Are females who inject drugs at higher risk for HIV infection than males who inject drugs: An international systematic review of high seroprevalence areas
Introduction
Gender disparities in risk for HIV infection are of considerable concern in many different countries (Madkan et al., 2006, UNAIDS, 2004, UNODC, 2006), with females who inject drugs (FWID) often at increased risk for HIV infection compared to males who inject drugs (MWID). Studies conducted in nine European countries documented greater HIV prevalence among FWID compared to MWID (EMCDDA, 2006). In sub-Saharan Africa, 40% of HIV infections in 1985 were diagnosed in females; by 2002, 60% of HIV infections were among females (DeLay, 2004). Globally, nearly 50% of HIV infections in the last five years have been diagnosed among females (United Nations Population Fund, 2005).
FWID often face significant stigma, leading to lower participation in drug treatment, needle/syringe exchange programs (NSP), and other harm reduction services (Network, 2010, Razani et al., 2007, Simmonds and Coomber, 2009). In Dhaka Bangladesh, nearly all NSP participants are male, with harm reduction services tailored toward MWID with little attention toward FWID (Azim et al., 2008).
A Russian survey among MWID found that 21% abused their FWID partners due to the female's drug addictions (Gorshkova ID, 2003); unfortunately, services for abused women are rarely tailored for FWID (Network, 2010). A 2003 Vancouver study reported 19% of MWID had a history of sexual violence compared to 68% among FWID.
FWID usually depend on male partners for drugs and injections, leading to elevated drug and equipment sharing (UNODC, 2006). An Iran study among IDU couples found that males admitted their female partners often needed help injecting and relied exclusively on them to acquire drugs and injecting equipment (Razani et al., 2007).
Many FWID participate in commercial sex work (CSW) to fund their drug habit, (Benotsch et al., 2004, Cleland et al., 2007, Lowndes et al., 2002), ranging from 7% in France to 83% in the Netherlands (Gollub et al., 1998, Renwick et al., 2002). Condom use is very infrequent; a China study reported condom use as low as 6% among regular/casual partners and less than 25% among clients (Lau et al., 2005). Females are biologically more susceptible to sexual transmission of HIV and often have higher prevalence of STI infection, such as HSV-2, which increases the probability of HIV infection.
The potential higher risk for HIV among females raises the issue of general versus targeted HIV prevention programs for FWID. Should HIV prevention efforts be aimed at PWID populations as a whole, with large-scale programs possibly achieving a community-level protective effect (Des Jarlais et al., 2005a)? Or if FWID are at higher risk and not likely to be reached by general programs, are prevention programs specifically targeted to females required? Specifically targeted programs may have higher costs per person served than general programs, but they may be quite cost effective in averting infections among females. This issue becomes of particular importance in resource limited settings, where implementation of programs aimed specifically at FWID may reduce resources available for HIV prevention in the injecting community as whole.
The question of whether females who inject are more likely to be infected with HIV compared to males who inject is, however, an empirical question. Data on differences in HIV infection between the two genders can be utilized for scarce-resource allocation decisions. In this study, we conducted an international systematic review and meta-analysis to assess differences in HIV prevalence among females and males who inject drugs in high seroprevalence areas.
Section snippets
Methods
As the same odds ratio (OR) is of greater public health importance in a setting of high HIV prevalence versus low prevalence, we restricted our study to areas that at one time had greater than 20% HIV prevalence among PWID. Countries with high seroprevalence (>20%) HIV epidemics among PWID were identified from the Reference Group to the UN on HIV and Injecting Drug Use (Mathers et al., 2008). The countries identified and included in this review are Argentina, Brazil, China, Estonia, France,
Search results
Fig. 1 shows the PRISMA diagram (Liberati et al., 2009, Moher et al., 2009) for the searching and screening that led to the final number of studies included in this review. Searching identified 3552 article titles. Six papers in languages other than English that could not be obtained were eliminated. We screened 3546 abstracts against the inclusion criteria and retrieved 738 full text articles. Of the articles and reports retrieved, 117 met all criteria for inclusion and were coded for our
Discussion
Gender disparities in HIV/AIDS have been of great concern in many different countries (Madkan et al., 2006, UNAIDS, 2004, UNODC, 2006). To our knowledge, this is the first systematic review to assess female:male differences in HIV infection among PWID. This review was restricted to countries that have experienced high seroprevalence epidemics among PWID (seroprevalence reached 20% or higher). Determining whether the findings from high seroprevalence areas also hold for low to moderate
Role of funding source
Funding for this study was provided by NIH Grant R01 AI 083035-02; NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
D. Des Jarlais and H. Hagan designed the study and wrote the protocol. J. Feelemyer and S. Modi managed the literature searches and summaries of previous related work. K. Arasteh undertook the statistical analysis, and author D. Des Jarlais wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors have no conflicts of interest with respect to the submitted manuscript.
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