Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 http://www.biomedcentral.com/1472-698X/13/9 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 ©2013Kermodeetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited. Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page2of8 http://www.biomedcentral.com/1472-698X/13/9 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 Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page3of8 http://www.biomedcentral.com/1472-698X/13/9 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. Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page4of8 http://www.biomedcentral.com/1472-698X/13/9 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 Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page5of8 http://www.biomedcentral.com/1472-698X/13/9 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) Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page6of8 http://www.biomedcentral.com/1472-698X/13/9 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 Kermodeetal.BMCInternationalHealthandHumanRights2013,13:9 Page7of8 http://www.biomedcentral.com/1472-698X/13/9 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. 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