People who inject drugs (PWIDs) in India are at high risk for HIV infection and transmission, with women being at elevated risk. Research is needed to examine gender differences in factors contributing to HIV risk. Using a socio-ecological framework, this study identified factors at individual, relationship, and community/institutional levels that were differentially or similarly associated with HIV risk behaviors in men and women PWIDs.
6453 PWIDs (5677 men and 797 women) from 7 cities in North-east India were recruited using a respondent-driven sampling. Participants completed a survey and point-of-care HIV testing. We used multi-level logistic regression models to assess factors associated with 2 injection-related (daily use and sharing needles/syringes) and 3 sex-related (multiple partners, exchange sex and unprotected sex) HIV risk behaviors separately in men and women.
Women (52.8%) were more likely to be HIV positive than men (18.4%). Women were significantly more likely to report multiple recent sex partners, whereas men were significantly more likely to report recent exchange sex. Among women, factors associated with HIV risks included: younger age (aOR=0.76 per 5 years older, CI=0.61-0.93), earlier initiation of injection drug use (aOR=0.70 per 5 years older, CI=0.57-0.87), low education (aOR=2.05, CI=1.09-3.84), marital status (aOR=1.87, CI=1.13-3.09), and frequent financial stress (aOR=2.32, CI=1.46-3.69). In contrast, for men, factors associated with HIV risks were older age (aOR=1.22 per 5 years older, CI=1.03-1.45), later initiation of injection drug use (aOR=1.24 per 5 years older, CI=1.10-1.38), and higher levels of internalized stigma (aOR=1.42, CI=1.09-1.84) and enacted stigma (aOR=2.56, CI=1.77-3.69).
The findings highlight the need for gender-specific contextually-integrated HIV prevention and intervention efforts among PWIDs. For example, programs that include economic empowerment, and build skills in addressing gender power dynamics in safe sex negotiation may be effective in preventing HIV among women. Stigma free services and programs that include coping skills training and mental health counseling to address the negative attitudes and behaviors resulting from stigma, may reduce HIV risk, particularly among men.