& Jenny Jain, MPH

Hiding in Plain Sight: The Plight of Opiate

Addiction among Women and its Link to HIV

Epidemics in North AmericaSteffanie A. Strathdee, Harold Simon Professor,

Associate Dean of Global Health Sciences, UCSD

The US Opioid Crisis

Cicero TJ et al., JAMA Psychiatry 2014.

The Changing Face of Heroin Use in

the US

493

3139 3095

222

2007

2986

0

500

1000

1500

2000

2500

3000

3500

4000

1 2 3

Series1Series2

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Deaths Involving Natural & Semi-

Synthetic Opioids

Rudd RA et al., MMWR Morb Mortal Wkly Rep 2016

Rates of U.S. Adults > 18 and Older Reporting Pain, 2015

CDC and NCHS, 2015

9.7

27.6

13.9

20.9

30.4

17.4

0

5

10

15

20

25

30

35

1 2 3

Series1 Series2

Women: suffer more pain in many categories & prescribed more opioids

0

20000000

40000000

60000000

80000000

100000000

120000000

140000000

1 2 3 4 5 6 7 8 9 10 11 12

Series1 Series2

Opioid Prescriptions U.S. Retail Pharmacies, 2002-2013

Source: IMS Health, National Prescription Audit

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Rural Female PWID

• 75% of women in the longitudinal

Social Networks among

Appalachian People (SNAP) study

had a history of injecting drug use

• 64% reported initiating injection with

a prescription opioid; 87% were

injecting prescription opioids at the

baseline interview (2008-2010)

Young AM, Larian N, and Havens JR. Drug Alcohol Depend, 2014. 134: 440-45.

Gender Differences among Rural PWID

– more likely to report pressure to

initiate injection

– more likely to be initiated by a

sexual partner

– more likely to be initiated by a

much older person

– More likely to initiate injection with

a used syringe

– 2X as likely to report engaging in

sexual encounters after injecting

Young AM, Larian N, and Havens JR. Drug and Alcohol Depend, 2014. 134: 440-45.

Compared to rural men PWID, rural women were significantly:

Characteristics of the 2015 Scott County

Indiana HIV Outbreak (n=181)

Female 42.5%

Age < 34 yrs 53.6%

White 98.8%

Injection drug use 95.6%

Sex work (females only) 24.7%

Peters et al, NEJM 2016

Life Expectancy among HIV+ Canadians

after Initiating ART (2000-2014)

S. Patterson et al, BMC Inf Dis 2015

Health and Fiscal Impact of Opioid Use During Pregnancy in the US

• On average, women take between 3 – 5 prescription medications during pregnancy

• Increased prevalence of opioid use during pregnancy ≥ 5 times increase in neonatal opioid withdrawal symptoms (NOWs)

• In 2012, nearly 22,000 infants were born with NOWs in U.S.

• Nationwide: $1.5 billion in hospital charges for treating infants with NOWs

• Vertical transmission is the leading cause of childhood HCV infection

• No intervention has been clearly demonstrated to reduce the risk for mother-to-infant HCV transmission.

Women

substance

users have

special

needs…

Social Determinants influencingHIV Risks among Women

HIV

Drug use

IPV

Societal Messaging Promotes Substance Use

Motivations for Meth use by Gender

Cheng et al, 2009

Women in the Criminal Justice System

HIV prevalence among imprisoned U.S. women is ~2% (Maruschack, 2012)

Of 33% who reported sexual favors for police, 86.2% of these were in exchange for not being arrested.

29.1%

36.1%

32.6%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

1 2 3

Percentage of Female Sex Workers Injecting Drugs who were solicited for sexual favors

from police in the last 6 months, Tijuana and Ciudad Juárez, 2008 (N=515)

Beletsky et al, 2012

Of 48% who reported having syringes confiscated by police, 61% were in exchange for not being arrested.

38.2%

57.9%

48.2%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

1 2 3

Percentage of Female Sex Workers Injecting Drugs reporting that police confiscated their syringes in the last 6 months,

Tijuana and Ciudad Juárez, 2008 (N=515)

Beletsky et al, J Urb Health 2013

Factors Independently associated With HIV Infection

among FSWs Injecting Drugs in Tijuana and Cd.

Juarez (n=600)

Adjusted Odds Ratio 95% Confidence

Interval

Often/Always

injected with a client

in past month

2.9 1.33-6.36

Police took needle in

exchange for not

arresting

2.85 1.3-2.61

Syphilis Titers ≥ 1.8 5.82 2.55-13.29

Strathdee et al, PLoS ONE 2011

Mujer Mas Segura: Intervention to reduce HIV/STI among

FSW-IDU: Syringe Contamination Video

Conceived of and featuring women from the sex worker

Community*

*all women gave written permission for full use of video and photos

Mujer Mas Segura: Findings

• Injection risk intervention associated with significantly lower risk behaviors, especially in Cd. Juarez, where there was sub-optimal syringe access

• Women receiving the active format of the sexual risk intervention had significant reductions in STI incidence

• Female sex workers who inject drugs can change their risk behaviors if given the opportunity and resources

Strathdee et al, PLoS ONE, 2013

o Target early interventions towards vulnerable

girls to create socioeconomic opportunity, limit

drug use, and abusive relationships

o Address criminalization of drug use and sex

work and human rights violations

oDevelop integrated interventions for pregnant

women and babies that addresses drug use,

HCV and HIV

o Address the intersections of HIV-related risk

created by poverty and gender inequality

o Ban advertisements that promote addiction

Potential intervention targets for HIV prevention among

high risk women who inject drugs

Strathdee, Wechsberg, Kerrigan and Patterson, 2013

Acknowledgements

• Co-investigators and participants

• NIH grants R01DA023877 and R37 DA019829

• Drs. J. Havens, N. el-Bassel , N. Volkow, K.

Page, C. Hankins