-
40. KermodeM,LonglengV,SinghBC,HockingJ,LangkhamB,CroftsN:My
positivepersons.AlcoholClinExpRes2005,29:837–843.
firsttime:InitiationintoinjectingdruguseinManipurandNagaland,
17. WeiserSD,LeiterK,HeislerM,McFarlandW,Percy-deKorteF,DeMonner
North-eastIndia.HRJ2007,4:19.
SM,TlouS,PhaladzeN,IacopinoV,BangsbergDR:Apopulation-based
41. GreenfieldSF,BrooksAJ,GordonSM,GreenCA,KroppF,McHughRK,
studyonalcoholandhigh-risksexualbehaviorsinBotswana.PLoSMed
LincolnM,HienD,MieleGM:Substanceabusetreatmententry,retention,
2006,3:e392.
andoutcomeinwomen:Areviewoftheliterature.DrugAlcoholDepen
18. FisherJC,CookPA,SamNE,KapigaSH:Patternsofalcoholuse,problem 2007,86:1–21.
drinkingandHIVinfectionamonghigh-riskAfricanwomen.SexTransm
42. FritzK,MorojeleN,KalichmanS:Alcohol:theforgottendruginHIV/AIDS.
Dis2008,35:537–544. Lancet2010,376:398–400.
19. ShuperP,JoharchiN,IrvingH,RehmJ:Alcoholasacorrelateof
43. ShuperPA,NeumanM,KanteresF,BaliunasD,JoharchiN,RehmJ:Causal
unprotectedsexualbehavioramongpeoplelivingwithHIV/AIDS:review considerationsonalcoholandHIV/AIDS–asystematicreview.Alcohol
andmeta-analysis.AIDSBehav2009,13:1021–1036. Alcohol2010,45:159–166.
20. FisherJC,CookPA,KapigaSH:AlcoholusebeforesexandHIVrisk:
Situationalcharacteristicsofprotectedandunprotectedencounters
amonghigh-riskAfricanwomen.SexuallyTransmDis2010,37:571–578. doi:10.1186/1472-698X-13-9
Citethisarticleas:Kermodeetal.:Fallingthroughthecracks:a
21. VermaRK,SaggurtiN,SinghAK,SwainSN:Alcoholandsexualrisk
qualitativestudyofHIVrisksamongwomenwhousedrugsandalcohol
behaviouramongmigrantfemalesexworkersandmaleworkersin inNortheastIndia.BMCInternationalHealthandHumanRights201313:9.
districtswithhighin-migrationfromfourhighHIVprevalencestatesof
India.AIDSBehaviour2010,14:S31–S39.
22. AkarroRR:Somefactorsassociatedwithhighriskbehavioursamongbar
maidsinTanzania.CurrResJSocSci2011,3:207–212.
23. BryantKJ:Expandingresearchontheroleofalcoholconsumptionand
relatedrisksinthepreventionandtreatmentofHIV/AIDS.SubstUse
Misuse2006,41:1465–1507.
24. ChiaoC,MoriskyDE,RosenbergR,KsobiechK,MalowR:Therelationship
betweenHIV/sexuallytransmittedinfectionriskandalcoholuseduring
commercialsexepisodes:resultsfromthestudyoffemalecommercial
sexworkersinthePhilippines.SubstUseMisuse2006,41:1509–1533.
25. FisherJC,BangH,KapigaSH:TheassociationbetweenHIVinfectionand
alcoholuse:asystematicreviewandmeta-analysisofAfricanStudies.
SexTransmDis2007,34:856–863.