HIV vulnerability of women involving in sex work and drug use: use of Syndemic theory

Abstract

Background A close link between female sex work and injecting drug use in high, middle and low income settings was identified many years ago. In comparison to the general population, drug use is more common among female sex workers (FSWs) and also sex work is common among female drug users (FDUs) which compound HIV risk among them. Problematic drug use (injecting drug use and sex trade for drug purchase) among FSW has become one of the major public health issues because of its association with HIV infection. The high risk of HIV among this population is determined by the high number of sexual partners, frequent changes in sexual partners, unprotected anal intercourse, low condom use during intercourse and sharing of needles. The overlap of sex work and injecting drug use has caused increased concern recently. A study conducted in India found that the prevalence of HIV among female sex worker who inject drug (FSW-IDU) was nine times higher than those who do not. Similarly, a study conducted in Nepal showed that 50 percent of female injecting drug users (FIDUs) are involved in sex work, and the HIV rate among them is 63 percent which is much higher than that of male IDUs. Methods Literature review was done to identify the vulnerability of sex work and drug use overlapping women (FSW-FIDU) population of Nepal and Northeast (NE) India to HIV infection. Syndemic theory was used to uncover the factors that interact with HIV infection among those vulnerable populations. Results Despite of variance in socio-cultural and geographical aspect, the situation of FSW-FIDUs was found to be similar among Nepal and NE India. Different factors interacting with HIV infection among FSW-FIDUs were identified using syndemic theory. The main factors identified were socio-economic status, power relationship with their sexual partners, violence, non-use of condoms, sharing pattern of syringes and needles, illegality of sex work and drug use and lack of access to health and harm reduction services provided. However, complex web of interaction were found among those factors as each factor have their different interaction with others. Thus, consideration of this complex web might be useful for effective HIV prevention programs. Conclusion Regardless of little literature, the factors interacting with HIV infection among FSW-FIDU of Nepal and NE India were identified. This is the only study conducted in both the countries that identified primary sexual partners as the main factor interacting with other two main factors i.e. non use of condoms and sharing of needles and syringes which results in high risk behaviour among that population. Further future studies in role of primary sexual partner among this population are recommended. In spite of individual focused prevention programs, multisectoral approach is also recommended for effective HIV prevention programs. Key words 'Female sex workers (FSW)', 'Female injecting drug users (FIDUs)', 'female drug users (FDU)', 'female drug users who inject drugs (FSW-IDU)', 'HIV/AIDS', 'Nepal' and 'Northeast India'