Eastern Europe and Central Asia – Mapping harm reduction services for women who use drugs

Key findings

 

Background

In their Global State of Harm Reduction: 2019 updates, Harm Reduction International (HRI) note that the spread of harm reduction services is still stalling globally in continuation of a trend observed since 2012. The 2018 Global State of Harm Reduction 2018 briefing, highlights that although women are estimated to account for one third people who use drugs globally and are consistently reported to have less access to harm reduction services and to be at higher risk of HIV and hepatitis C infection, robust data on this subject is scarce, and research on drug use and related health issues rarely produces information about women.

While tools exist to enable harm reduction services to institute a gender lens and gender mainstreaming in their programming in order to improve relevance and reach to women who use drugs, services that have introduced such approaches are thin on the ground. Where they do exist, there is not necessarily scope to document and promote experience.

In order to leverage greater accountability from governments that have endorsed UN guidelines and resolutions around the provision of services for women who use drugs (WUD), it is important to document and promote such services where they do exist. With this, models can be replicated, resourced and established at other harm reduction programmes, while pressure builds to reverse the stalling of actions that improve respectful access to health for women who use drugs.

With this in mind, WHRIN undertook a survey, in order to attempt a ‘mapping’ of services designed for women who use drugs around the world.

Method

Regional focal points, identified among WHRIN membership, worked with the WHRIN coordinator to create survey participant lists targeting two well networked women who use drugs and two additional key informants with a good understanding of harm reduction services in their country, per country (or state/province in Canada, US and Australia).

Separate short survey monkeys were created per region. These applied the same 7 questions aimed to identify key barriers to service access and to ‘map’ harm reduction services designed for women who use drugs. Data for each region was processed into short reports.

 

Region Month 2020
Asia April
W Europe May
EECA June
MENA July
Oceania Aug
N America/Canada Sept
Africa (E,W,S) Oct
Latin America Nov

 

WHRIN acknowledge some limitations to the approach of relying primarily on participation from membership and other recommendation contacts where available. In some cases, a country or state participant could not be identified, or there was not a full complement of 4 participants for every state/country. The survey was short and simple and may not have delivered on required specificity in all cases. For these reasons, the survey reports cannot be said to be exhaustive, but they do serve a role in beginning to map and promote services for women who use drugs around the world.

Results

Participants

Seventeen (17)  women from 7 countries in Eastern Europe and Central Asia (EECA) responded to the survey. They were based in Montenegro, Russia, Belarus, Kyrgyzstan, Kazakhstan, Georgia and Ukraine.  Eleven (65%),  of the respondents identified as WUD.

 

Harm reduction services for women who use drugs

Of the 17 respondents, 76% knew of harm reduction services designed for WUD. These were in all countries except Russia, where none were reported.  Participants reported the following harm reduction services designed for WUD:

 

Montenegro: A drop in centre run by NGO Juventas provides services for PWUD and sex workers.

Belarus:  Republican Public Organisation “Belarusian Association of UNESCO Clubs” works with women sex workers, some of whom are drug users. Services are focused on the specific needs of women.  Services are provided in a separate location, at a separate time from when men attend. Reception is conducted by female social workers, a woman lawyer specializes in providing advice on social issues, including maternity and childhood protection. Special wishes and needs are taken into account, for example, there are toys for children of mothers who have come to receive services. If needed, clients are referred for STI screening to a trusted project doctor. Buses run through service delivery points (outlets) with a team of social workers to provide handouts, social counselling and HIV testing.

There are services for free and anonymous rapid HIV tests and coupons for free and anonymous examination of sexually transmitted infections. Condoms, disposable syringes and needles, sanitary napkins and alcohol napkins are provided for free.

Kyrgystan:.

There are hostels for WUD, but the length of stay is limited. Services that women can receive include 1. Grocery packages  2.  Violence counselling 3.  Peer counselling 4.  social support 5. Free rehabilitation until the end of 2020, after which it will be on a paid basis 6. Services of street lawyers.

Other services include self-help groups, social bureaus, drug provision, examination and diagnostics, legal advice and defence of clients by a lawyer in court, motivation packages, referral to syringe exchange points (SEP)/ referral to Needle Syringe Programs (NSP), Opioid Substitution Therapy (OST), and other friendly organizations.

There are pregnancy management protocols for women on methadone maintenance treatment (MMT). There are low threshold services, hospitalization, informational counselling on HIV / STI topics, harm reduction and legal and psychological counselling.

A link to organisations could not be given. HR services for women are not officially described anywhere. In general, social media marketing is not developed and it is not always safe to provide information about help for WUD.

Kazakhstan: Methadone program.

Georgia: NSP, medical and legal services at the counselling level, implementation in OST programs

Ukraine: There are a little number of  services for WUD in Ukraine – all services of Harm Reduction are for PUD. There is only WINGS (Women Initiating New Goals of Safety) in Ukraine adapted for WUD (innovative GBV Screening, brief intervention and referral to treatment at Harm Reduction services with women-specific HIV testing and counselling. WINGS is a short intervention and therapeutic tool designed to identify various types of gender-based violence among women and enhance safety. https://clubeney.org.ua/action/struggle-against-violence/

Georgia and Kyrgyzstan and Kazakhstan also implement the WINGS tool for WUD.

Apart from in Montenegro and Belarus no links or organisational names were provided. One participant reported that  there was very little written information available about services designed for WUD and that it was not always safe to provide information.

 

Key barriers to access

When asked to rank the three top issues limiting access harm reduction services for WUD, 66% of respondents listed lack of access to harm reduction services per se in first rank. Also in the first rank, criminalisation of drug use was listed by 27% and one respondent nominated gender-based violence as limiting access. These 3 issues were also the most frequently reported when respondents were asked to rank the 2nd and 3rd top issues limiting access in their country. WUD Vs other key informant responses were very similar across all rankings.

 

Other priority issues

Criminalisation of drug use –  respondents provided many examples of how the criminalisation of drug use in their countries limited service provision and the access of WUD to harm reduction and other services. “Criminalisation means that HR services are “outside/under the law” (Rus).

Criminalisation resulted in persecution both by law and in society. Criminalisation also resulted in employment restrictions (Bel), deprivation of parental rights, financial insecurity (Rus) and an insufficiently developed infrastructure and imperfect legal framework. (Kyrg). HR services are supported by donors not the state.

Discrimination against WUD – this was reported widely and included inadmissibility and disgust towards women on the part of workers in SEP and OST programs. This was found in men and abstinence based workers. A lack of friendly-minded medical workers even in institutions associated with HR, discrimination by medical officers, police, neighbors was reported. Criminalization was linked to persecution in society and by the law, “this is the worst thing, people are misinformed about WUD – among us there are quite adequate people with the right approach of the state….”  (Rus).Respondents gave examples of the fear associated with stigma.

Lack of services and choice – Respondents reported WUD lacked choice about services. This included treatment services including OST, shelter, childcare and social services, access to professional, more in-depth psychological help,

 Lack of rehabilitation services for WUD– when WUD wanted assistance with “resocialization”, “rehabilitation” or re-entry into society, this was not available. “Give me a choice so that I can choose which program to go to and not just methadone….”

Lack of women specific services for WUD – this was widely reported. Where there was no separate centres or programs for WUD tailored to their needs it was difficult for women to freely accept harm reduction and other services. Areas lacking included gender-sensitive provisions such as child-care or tailored approaches to gender-based violence (Geo/Bel). The HR services that existed were designed by men for men and women’s needs not taken into account (Krg). There was no funding for services for female drug users.

 

Key service gaps

When asked what were the most serious services gaps in provision of HR services for WUD, participants responses were similar to those regarding barriers to access.

Solutions were needed for problems associated with the criminalisation of drug and associated discrimination against WUD

These included restrictions on employ opportunities, deprivation of parental rights, discrimination by medical officers, police, neighbours, a lack of non-discriminatory services, harm reduction operating outside the law because of criminalization of drug users.

 Services for WUD  were needed

There a were no specific programs for WUD, a lack of public health workers, poor infrastructure and legal framework, no state services, no rehabilitation and no childcare available.

Discussion

The results of this survey suggest that there are very few harm reduction services in EECA countries for women who use drugs. The criminalisation of drug use and associated stigma and discrimination, as well as negative attitudes toward women who use drugs within existing services, as well as society generally, were widely reported in EECA countries. The information provided by the women who participated in this survey strongly suggests a link between these issues.

In the interests of public health and the rights of women who use drugs, international and national bodies, both government and non-government, must identify and address the harms arising from criminalisation of drug use for women who use drugs and the stigma and discrimination against women who use drugs. In addition investment in harm reduction services that prioritise the health and human rights of women who use drugs is required.