Intimate relationships can contribute to both vulnerability and resiliency to hepatitis C and HIV for women who inject drugs. This article explores these ideas and provides some suggestions to help front-line workers support women who inject drugs.

Note: This article focuses on cisgender (non-trans) women in heterosexual relationships because the body of research this article is based on is about cisgender women who are in relationships with cisgender men. However, many of the discussion points may apply to trans women who are in relationships with cisgender men.

Canadian evidence for vulnerability to hepatitis C and HIV among women who inject drugs

Hepatitis C and HIV are prevalent among women who inject drugs in Canada. According to the latest data from I-track,¹ a Canadian study of people who inject drugs:

• 68.1% of women who inject drugs have a past or current hepatitis C infection
• 10.4% of women who inject drugs have HIV
• 9.5% of women who inject drugs have both HIV and a past or current hepatitis C infection

Women in I-Track were more likely than men to report their regular sex partner was the person with whom they had most commonly injected drugs in the past six months (44% versus 25%).

Women in the same study were also more likely than men to have injected with a used needle and/or syringe in the past month (20% versus 14%).

How is vulnerability to hepatitis C and HIV created in intimate relationships?

Intimate relationships and people who inject drugs

People who inject drugs are sometimes stereotyped as people who cannot form loving and intimate relationships.² However, many people who inject drugs view their intimate partnerships as places where they feel safe and accepted and experience stability.^2,3,4 Some of these relationships, like all types of intimate relationships, may be abusive, but abuse is not a fundamental dynamic of intimate relationships between people who inject drugs.

Building intimacy and trust in the context of drug use

Intimate heterosexual relationships, where both partners inject drugs, can result in vulnerability for women to hepatitis C and HIV, but such relationships can also build resiliency where partners experience caring, trust and mutual support.²

Within the context of intimate relationships, using drugs together can have important emotional meanings. For example, sharing needles and other injection equipment within the relationship can create intimacy, emotional connections, trust and commitment.⁵ Many couples have rituals about who plays what role in acquiring, preparing and using drugs. These rituals can be one way for a couple to build and sustain their relationship.²

For some women who don’t inject drugs but have a partner who does inject, the desire for closeness can lead to a shift to injection drug use with her partner.² While this can lead to a feeling of greater closeness it may also lead to needle sharing and a decreased concern about health risks such as HIV.⁵

Not wanting to share drugs and injection equipment can have a negative impact on building intimacy. For example, a refusal to share injection equipment can be seen as an act of betrayal and an indication of a lack of trust.²

As in many heterosexual relationships,⁶ condom use is generally low in intimate relationships between men and women who inject drugs.⁵ Heterosexual couples who inject drugs often choose not to use condoms because of feelings of love, trust and commitment with each other. If there are assumptions about monogamy in a relationship and one or both partners is having other sexual relationships this can make partners more vulnerable to HIV and other STIs.⁵

Injecting together to protect each other from harm

There are several different ways that couples who inject together may try to help each other to lessen some of the harms associated with using injection drugs. Some couples may choose to inject only with each other as a strategy to avoid the risks associated with injecting with other people who commonly share injection drug use equipment.²

As well, some women who don’t know how to inject themselves may feel safer having their partner inject them rather than another person to ensure they have a less damaging injection.⁵

While some of these strategies may offer a measure of protection, they may also increase risk in some circumstances. For example, if one partner has HIV or hepatitis C and doesn’t know it, then there is a risk they may pass the infection(s) to their partner.

Control over drug use and condom use

Partner abuse is defined as when a partner in an intimate relationship uses a pattern of psychological, physical and/or sexual coercion to have power and control over their partner.⁷ In intimate heterosexual relationships where both partners inject drugs, one-way relationships can become abusive if access to drugs and injection equipment is controlled by the male partner.⁵ In these relationships, a woman may have limited control over getting, preparing and injecting drugs, and how the sharing of equipment or drugs happens.⁵ Women are also less likely to use harm-reduction services than men.⁸ This makes women less likely to have direct access to new drug use equipment and harm-reduction support that might enable them to be more independent in their drug use.

For many women, their first time injecting drugs is with an intimate partner who injects them.⁵ If a woman does not learn how to inject herself, she will be dependent on other people to inject her. Women in this situation run the risk of being injected with a needle that has already been used (also known as being “second on the needle”),⁵ creating the potential for hepatitis C and HIV transmission. When a woman is experiencing symptoms of withdrawal and also needs someone to help her inject, this may make it challenging to request the use of new injection equipment.

There are other forms of control and abuse that can happen within intimate heterosexual relationships where people inject drugs. Examples include a male partner preparing a smaller amount of the drug for his partner than for himself, not giving her drugs so she experiences withdrawal, and trying to get his partner to be more dependent on the drug so he has more control. ⁹

Relationships may not necessarily start out as abusive but may become more abusive over time. For example, some women report that their relationship with their partner shifted from a traditional partnership to one where their partner controlled many aspects of their life. This included limiting access to condoms for sex work, and to drugs and injection equipment. As a result, the women’s ability to control safer sex and injection practices was restricted.¹⁰

Violence

Violence or the threat of violence is a significant contributor to HIV and hepatitis C vulnerability among women who inject drugs.^11,12 This violence is often exacerbated for women who are living on or close to the street or who experience other forms of discrimination, such as women who are Indigenous, transgender, racialized, disabled and/or work in the sex trade.^10,13

For women who experience poverty and homelessness, this violence can be so frequent that it becomes normalized,¹⁴ sometimes to the point where it is no longer perceived as violence.⁹ In some places, the street culture creates and perpetuates violence by devaluing women and limiting the roles they can take to gain respect and resources.¹³ This violence can include robbery, physical abuse, rape, threat of child removal by child protective services or arrest. Surviving these threats competes with and can take precedence over HIV and hepatitis C prevention.¹³

The prevalence of intimate partner violence (IPV) is three- to five-times higher for women who use or inject drugs compared to women who don’t use drugs.⁵ There are some theories for why IPV is higher for women who use drugs. Certain drugs like crack, cocaine, amphetamines and benzodiazepines are linked to an increase in violence and aggressive behaviour, although there is debate about whether drug use causes violence or if drug use and violence are linked together by other factors.¹⁵ Another theory is that using drugs in a society in which they are criminalized creates a climate of stress that facilitates violence where people who use drugs experience desperation about acquiring drugs, fear of arrest, and a lack of legal ways to resolve drug-related disputes.^9,15 Another perspective is that women who use particular drugs, such as crack, are perceived to have a low social status, which may mean some partners feel more entitled to abuse.¹⁶

In abusive intimate relationships, women who inject drugs may be threatened with violence if they don’t share needles or have condomless sex. Having previous experience with IPV may also make it challenging to request condom use or to refuse to share injection drug use equipment for fear of being exposed to more violence.⁵

Among women who use drugs there is a high prevalence of mental health issues, in particular post-traumatic stress disorder (PTSD), which is often connected to experiences of physical or sexual abuse. Some women may use drugs to cope with the difficult symptoms of PTSD.¹⁷ Many women who use drugs may face violence from multiple sources, which impacts their health and wellness and ability to engage in safer drug use and sex.

What can service providers who work with women who inject drugs do?

People working with women who inject drugs play an important role in supporting women to learn about effective harm-reduction strategies, such as the use of new injection equipment, condoms and pre-exposure prophylaxis (PrEP). Service providers can also support women who inject drugs to get tested for HIV and hepatitis C, and/or linked to care and treatment if they are living with HIV and/or hepatitis C.

Service providers can also offer HIV and hepatitis C prevention counselling or link women to additional services to support them to address vulnerability to HIV and hepatitis C, and any underlying issues linked to substance use, such as trauma, past experiences of abuse, mental health issues, child custody loss or alcohol use. They can help support access to or link women to services and resources that will enhance women’s overall health, such as income supports, housing, and access to food and health services.

Improve access to harm-reduction services for women

There are many things programs can do to make their services more accessible to all women who use drugs, such as:

• Offering women-only (trans inclusive) hours at programs that serve women who inject drugs
• Developing a screening protocol for IPV for your organization
• Being open at times that work for women, for example women who do sex work may need access at night
• Hiring cis and trans women¹⁸
• Providing mobile harm-reduction services that can meet street-involved women where they are at¹⁸
• Providing on-site child care for women who need to access services¹⁸
• Recognizing that mothers who use drugs may avoid services for fear of child protective services (CPS) being called, and becoming informed about when CPS is required to be called if a mother is using drugs
• Develop policies in collaboration with mothers who use drugs about how women will be interacted with before, during and after CPS is called
• Creating opportunities for women who use drugs to come together to share experiences and advocate for change
• Offering regular hepatitis C and HIV testing to women and to couples who use drugs together
• Partnering with shelters and IPV and sexual violence services to support women who are experiencing violence¹⁶
• Developing partnerships with other programs and services to connect women who inject drugs to services such as sexual and reproductive health, employment, housing income supports, and needle and syringe programs¹⁶
• Offering anti-racist, culturally competent and non-stigmatizing services that are respectful of all women, including Indigenous women, racialized women, and women with children
• Creating safe spaces for sex workers and offering condoms and keeping bad date sheets¹⁸
• Supporting access to opiate-substitution therapy and pre-exposure prophylaxis (PrEP) for women that want it¹⁹
• Offering couples HIV and hepatitis C testing and counselling together 

To learn more about couples HIV testing and counselling see:

Couples HIV Testing and Counselling

Views from the front lines: Couples testing and counselling

Acknowledgments: Special thanks to Sheryl Jarvis and Kate Kenny for providing invaluable insights on a draft of this article.

References

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