AIDS Care, 2015 Vol. 27, No. 3, 301–306, http://dx.doi.org/10.1080/09540121.2014.985182
HIV-related characteristics among female partners of injecting drug users in Kelantan, Malaysia: a descriptive study Aishah Mohd Nasarruddina*, Wan Mohd Zahiruddin Wan Mohammadb, Nik Hazlina Nik Hussaina, Siti Hawa Alia and Hazura Mat Zubirc a
Women’s Health Development Unit, Universiti Sains Malaysia, Kubang Kerian, Malaysia; bDepartment of Community Medicine, Universiti Sains Malaysia, Kubang Kerian, Malaysia; cHIV/STI Unit, Kelantan State Health Department, Kota Bharu, Malaysia (Received 7 May 2014; accepted 4 November 2014) Kelantan, a northeastern state in Peninsular Malaysia, is one of the states that has been acutely hit by injecting drug user (IDU)-driven HIV epidemic, in addition to having a high number of infected women in Malaysia. This cross-sectional study describes the socio-demographic characteristics, HIV risk factors, risk perception, and adoption of preventive behaviors among female partners of IDUs in Kelantan. Out of 101 women, the majority of them are from low socioeconomic background and have no other risk factors besides heterosexual HIV transmission from their male IDU partners. Although 45.5% have not been tested for HIV and more than half (53.5%) of them did not use condoms during sexual intercourse, only 44.6% of the women perceived themselves to be at risk of being infected with HIV. Most of the women (86.1%) were willing to undergo voluntary counseling and testing (VCT). Female partners of IDUs continue to be vulnerable to HIV due to having sexual contact with IDUs, and also due to their socioeconomic position in the community. To prevent HIV transmission among female partners of IDUs, consolidating HIV prevention efforts from multiple approaches is needed. Keywords: HIV; characteristics; women; partners; injecting drug users; Kelantan
In the early stages of the pandemic, HIV was thought to primarily affect men, as the disease was predominantly found among men in many countries around the world. However, as years passed, women have emerged as another group being hit by this disease due to the complexities of biological and sociocultural factors. Women from different subgroups are exposed to different forms of HIV risks and increasingly being infected with HIV. At the end of 2010, around 50% of people living with HIV globally were women (UNAIDS, 2011). Malaysia, like other countries, has not escaped the globalization of feminization of HIV, as the percentage of women being infected is on the rise. Malaysia is a country with a concentrated epidemic, where HIV prevalence is less than 1% in the general population but consistently higher than 5% among key populations at risk of HIV, such as IDUs. Although men continue to be the majority of cumulative HIV cases in Malaysia, the female to male infection ratio has increased drastically from 1:99 in 1990 to 1:4 in 2011.While the cases of HIV in many states in Malaysia have been predominantly sexually driven, the states in eastern regions such as Kelantan, Terengganu, and Pahang are still IDUdriven, with HIV prevalence among IDUs in Malaysia reported to be 22.1% (Suleiman, 2012). In Kelantan, although new cases of HIV infection are generally decreasing in trend, it remains among the states which *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
report the highest notification rate (Zubir, 2012). In 2007, Kelantan recorded the highest number of infected housewives in Malaysia and the highest cumulative number of women infected with HIV compared to other states (UNICEF and Ministry of Health Malaysia, 2008), which, over time, continued to fluctuate. The overlapping high-risk behavior involving injecting drug use and sex work, as well as the intertwined sexual relationships between populations at risk, has resulted in more people becoming vulnerable to HIV infection through heterosexual transmission. This is especially true for female partners of IDUs, who are more likely to have a higher risk of contracting HIV compared to women in the general population, due to exposure from their drug-abusing partners. However, little is known regarding female partners of IDUs in Kelantan despite their vulnerability, as HIV preventions such as methadone maintenance therapy (MMT) and needle syringe exchange program (NSEP) are primarily targeted at drug users themselves as opposed to their partners. Unlike other at-risk women such as female sex workers and injecting female drug users, there is no specific intervention program that directly targets female partners of IDUs. In 2011, 57% of as many as 19,804 people tested in the anonymous voluntary counseling and testing (VCT) program were males. VCT has been incorporated into
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prevention of mother-to-child transmission (PMTCT) programs to increase HIV testing uptake by females, where mothers are offered HIV routine screening with an opt-out approach and also intra-partum HIV screening to cover the missed-opportunity mothers (Suleiman, 2012). Nevertheless, there is no refined data regarding HIV testing specific to female partners of IDUs. Furthermore, research showed moderate evidence of VCT effectiveness in risk reduction in developing countries. It was shown that VCT recipients were significantly less likely to practice unprotected sex compared to before having undergone VCT or among people who did not undergo VCT, but it had no significant effect on number of partners (Denison, O’Reilly, Schmid, Kennedy, & Sweat, 2008). However, the findings did not negate the necessity of VCT access expansion, although VCT uptake globally is poor, as it was estimated that 50% of people living with HIV do not know their status (UNAIDS, 2012). Since there is limited information about the female partners of IDUs in Kelantan, it is necessary to be acquainted with the condition of this group of the population, as this is undoubtedly the first step toward curtailing the spread of HIV among vulnerable women in Kelantan. This paper describes the association between HIV-related characteristics such as socio-demographics, perceived HIV risk, HIV risk factors, and adoption of preventive behaviors with the willingness toward VCT for HIV. Based on the findings, we propose recommendations for prevention measures relevant to this group of women, and also suggest research gaps that need to be further explored in order to understand more about the impact of HIV on female partners of IDUs in Kelantan.
Method This cross-sectional survey was conducted between March and July 2012, involving female partners of IDUs residing in four districts within Kelantan. These districts are: Kota Bharu, Pasir Mas, Jeli and Gua Musang. Participants of this study were part of a larger research project involving women and girls of high and low susceptibility toward HIV in Kelantan. To obtain the study population, first, male IDUs were selected by facility-based sampling from NSEP clinics. The study was described to them and they were asked to invite their primary female partners to be participants of the study. Once they agreed, verbal consent was obtained to approach and interview their female partners. Participants had to be at least 18 years of age and were not diagnosed to have HIV; either they had not been tested or they had received negative test results. They were informed about the confidentiality of the data and written consent was obtained prior the interview.
This was done with the help of Persatuan Perantaraan Pesakit-Pesakit Kelantan (SAHABAT), a nongovernmental organization (NGO) in Kelantan affiliated with the Malaysian AIDS Council, which serves the underserved communities of drug users and people living with HIV (PLHIV). A questionnaire adapted and modified from previous studies was utilized; it was then translated into the Malay language and validated. The Cronbach’s alpha generated was 0.7. Face-to-face interview was used as it has higher response rate and is more appropriate for sensitive issues compared to other methods. These elements are important because partners of IDUs are hard-to-reach populations due to involvement in stigmatized HIV risk. SPSS version 20 was used for data management and analysis. Exploration of data was conducted to obtain descriptive statistics for all variables. Frequency and percentage were used to describe categorical variables, while mean and standard deviation were obtained for numerical variables. This study was approved by the Research and Ethics Committee of Universiti Sains Malaysia (USMKK/PPP/ JEPeM [243.3.(14)]/Amend.(01)).
Results A total of 101 female partners of IDUs with the mean age of 34 years were interviewed. All of them were Muslims and 99% of them were Malays. The majority (71.3%) of them had received education up to secondary school, and 64.4% were unemployed or homemakers. More than half (59.4%) of the women’s income was below Kelantan’s poverty level (see Table 1). In terms of risk factors, 85.1% (86) of the women admitted to be monogamous to their IDU partners. Only 3% (3) of them have more than one partner, while the remaining 11.9% (12) avoided answering this question. Regarding drug-related behavior, 11.9% (12) had history of illicit drug use but only 1% (1) had actually injected drugs. Three percent of them (3) had history of remuneration for sex and only 1% (1) admitted to have a sexually transmitted infection (STI). As far as intimate partner violence is concerned, 10.9% (11) of the women had history of forced sex (see Table 2). Although the majority of them 90.1% (91) agreed that HIV poses a risk to the community, despite being partners of IDUs, less than half of the women 44.6% (45) actually perceived themselves to be at risk of HIV. Adoption of HIV preventive measures was unsatisfactory. A significant proportion of the women 45.5% (46) have not been tested for HIV and more than half of them 53.5% (54) did not use condoms during sexual intercourse (see Table 3). The majority 86.1% (79) of the women were willing to undergo VCT.
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Table 1. Socio-demographic characteristics of female partners of IDUs (n = 101).
Table 3. HIV risk perception and adoption of preventive behavior among partners of IDUs (n = 101).
Characteristics
Characteristics
n (%)
Age 18–29 years old 30–39 years old 40–49 years old >50 years old Education level Primary school Secondary school Tertiary education Marital status Married Unmarried Employment status Employed Unemployed Income level (RM)
HIV-related characteristics among female partners of injecting drug users in Kelantan, Malaysia: a descriptive study Aishah Mohd Nasarruddina*, Wan Mohd Zahiruddin Wan Mohammadb, Nik Hazlina Nik Hussaina, Siti Hawa Alia and Hazura Mat Zubirc a
Women’s Health Development Unit, Universiti Sains Malaysia, Kubang Kerian, Malaysia; bDepartment of Community Medicine, Universiti Sains Malaysia, Kubang Kerian, Malaysia; cHIV/STI Unit, Kelantan State Health Department, Kota Bharu, Malaysia (Received 7 May 2014; accepted 4 November 2014) Kelantan, a northeastern state in Peninsular Malaysia, is one of the states that has been acutely hit by injecting drug user (IDU)-driven HIV epidemic, in addition to having a high number of infected women in Malaysia. This cross-sectional study describes the socio-demographic characteristics, HIV risk factors, risk perception, and adoption of preventive behaviors among female partners of IDUs in Kelantan. Out of 101 women, the majority of them are from low socioeconomic background and have no other risk factors besides heterosexual HIV transmission from their male IDU partners. Although 45.5% have not been tested for HIV and more than half (53.5%) of them did not use condoms during sexual intercourse, only 44.6% of the women perceived themselves to be at risk of being infected with HIV. Most of the women (86.1%) were willing to undergo voluntary counseling and testing (VCT). Female partners of IDUs continue to be vulnerable to HIV due to having sexual contact with IDUs, and also due to their socioeconomic position in the community. To prevent HIV transmission among female partners of IDUs, consolidating HIV prevention efforts from multiple approaches is needed. Keywords: HIV; characteristics; women; partners; injecting drug users; Kelantan
In the early stages of the pandemic, HIV was thought to primarily affect men, as the disease was predominantly found among men in many countries around the world. However, as years passed, women have emerged as another group being hit by this disease due to the complexities of biological and sociocultural factors. Women from different subgroups are exposed to different forms of HIV risks and increasingly being infected with HIV. At the end of 2010, around 50% of people living with HIV globally were women (UNAIDS, 2011). Malaysia, like other countries, has not escaped the globalization of feminization of HIV, as the percentage of women being infected is on the rise. Malaysia is a country with a concentrated epidemic, where HIV prevalence is less than 1% in the general population but consistently higher than 5% among key populations at risk of HIV, such as IDUs. Although men continue to be the majority of cumulative HIV cases in Malaysia, the female to male infection ratio has increased drastically from 1:99 in 1990 to 1:4 in 2011.While the cases of HIV in many states in Malaysia have been predominantly sexually driven, the states in eastern regions such as Kelantan, Terengganu, and Pahang are still IDUdriven, with HIV prevalence among IDUs in Malaysia reported to be 22.1% (Suleiman, 2012). In Kelantan, although new cases of HIV infection are generally decreasing in trend, it remains among the states which *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
report the highest notification rate (Zubir, 2012). In 2007, Kelantan recorded the highest number of infected housewives in Malaysia and the highest cumulative number of women infected with HIV compared to other states (UNICEF and Ministry of Health Malaysia, 2008), which, over time, continued to fluctuate. The overlapping high-risk behavior involving injecting drug use and sex work, as well as the intertwined sexual relationships between populations at risk, has resulted in more people becoming vulnerable to HIV infection through heterosexual transmission. This is especially true for female partners of IDUs, who are more likely to have a higher risk of contracting HIV compared to women in the general population, due to exposure from their drug-abusing partners. However, little is known regarding female partners of IDUs in Kelantan despite their vulnerability, as HIV preventions such as methadone maintenance therapy (MMT) and needle syringe exchange program (NSEP) are primarily targeted at drug users themselves as opposed to their partners. Unlike other at-risk women such as female sex workers and injecting female drug users, there is no specific intervention program that directly targets female partners of IDUs. In 2011, 57% of as many as 19,804 people tested in the anonymous voluntary counseling and testing (VCT) program were males. VCT has been incorporated into
302
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prevention of mother-to-child transmission (PMTCT) programs to increase HIV testing uptake by females, where mothers are offered HIV routine screening with an opt-out approach and also intra-partum HIV screening to cover the missed-opportunity mothers (Suleiman, 2012). Nevertheless, there is no refined data regarding HIV testing specific to female partners of IDUs. Furthermore, research showed moderate evidence of VCT effectiveness in risk reduction in developing countries. It was shown that VCT recipients were significantly less likely to practice unprotected sex compared to before having undergone VCT or among people who did not undergo VCT, but it had no significant effect on number of partners (Denison, O’Reilly, Schmid, Kennedy, & Sweat, 2008). However, the findings did not negate the necessity of VCT access expansion, although VCT uptake globally is poor, as it was estimated that 50% of people living with HIV do not know their status (UNAIDS, 2012). Since there is limited information about the female partners of IDUs in Kelantan, it is necessary to be acquainted with the condition of this group of the population, as this is undoubtedly the first step toward curtailing the spread of HIV among vulnerable women in Kelantan. This paper describes the association between HIV-related characteristics such as socio-demographics, perceived HIV risk, HIV risk factors, and adoption of preventive behaviors with the willingness toward VCT for HIV. Based on the findings, we propose recommendations for prevention measures relevant to this group of women, and also suggest research gaps that need to be further explored in order to understand more about the impact of HIV on female partners of IDUs in Kelantan.
Method This cross-sectional survey was conducted between March and July 2012, involving female partners of IDUs residing in four districts within Kelantan. These districts are: Kota Bharu, Pasir Mas, Jeli and Gua Musang. Participants of this study were part of a larger research project involving women and girls of high and low susceptibility toward HIV in Kelantan. To obtain the study population, first, male IDUs were selected by facility-based sampling from NSEP clinics. The study was described to them and they were asked to invite their primary female partners to be participants of the study. Once they agreed, verbal consent was obtained to approach and interview their female partners. Participants had to be at least 18 years of age and were not diagnosed to have HIV; either they had not been tested or they had received negative test results. They were informed about the confidentiality of the data and written consent was obtained prior the interview.
This was done with the help of Persatuan Perantaraan Pesakit-Pesakit Kelantan (SAHABAT), a nongovernmental organization (NGO) in Kelantan affiliated with the Malaysian AIDS Council, which serves the underserved communities of drug users and people living with HIV (PLHIV). A questionnaire adapted and modified from previous studies was utilized; it was then translated into the Malay language and validated. The Cronbach’s alpha generated was 0.7. Face-to-face interview was used as it has higher response rate and is more appropriate for sensitive issues compared to other methods. These elements are important because partners of IDUs are hard-to-reach populations due to involvement in stigmatized HIV risk. SPSS version 20 was used for data management and analysis. Exploration of data was conducted to obtain descriptive statistics for all variables. Frequency and percentage were used to describe categorical variables, while mean and standard deviation were obtained for numerical variables. This study was approved by the Research and Ethics Committee of Universiti Sains Malaysia (USMKK/PPP/ JEPeM [243.3.(14)]/Amend.(01)).
Results A total of 101 female partners of IDUs with the mean age of 34 years were interviewed. All of them were Muslims and 99% of them were Malays. The majority (71.3%) of them had received education up to secondary school, and 64.4% were unemployed or homemakers. More than half (59.4%) of the women’s income was below Kelantan’s poverty level (see Table 1). In terms of risk factors, 85.1% (86) of the women admitted to be monogamous to their IDU partners. Only 3% (3) of them have more than one partner, while the remaining 11.9% (12) avoided answering this question. Regarding drug-related behavior, 11.9% (12) had history of illicit drug use but only 1% (1) had actually injected drugs. Three percent of them (3) had history of remuneration for sex and only 1% (1) admitted to have a sexually transmitted infection (STI). As far as intimate partner violence is concerned, 10.9% (11) of the women had history of forced sex (see Table 2). Although the majority of them 90.1% (91) agreed that HIV poses a risk to the community, despite being partners of IDUs, less than half of the women 44.6% (45) actually perceived themselves to be at risk of HIV. Adoption of HIV preventive measures was unsatisfactory. A significant proportion of the women 45.5% (46) have not been tested for HIV and more than half of them 53.5% (54) did not use condoms during sexual intercourse (see Table 3). The majority 86.1% (79) of the women were willing to undergo VCT.
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Table 1. Socio-demographic characteristics of female partners of IDUs (n = 101).
Table 3. HIV risk perception and adoption of preventive behavior among partners of IDUs (n = 101).
Characteristics
Characteristics
n (%)
Age 18–29 years old 30–39 years old 40–49 years old >50 years old Education level Primary school Secondary school Tertiary education Marital status Married Unmarried Employment status Employed Unemployed Income level (RM)
