- Thirteen (62%) of the 21 survey participants knew of harm reduction services designed for women who use drugs.
- Criminalisation of drug use, a lack of harm reduction services per se and gender based violence (GBV) were identified as the key barriers to access for women who use drugs to access harm reduction services.
- The lack of services that could provide for the specific needs and vulnerabilities of women who use drugs was most often reported as the most serious service gap. This included services addressing GBV, sexual and reproductive health and domestic violence .
- Wide spread stigma and discrimination toward women who use drugs made a significant contribution to limiting women’s access to harm reduction and other necessary services.
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 women friendly services 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 (KI) per country (or state/province in Canada, US and Australia). These were women with a good understanding of harm reduction services in their country.
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 was processed into short reports, to share back with all original survey participants in draft form for feedback before finalisation and dissemination.
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.
21 women from 11 countries in East, West and South Africa responded to the survey. From West Africa, the countries were Nigeria, Cameroun and Senegal, from East and Southern Africa – Kenya, Burundi, Tanzania, Zanzibar (semi-autonomous region of Tanzania) , Seychelles, Mozambique, South Africa and Mauritius (2,000 kilometres off the southeast coast of Africa). One country was not named by the respondent.
Fourteen (67%) of the respondents identified as women who use drugs (WUD).
Of the respondents, 62% knew of harm reduction services designed for WUD in their country. It was not always clear from the responses to what extent the services were designed for WUD. Participants reported the following harm reduction services used by WUD:
Nigeria: “we don’t have HR services for WUD in Nigeria”
Cameroun: There is free HIV testing services in some hotspots for WUD. STI treatment alongside condom and lubricant services in four regions of Cameroon was also reported. These services are offered to all drug users, with no specific approach for women and no female peer educators.
Senegal: From 2016 gynaecological consultations and support was provided by the CoDISEN project and since 2016 programs included awareness raising on harm reduction, demonstration and distribution of HIV self-tests (ATLAS project). From 2017 gynaecological consultations were carried out by CEPIAD collaborating with ENDA sante . In Senegal there has been support for the establishment of OSIWA, the first Association of Women Drug Users in Senegal. A program of distribution of kits containing syringes, cups, distilled water from cotton, condoms and OraQuick HIV self-tests was reported.
Kenya: MEWA programmes, including drop in centres, Women’s Shelter House , community paralegal services and ancillary services (e.g. showers, women’s hygiene kits, nutritional support and washing) that have also increased access to health services, methadone and NSPs. Global Fund Implementers Kenya
Burundi: Condom distribution, HIV/TB testing and treatment, reproductive health care
Tanzania: “Only SALVAGE is trying to help WUD by providing shelter services and advocating for WUD”.
The African PUD network is also present. Sober house accommodation and a methadone maintenance programme is offered in community based therapeutic care (CTC).
Zanzibar (semi-autonomous region of Tanzania): No response
Seychelles: Needle Syringe Programme (NSP), Methadone Maintenance Programme, HIV, STI and viral hepatitis Prevention Testing and Treatment and HIV Post exposure Prophylaxis.
Mozambique: For WUD there are sexual and reproductive health (SRH) and family planning (FP) services on Wednesdays. This service is provided by a doctor who visits the drop-in centre once a week. The centre is run by UNIDOS/MSF and Mozambican Network of PWUD (MozPUD) does the community outreach.
“We as MozPUD (Mozambican Network of PWUD) in partnership with MSF (Doctors without Borders) and UNIDOS have a community centre for people who use drugs (CCPUD) in Mafalala. We support PWUD by harm reduction services which include NSP, OST and Naloxone and also includes WUD”.
South Africa: One respondent reported a TB/HIV Care Step-Up Programme in 4 South African cities providing women specific services for WUD. Research done in South Africa and smaller community advisory groups for WUD in some cities in South Africa was reported . No further detail was provided.
Mauritius: Needle exchange programme, MMT, nicotine replacement therapy, condom distribution. One induction centre for MMT and Chrysalide, a residential rehabilitation centre for women who use drugs and alcohol
Key barriers to access
When asked to rank the three top issues limiting access to harm reduction services for WUD, in the first rank 6 of the 20 women respondents reported a lack of harm reduction services per se, 5 reported criminalisation and 4 gender based violence (GBV). Criminalisation of drug use and GBV as well as harm reduction services dominated by male service users were also most often reported when respondents were asked to rank the 2nd and 3rd top issues.
Other priority issues
4 respondents did not have other priority issues . Of those that did, the most frequently reported were those associated with wide reaching stigma and discrimination toward WUD. Respondents described judgemental, unsupportive, discriminatory environments in health and social welfare, harm reduction, drug treatment, employment, legal, law enforcement and penal settings. In the words of the women who responded – WUD are seen as “”immoral persons….” , WUD “lack acknowledgement and the right to be equal before law and the rest of society”. “Women who use drugs are not being meaningfully represented on various country mechanisms especially at decision making levels”. A lack of access to women’s drug treatment , MMT and harm reduction services including in prison was also reported.
Key service gaps
When asked what were the most serious services gaps in provision of harm reduction services for WUD in Africa EWS, the lack of services for WUD that could provide for their specific needs and vulnerabilities was most often reported. This included services addressing GBV, SRH, pregnancy and gynae needs and domestic violence . The domination of existing services by male service users and stigma and discrimination against WUD limited women’s access. Other service gaps were childcare services, including for women in drug treatment, housing and sober houses for women. Continuing stigma and discrimination and the absence of WUD at policy and planning levels and was also considered a barrier to service provision.
The results of this survey suggest that women who use drugs (WUD) in East, West and Southern Africa have limited or no access to a comprehensive range of harm reduction services for WUD. The criminalisation of drug use, a lack of harm reduction services per se and gender based violence (GBV) were identified as the key barriers to access. Few services could provide for the specific needs and vulnerabilities of women who use drugs. It seems a key factor underlying the lack of access to harm reduction and other necessary services was wide spread stigma and discrimination toward women who use drugs.
In the interests of public health and the rights of WUD, national and international bodies must address these issues. Work toward drug law reform is required. Assisting law enforcement and other criminal justice agencies to understand and implement drug use harm reduction strategies in their work, including the exercise of discretion, partnerships with health services and NGOs and diversion of WUD from the criminal justice system is also needed.
Similarly it is important to address the stigma and discrimination toward WUD. This includes within systems and organisations that have a responsibility to provide services to WUD, amongst health care workers as well as male drug users.
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