Key findings 

• Nine of the eleven survey participants knew of harm reduction services designed for women who use drugs.
• A lack of harm reduction services per se and gender based violence were identified as the key barriers for women who use drugs to access harm reduction services.
• The majority of participants identified the lack of women specific harm reduction services as the most serious service gap for women who use drugs.
• Community conservatism and socio-cultural issues such as religious and rural conservatism appear to be important reasons why harm reduction services for women are limited.

 

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 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’ harem reduction services designed for women who use drugs. Data was processed into short reports, with some respondent clarification ahead of finalisation and dissemination.

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

 Eleven (11)  women from 7  countries in the Middle East and North Africa (MENA) responded to the survey. They were in Algeria, Afghanistan, Bahrain, Morocco, Pakistan, Palestine/East Jerusalem and Syria. Only four (36.7%) respondents identified as WUD.  These were from Afghanistan and Morocco.

Of the 7 countries, six had one respondent per country and Morocco had 5. To adjust for this, in presenting the overall results of the survey the data from Morocco has been summarised into one response where possible. This will result in 7 respondents.

 

Harm reduction services for women who use drugs 

Of the respondents, 71% knew of harm reduction services designed for WUD in their country. It was not clear from the responses to what extent the services were designed for WUD. Participants reported the following harm reduction services used by WUD:

 

Algeria: The National Detoxification Centre for Drug Users.

Palestine/East Jerusalem: Services for counselling and increasing awareness of HIV and AIDS.

Pakistan: Services were known of but no information was provided.

Syria: No services were known.

Morocco:  Services provided included prevention (NSP, condoms and awareness raising) screening (HIV, hepatitis C, STI) and opioid agonist therapy.  Sexual & reproductive Health services , legal support and social and administrative support were also available. Links between harm reduction services and CSOs working on women’s rights was reported but no further details provided. The organisations were not named.

Bahrain: No services were known.

Afghanistan: The Bridge Hope Health Organisation (BHHO) working in Kabul providing NSP and wound care.

 

Key barriers to access

 When asked to rank the three top issues limiting access to harm reduction services for WUD, 3 of the 7 respondents reported gender based violence (GBV) in the first rank. Also in the first rank, 2 reported a lack of harm reduction services per se. GBV and  a lack of harm reduction services per se were also most often reported when respondents were asked to rank the 2^nd and 3^rd top issues limiting access in their country.

 

Other priority issues

Two respondents did not report other priority issues . Of those that did, the most frequently reported issues were:

• The impact of community conservatism and other socio-cultural issues, including religious and rural conservatism.
• Stigma and discrimination, including self-stigma
• Funding – services had closed due to lack of funds, available funds had been underspent or services were unavailable such as OST and overnight accommodation.
• GBV and the criminalisation of sex work was also reported.

 

Key service gaps

When asked what were  the most serious services gaps in provision of harm reduction services for WUD the overall lack of harm reduction services per se was reported.  Other services such as health centres and drug treatment was also lacking. In addition, when available, these services tended to prioritise drug treatment over provision of harm reduction services to WUD. A general absence of policies or strategies for working with WUD was also reported. Further to this, particularly in Morocco, the lack of links to other services and potential partners was noted. Respondents reported that these organisations tend to stigmatise and marginalise WUD. This included NGOs, hospitals and women’s rights services.

 

Discussion

The results of this survey suggest that there are very few, if any, harm reduction services in MENA countries for women who use drugs (WUD) . There is also a lack of funding for harm reduction services, a policy and strategy vacuum in this area and reports from all countries of gender based violence toward WUD.  The reasons for this were not directly stated, but the information provided by the women who participated in this survey suggest this is linked to widespread community and socio-cultural conservatism and stigma and discrimination, both organisational and individual, with regard to WUD.

In the interests of public health and the rights of WUD, international and national bodies, both government and non-government, must address these issues. As well as investment in harm reduction services that prioritise the health and human rights of women who use drugs it is essential to work with potential partners both within government and non-government to address negative attitudes, lack of information and stigma and discrimination toward WUD. WUD within the MENA region must be full partners in this work.

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