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One Stop Integrated Model for Women Who Use Drugs in Punjab An Implementation Document

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Abstract and Figures

Substance use and substance use disorder (SUD) has traditionally been seen from the lens of men; women have often been excluded from the discourse on substance use disorder. Most treatment services for substance use disorder in India allow access to all genders. There are no gender-segregated services for most of the different aspects of treatment services for SUD. The report documents one such effort made in Kapurthala, Punjab, India, wherein a one-stop integrated service model for women who use drugs was established. The report draws on the lessons from the implementation and provides recommendations for establishing women-specific services for management of substance use disorder in women.
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One Stop Integrated Model for
Women Who Use Drugs
in Punjab
An Implementation Document
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One Stop Integrated Model for
Women Who Use Drugs
in Punjab
An Implementation Document
Year of Publication: 2020
Principal Author: Dr Ravindra Rao, Additional Professor, National Drug Dependence Treatment
Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Alliance India Team
1. Kunal Kishore, Associate Director (Drug Use and Harm Reduction)
2. Ira Madan, Senior Regional Advocacy Officer (Drug Use and Harm Reduction)
3. Charanjit Sharma, Programme Manager (Drug Use and Harm Reduction)
Kapurthala Project Team
1. Dr Sandeep Bhola, Project Coordinator and Consultant Psychistrist, Civil Hospital, Kapurthala
2. Sarabjit Kaur, Project Manager
3. Gagandeep Kaur, Counsellor
4. Manjit Kaur, Outreach Worker
5. Indu Bala, Outreach Worker
6. Veena Rani, Punjab State Drug Use Forum Coordinator
7. Baksho, Peer Counsellor
8. Kashmir Kaur, Peer Counsellor
Copy editing: Anurag Paul, Alliance India
© Alliance India
6 Community Centre, Zamrudpur, Kailash Colony Extension, New Delhi - 110048
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TABLE OF CONTENTS
SL NO. TOPIC PAGE NUMBER
1 PREFACE 5
2 FOREWORD 6
3 LIST OF ABBREVIATIONS 7
4 BACKGROUND 8
5 OBJECTIVES OF THE REPORT AND 12
METHODOLOGY
6 EXISTING SITUATION AND APPROACH 13
IN PUNJAB
7 IMPLEMENTATION OF ONE STOP 18
INTEGRATED MODEL FOR WOMEN
WHO USE DRUGS
8 PROGRAMME MONITORING REPORT ANALYSIS 29
9 PUNJAB STATE DRUG USERS FORUM 31
10 REFLECTIONS AND LESSONS LEARNT 33
11 CONCLUSIONS 35
12 REFERENCES 36
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This document is a product of Global Fund Regional Harm Reduction Advocacy in Asia project (2017-
2020) that involves 7 countries in Asia (India, Vietnam, Indonesia, Cambodia, Thailand, Nepal, and the
Philippines). The project aims to maximize the impact of investments that help break the cycle of
transmission among people who inject drugs in concentrated epidemics by addressing legal, policy and
health system barriers that hinder necessary outreach and coverage of essential services. Strategic
engagement of the key stakeholders from relevant government ministries, UN agencies, civil society
organisations and community networks working on harm reduction for People Who Use Drugs (PWID) is
critical to achieving increased access to HIV and Harm reduction services.
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In March 2020, the Global Fund launched a technical guide titled “Harm reduction for people who use drugs”. It
reinforced the Global Fund's commitment to rights-based and gender-responsive approaches to the delivery of
health services, including harm reduction services as well as HIV and TB services for people who use drugs. The
technical brief describes how interventions for people who use drugs – including women and young people - are to
be incorporated into funding requests to the Global Fund.
As an important source of international financing to low- and middle-income countries for harm reduction
interventions, the Global Fund supports evidence-based interventions aimed at ensuring access to HIV
prevention, treatment, care, and support services for all key populations, including people who use drugs. The
starting point for this is to have appropriate data to inform services. The Global Fund encourages applicants to
have gender-disaggregated epidemiological data for HIV, HCV, and TB, and again gender-disaggregated
coverage data to better understand who is able to access services across the cascade of care. Having gender
disaggregated data, and thus understanding gender related barriers to accessing services is critical since in many
countries women who use drugs have disproportionately poor access to HIV prevention, treatment, and care
services, as well as TB-related services. HIV infection rates among women who inject drugs are often higher than
among their male counterparts. In addition, sexual partners of men who inject drugs also can be very vulnerable to
HIV. These women require harm reduction services that are tailored to their needs.
In 2017, people who inject drugs accounted for 9% of new HIV infections globally. Services for people who inject
drugs must therefore be prioritized immediately to ensure that 2030 targets to end AIDS might be attained possibly.
Also critical: accessing vulnerable women who remain beyond the reach of critical harm reduction services.
Women who use drugs are doubly stigmatized and discriminated against because of their drug use and
because of their gender. They are more exposed to gender-based violence and human rights violations that put
them at risk of HIV and other infections. Worldwide, few harm reduction programmes tailor their services to meet
the needs of women, and gender-based discrimination may make women feel unwelcome. HIV services often
don't cater to the needs of women who use drugs.
Given the urgency to both develop and scale up a meaningful response for women who use drugs, the Global Fund
is very pleased to note that its partner, the India HIV/AIDS Alliance, has developed and started implementing a
one-of-a-kind model for HIV services for women who use drugs, a “One Stop Integrated Model”, financed by the
Global Fund's flagship “Harm Reduction Advocacy in Asia” grant (HRAsia). This was possible through the fostering
of a unique collaboration between technical partners, academic institutions, members of the community of women
who use drugs and the Government of Punjab. I am very encouraged to hear of the successes of this model for
female drug users and expressions of appreciation by development partners and community beneficiaries. I am
delighted to hear that there is already a demand for the replication of the model of services for female drug users in
key countries through a partnership between public health and community actors. The evidence and tools of this
project will help shape future harm reduction and HIV prevention efforts for women who use drugs.
As the Global Fund's fund manager of the regional harm reduction grant funding advocacy for harm reduction
services through Asia, I encourage all potential service providers for HIV services for female drug users to use this
Implementation Document to advance our common endeavours in making services available to women who use
drugs while fully ensuring that their health and service needs are met without any prejudice or violation of their
human rights and dignity.
Nicole Delaney
Senior Fund Portfolio Manager
South and East Asia Team
The Global Fund to Fight AIDS, Tuberculosis and Malaria
PREFACE
FOREWORD
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It gives me immense pleasure to introduce this Implementation Document on our “One Stop Integrated Model for
Women Who Use Drugs” as our organization completes two years of implementing this unique demonstration
project at the Punjab's Kapurthala based civil hospital. It's almost like a dream come true for all of us at the India
HIV/AIDS Alliance as much as for the 235 beneficiaries from amongst the community of women who use drugs
now accessing women-friendly integrated services under one roof – all due to the unique partnership between the
community, public health and related departments including prisons, police etc. that we were able to foster. These
successes are transcending boundaries thanks to the support and encouragement from international
development partners and donors like Global Fund and UNAIDS. Infact, this project has inspired other countries in
Asia to replicate this model facilitated by India HIV/AIDS Alliance through knowledge sharing, capacity building
and study tours to and from the facility in Kapurthala to key Asian countries and regional forums like ASEAN and
SAARC.
The “One Stop Integrated Model for Women Who Use Drugs” is one of its kind that focusses on developing a
comprehensive health and human rights based model recommended by WHO. What started with just one client in
February 2019 is now a strong programme servicing 235 women with clinical and psychosocial interventions every
day. At India HIV/AIDS Alliance we have always kept the most marginalized and stigmatized communities at the
heart of all our endeavors. In doing so; we ensure that we do not leave behind the communities at large but even
more the less known and less talked about communities i.e., women who use drugs and specially those who inject.
This approach towards reaching the most unreached shaped our strategy for the “One Stop Integrated Model for
Women Who Use Drugs”. Over the last two years; we have learnt that women who use drugs, are doubly
stigmatized and discriminated against both because of their drug use and their gender.
They are also more exposed to gender-based violence and human rights violations which puts them at risk of HIV
and other infections. Infact, worldwide and in Asia; few harm reduction programmes tailor their services to meet the
needs of women. Further, gender-based discrimination may make them unwelcome and unaccepted. HIV related
services also often don't cater to the needs of women who use drugs inspite of the advancements of the HIV
service coverage.
I am glad that with our “One Stop Integrated Model for Women Who Use Drugs” we now have answers to these
critical questions which builds on sound evidence, experience, operational tools and with community at its core.
Ashim Chowla
Chief Executive
Alliance India
LIST OF ABBREVIATIONS
ART Anti-Retroviral Treatment
DAC De-Addiction Centre
DTC Drug Treatment Clinic
FSW Female Sex Worker
GBV Gender-Based Violence
HIV Human Immunodeficiency Virus
ICTC Integrated Counselling and Testing Centres
IRCA Integrated Rehabilitation Centre for Addicts
MoHFW Ministry of Health and Family Welfare
MoSJE Ministry of Social Justice and Empowerment
NACO National AIDS Control Organisation
NGO Non-Governmental Organisation
NSEP Needle Syringe Exchange Programme
OOAT Out-patient Opioid Agonist Treatment
ORW Outreach Worker
OST Opioid Substitution Therapy
PE Peer Educator
PM Project Manager
PMTCT Prevention of Mother To Child Transmission
PWID People Who Inject Drugs
SDUF State Drug Users Forum
SRH Sexual and Reproductive Health
STI Sexually Transmitted Infections
SUD Substance Use Disorder
TI Targeted Intervention
WID Women who Inject Drugs
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BACKGROUND
Substance use and substance use disorder (SUD) has traditionally been seen from the lens of men;
women have often been excluded from the discourse on substance use disorder. This is true of most
aspects of substance use disorder from epidemiology to treatment-related services. However, there is
enough evidence to suggest that the issues with women using psychoactive substances are quite
different compared to men. It is imperative that women should be treated as a separate entity within the
broad rubric of substance use disorder.
Epidemiology of substance use in women
Epidemiological studies across the world show that substance use and subsequent dependence is far
more in men compared to women. However, recent surveys show that the gender gap has narrowed in
recent years[1]. For example, recent surveys for alcohol use disorders show the male to female ratio of
3:1 compared to the ratio of 5:1 in earlier surveys in the 1980s[1]. As per the latest National Household
Survey on Drug and Health conducted in the USA in 2019, 7.2 million women (5.6% of the population
aged 18 years and above) had a substance use disorder.
In India, the first national household survey on extent and pattern of substance use in India did not include
women respondents; hence, the national prevalence of women using various psychoactive substances
was not known[2]. On the other hand, the recently conducted national survey on the magnitude of
substance use in India, 2018, included all the genders as respondents[3]. The survey showed that the
prevalence of alcohol use and alcohol dependence was higher in men. Yet, about 1.6 per cent girls and
women (of age 10 – 75 years) reported use of alcohol at least once in the last one year, and one in sixteen
of alcohol using females (about six percent) suffering from alcohol dependence. The rates of cannabis
and opioid use among women aged 10 75 years is 0.6% and 0.2% respectively.
Substance use in women
Generally, women start drugs at a later age than men[4]. However, they progress on to develop
dependence more rapidly than men. This phenomenon is called as telescoping that describes an
accelerated progression from initiation of substance use to the onset of dependence and first admission
to treatment[1,5]. Some of the common reasons for initiating substance use in women include the
influence of friends, stress and tension, and the influence of spouse or partner[2]. Women using
substances often report having a male partner[4,6]. Mental health problems are also incriminated as a
risk factor for initiation of substance use in women. Studies have shown the association of traumatic life
events such as childhood abuse or sexual assault to be associated with later development of substance
use and SUD[7]. Similarly, those with major depression have higher rates of developing alcohol use
disorder[8]. Women using substances also report higher rates of mental health problems[1].
Women also incur significant complications due to their substance use. Some physical complications
tend to happen earlier in women compared to men. For example, women develop many alcohol-related
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medical problems at lower levels of alcohol consumption than men, probably reflecting women's lower
total body water, gender differences in alcohol metabolism, and effects of alcohol on postmenopausal
estrogen levels[9]. Some complications such as HIV or other sexually transmitted infections can also be
a result of some women resorting to sex work for earning money for drugs[5]. The risk of women resorting
to sex work for drugs is higher than that of men. Participation in sex work is also associated with syringe
sharing and inconsistent condom use[10]. Women also have poorer social support and face greater
stigma and discrimination due to their drug use compared to males who use drugs. Women who use
drugs also face physical and verbal abuse due to their drug use[10]. Women face greater intimate partner
violence during their drug use.
Treatment for women who use psychoactive substances
The pathway to women seeking treatment for substance use may differ compared to men. Research
indicates that the proportion of women represented in substance abuse treatment facilities is lower than
the population prevalence of these disorders in women relative to men[11]. Studies also show that
women are more likely to experience various barriers to seek treatment, including economic barriers,
time to seek treatment due to family obligations, presence of a male drug-using partner, etc[12]. Higher
rates of co-morbid mental health problems make it difficult for obtaining treatment for both disorders.
Similarly, trauma history in women may mean that they would find it less comfortable to attend mixed-
gender treatment programmes[13]. Similarly, women may face lack of social support to seek treatment
and may face greater stigma and discrimination[11].
The results of gender differences in treatment retention show no difference in studies with large
population samples, while studies with small population samples show inconsistent results. Among
women enrolled in treatment, programme type or certain pre-treatment characteristics such as referral
source, psychological functioning, personal stability, and the number of children, may be important
predictors of length of stay or treatment completion[11].
Treatment set-up and treatment approach for women who use drugs
Although providing exclusively female treatment programmes is still a novel approach, such
programmes have been positively endorsed by women. Women who participate in them feel that they are
better understood and can more easily relate to other female attendants. Some women report that they
feel unsafe or are harassed in mixed-gender programmes. In women-only programmes, clients report
that the availability of individual counselling, the absence of sexual harassment and the provision of
childcare services are important [4]. It is seen that while treatment outcomes in women only treatment
setting and mixed-gender treatment setting may not differ, women may feel safer in women-only
treatment settings. Opening a women-only setting would not be enough; various patient-centred
approaches, facilities for trauma or sexual abuse counselling, mental health services, etc. would have to
be provided in these settings for the services to become more meaningful for women.
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Harm reduction services and women
As discussed above, women face a higher risk of acquiring HIV and other blood-borne viruses compared
to men due to various factors including women being “second on the needle” (injecting after their male
partner), greater involvement in sex work to sustain their drug use, lesser access to health services, etc.
Harm reduction services are generally tailored primarily towards men[14]. As a result, women who use
drugs often find that these services often do not address their specific needs and are not sensitive to their
needs. The women may not find these predominantly male-centred programmes to be safe. Such harm
reduction programmes may not guarantee the confidentiality or provide sexual and reproductive health
(SRH) services, prevention of mother-to-child transmission (PMTCT) services, or childcare. The staff in
harm reduction programmes may not be trained to provide gender-specific services such as support for
women who inject drugs (WID) who are sex workers or who are victims of gender-based violence (GBV).
The practical guide document on gender-responsive HIV services for women who use drugs
recommends an integrated system that provides as many services as possible in one location[14].
Where this is not possible, strong referral linkages with external service providers should be built. Some
steps recommended include:
Establishing effective working linkages with providers of services such as those focusing on or
offering relevant support for sex workers, SRH, PMTCT, maternal and child health, GBV, legal
support and evidence-informed drug dependence treatment.
Integrating harm reduction services with family planning, maternal health care and within primary
care facilities.
Staff training to build capacity for WID-friendly service delivery along with other measures such as
assisted referral and low-threshold access processes.
Ensuring that local health care facilities, including ART providers and antenatal clinics, welcome all
women in need of treatment and care regardless of their drug use status.
Existing service structure for women who use drugs in India
Most treatment services for substance use disorder in India allow access to all genders. There are no
gender-segregated services for most of the different aspects of treatment services for SUD.
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The demand reduction efforts in India are led by the Ministry of Social Justice and Empowerment
(MoSJE), Government of India, and the Ministry of Health and Family Welfare (MoHFW), Government of
India[15]. MoSJE provides funds to the Non-Governmental Organisations to run Integrated
Rehabilitation Centres for Addicts (IRCA). The IRCAs provide mainly inpatient treatment ordinarily
lasting for about 30 days. More than 400 IRCAs are operating in different parts of the country. There is no
provision for treatment of women who use drugs separately.
The MoHFW through the Drug De-addiction Programme (DDAP) has set up 122 Drug De-Addiction
Centres (DACs) in the country that provide outpatient and inpatient treatment for SUD in government
hospitals. The outpatient services have been strengthened recently through the introduction of Drug
Treatment Clinics (DTCs). There is no entry barrier for women to these centres as well; all have services
for all genders. Except for some centres, there are no women-specific centres in Government hospitals
as well.
Another agency involved in providing help to people who use drugs is the National AIDS Control
Organisation (NACO) which aims to prevent HIV among people who inject drugs (PWID). NACO
supports NGOs in setting up Targeted Interventions for PWID for providing HIV prevention interventions
including Needle Syringe Exchange Programmes (NSEP) and condom provision. Opioid Substitution
Therapy (OST) is provided mainly in Government hospitals. Additionally, other HIV services including
Integrated Counselling and Testing Centres (ICTC) and Anti-Retroviral Treatment (ART) are set up
through NACO funding in Government hospitals. NACO has funded six exclusive Targeted Interventions
for women who inject drugs (WID) in the North-Eastern states. Not much information is available
regarding the model or the services provided in these TIs. There are no women-specific TIs in other parts
of the country.
“I am RS (name changed). While growing up, my parents had so many conflicts, they used to argue
every day on little things as my father is drug dependent, he used to raise his hand on my mother
and abuse her. Due to which my mother became depressed and started using Alprax (sic) and also
started taking tramadol injection. I was not able to bear this and I left my parents' house. I started
staying in my first cousin's place. One day my cousin told me that at midnight my mother left her
house & passed away in a road accident. I was in a shock and went to stay with my father but after a
few days my father left me and went somewhere. Thereafter I started staying at my friends' place.
She was working in a salon and she took me to the same salon. One lady in the salon introduced me
to sex work. After a few days, I started taking heroin and later ended up injecting heroin daily.
Whatever I used to earn from my job was spent on heroin. One fortunate day, I met a girl living in the
neighbourhood, she advised me to take help from the Child Care department. The next day she
took me to them and they further referred me to Navkiran Kendra, Kapurthala. I feel happy that I can
quit drugs, they told me about HCV, HIV, TB etc. I feel I am in safe hands now. My life has changed.
I am thankful to God that I have come out of hell.
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OBJECTIVES OF THE REPORT AND METHODOLOGY
The report seeks to document the one stop integrated service model for women who use drugs
established in Kapurthala, Punjab and to draw lessons from the implementation of the model. The report
uses different sources of data to document the model of services provided. The documents available with
India HIV/AIDS Alliance (Alliance India), including data related to the monitoring and evaluation
documents were reviewed. Additionally, the staff working in the demonstration site were interviewed to
understand the process of implementation, achievements, and challenges in the implementation of
services for women who use drugs. Finally, the end beneficiaries of the services were also interviewed to
understand the benefits availed by them and the gaps in services provided.
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EXISTING SITUATION AND APPROACH IN PUNJAB
Drug Use Situation in Punjab
As per the Punjab Opioid Dependence Survey conducted in 2015, there are 860,000 users of opioids and
230,000 individuals dependent on opioids in the state[16]. The survey also shows that heroin is the most
widely used opioid followed by natural opiates such as opium and poppy straw. About one-third of the
individuals dependent on opioids use opioids through injecting route, which means that there are 75000
PWID in Punjab. As per this survey, there has been a wide gap between the availability of treatment
services despite huge demand and the evidence-based treatment options are not widely available.
Another survey was conducted by the Post-Graduate Institute, Chandigarh, along with the Indian Council
of Medical Research (ICMR) in 2016-17[17]. The survey shows that there are more than 22 lakhs
alcohol-dependent persons and 16 lakh tobacco-dependent persons. One percent of the population was
estimated to be dependent on opioids.
According to the National survey on the magnitude of substance use in India (2019), there are 27 lakh
alcohol-dependent persons in Punjab[3]. The survey has shown that Punjab has the second highest
number of individuals with problematic cannabis use (5.7 lakhs problems users). Similarly, in case of
opioid use, Punjab has the second-highest number of individuals with problem opioid use (7.2 lakhs
problems users). Punjab has 88 lakhs PWID as per the national survey.
Existing services for women who use drugs available in Kapurthala
The civil hospital in Kapurthala already had the following services established and functional before the
initiation of the comprehensive harm reduction services for women by Alliance India:
1. Drug Deaddiction Centre: Started in 2007, Navjeevan Kendra was established as a unique
initiative of District Administration and Health Department and Indian Red Cross Society. This is a
30 bedded In-Patient facility which delivers a 21 days' drug de-addiction and detoxification
programme for men who use drugs. The centre is a full-fledged facility to address the needs of
patients who want to undergo a residential de-addiction programme. Regular individual counselling
sessions, group sessions and weekly family meetings are conducted along with access to yoga,
meditation etc. Regular follow-ups of clients are conducted with a nodal officer every month to
ensure the complete well-being of clients. However, there were no separate wards/enclosures for
women in this in-patient facility.
2. Opioid Substitution Therapy Clinic: Started in 2015 with the sponsorship of NACO through
Punjab State AIDS Control Society (PSACS), the clinic provides buprenorphine as a long-term
treatment for PWID The medicine is provided on a daily dispensing basis to PWID only.
3. Drug Treatment Clinic (DTC): started in 2015, building on the methadone maintenance treatment
(MMT) clinic that was initiated as part of a pilot project in 2012, the DTC provides outpatient-based
treatment for all substances, including long-term pharmacotherapy for opioid dependence.
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Methadone is provided through this clinic. The DTC is supported by the National Drug Dependence
Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi through
funding from the DDAP, MoHFW, Government of India.
4. Drug Rehabilitation Centre: Nav Nirman Kendra was started in 2018 for drug rehabilitation
treatment for men who use drugs. This is a 50 bedded In-Patient facility, which offers individual,
group and weekly family counselling sessions and meetings with detoxification facility and
recreational activities. This is supported by the Health Department, Government of Punjab.
5. Drug Deaddiction Centre for Women and Children: Nav Kiran Kendra, started in 2018, is a 15-
bed centre exclusively for women who use drugs through a coordinated initiative of the district
administration, the health department, Govt. of Punjab, and the District Red Cross Society. Other
than the 15-bed facility, the health department has created another 10-bed facility in the hospital to
accommodate children less than 14 years of age. The centre is a full-fledged facility to take care of
patients, who want to undergo a residential de-addiction programme with provision for individual,
group and family counselling sessions and meetings.
6. Targeted Interventions (TI): Kapurthala also had one core composite TI that provided HIV
prevention services to female sex workers (FSWs) and PWID. They also reach out to female sex
partners (FSPs) of IDUs.
7. Services in the Civil Hospital, Kapurthala: Apart from this, the hospital where the above-
mentioned services are located also has other services that are required for women who use drugs.
These include – Anti-retroviral treatment (ART) clinics, ICTC, STI clinic, Gynecology department,
Medicine department, psychiatry department, etc.
Despite the presence of these services, the service uptake by women who use drugs was minimal. Even
the existing TI failed to attract women who inject drugs, though there was no bar on registration of this
sub-group. The FSW intervention focused on condoms and HIV testing and treatment; there was no
focus on addressing drug use-related issues even among those FSWs found to be using drugs. The
analysis of the data collected from the clients at the time of registration attests to low uptake of existing
services by women who use drugs.
Results from the analysis of registration-related data
The project would collect some baseline information during registration on an excel sheet prepared for
this purpose. The sheet would be filled by the Programme Manager or the Counsellor soon after a client is
identified for receiving services from the project. A total of 226 women were registered in the project
period. The results of the analysis of the data collected in this manner are described below:
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Socio-demographic profile
The mean age of the 226 clients was 31.7 years (SD: 9.2). Three clients registered were Transgenders.
Most clients had received some form of education. Only one-third (32.7%, n=74) were unemployed at the
time of registration. Half of the clients reported to be married and staying with their partner at the time of
registration. Only four clients reported that their spouse were HIV positive; 44% (n=99) clients did not
know the HIV status of their spouse. Eight clients reported that they were pregnant and about four per
cent clients (n=8) were breastfeeding their child at the time of registration.
Drug Use Characteristics
About 32.3% (n=73) clients reported to be injecting at the time of registration. All these clients reported
injecting heroin at the time of registration. About 14% (n=32) reported using a needle used by someone
else in the past 15 days. About 46% (n=104) clients reported that their spouse/partner was using drugs at
the time of registration. About 7% (n=16) clients disclosed to be diagnosed as HIV positive. About 20%
(n=46) clients reported that they had tested positive for Hepatitis-C.
Sex-related risks
About 66% (n=149) reported that they have an active sex partner. About 55% (n=125) clients identified
themselves as sex workers. About 26% (n=59) clients reported having regular sex partners. Only 27%
(n=61) reported using a condom during their last sexual activity. About 26% (n=58) reported having
sexually transmitted infections (STI) symptoms in the last one year. The STI symptoms included – pain
during urination, itching, pain abdomen, vaginal discharge, etc.
Services availed before registration
None of these clients had availed NSEP facility from the TIs. Only 12% (n=27) clients reported to have
been to a drug treatment centre ever in their lifetime, while only three clients reported that they have been
registered in a Targeted Intervention in their lifetime. Only ten clients reported that they were on OST at
the time of registration. Twelve of the 16 clients tested HIV positive were registered in ART centre. Only
eight clients (overall 4%, 16% of those with Hepatitis-C) clients were treated for Hepatitis-C.
Other challenges and needs
About 15% of clients (n=34) reported facing violence in their lifetime. The common perpetrators of
violence were family members (10%, n=21), friends/colleagues (3%, n=6), gundas (n=3) or society
members (n=3). About 32% (n=72) clients expressed their desire to be linked to a social welfare scheme.
The results above clearly showed that:
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Women who use drugs are a vulnerable group. They are young belonging to the reproductive age
group. About half of them are married, and two-third have an active sex partner. More than half of
the clients identified themselves as sex workers. Only one-fourth of the clients reported using
condoms during their last sex act. One-third were injecting drugs, of whom almost one-third had
used unsafe needle/syringe recently. Almost one-third are illiterate and unemployed, adding to their
vulnerability. All these factors show that women who use drugs have multiple injecting and sex-
related vulnerabilities that can place them at risk for infections such as HIV and Hepatitis-C, or other
sexually transmitted infections.
This is reflected in the high HIV positivity reported by the clients almost 7% of the women reported
to be HIV positive at baseline. Similarly, one-fifth of the clients reported to be positive for Hepatitis-
C. Almost one-fourth also reported to have one or the other symptoms of STI in the past year.
Despite the availability of most services in Kapurthala, the uptake of services was very less. None of
the clients who were injecting drugs had availed needle syringe programme from the TIs. Less than
five per cent of the clients had access to OST, and one-tenth of the clients had visited an addiction
treatment centre.
The drug treatment and HIV-related services were open for individuals of all genders; however, there was
no separate system followed for women in most of these service points that could make these services
more accessible to this population sub-group. What was also lacking was a common thread to facilitate
linkage of women who use drugs to these services. The fact that few women accessed these services
meant that there were either not that many women who use drugs or women who use drugs did not find
these services to be accessible or friendly. However, anecdotal information and the service providers, as
well as handful of women recipients in these service points, reported that there is a sizeable population of
women who use drugs and need help. This prompted the initiation of this project in Kapurthala.
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ANOTHER WORLD, SIMILAR STORY…
Neelam (name changed) is a 26-year old dance artist from Punjab. She started working as a dance artist since the
age of 15 years after the death of her father. As the eldest child in the family, she had to support the family financially
and had to quit school after class eight. As a dance artist, she was expected to dance at private parties, cultural
shows, and dance bars. At the age of 18 years, a month after her birthday, she was married off by her family.
For six months, her life with her husband was good till he started using drugs. He started beating her up under the
influence of drugs; the physical abuse went on for two years. He kept using drugs and the abuse continued for
Neelam. When she became pregnant, the physical and verbal abuse increased, along with continuous harassment
from her husband's parents for dowry. She had even asked her husband that if he was willing to quit his drug use,
she would start working again to support him and his family while he was in drug treatment facility even if it was for
more than six months. He did not agree, and she shifted to her mother's place with her four-month-old son to
escape from the abusive environment at her in-law's place. Her son was very weak and faced health issues like
anaemia, weakness, to the point that he had to be admitted in the hospital. ''For my son's treatment, we had to take
a loan against my mother's house to pay the ever-increasing hospital bills. All my mother's savings were spent, and
that is when I decided to go back to dancing to support my son and the family'', Neelam recalls.
When she got back in the dancing profession, her fitness and overall look was heavily impacted due to the stress of
her child's health and the financial problems she and her family were facing. She also understood that, in the world
of dancing, she can only be successful if she can put in more hours and is able to maintain her looks. But due to the
stress and her deteriorating health, she was not able to continuously work for long hours. She reached out to her
friend, who, she knew, was involved in sex work. The friend took Neelam under her wing and introduced her to a few
clients, initiating her into sex work. At her first time, she cried and became very sad, but she also felt helpless as she
needed the money. She regularly started attending to clients while also putting up dance shows.
Over a period of time, she started feeling unwell and was not able to cope with the pressure of the work. She was
aware of girls who used drugs in her dancing profession and was told by one of them to try a line of white (heroin) as
it would give her stamina to work continuously. She was 22 years old when she used drugs (heroin) for the first time.
She started using drugs to keep up her stamina as she had to dance the entire day and then attend to the clients for
sex work. “One also needs to look and behave energetically, then only, clients would feel happy and come back”
was her opinion. Initially, she would do a line of white only once a day, but eventually, the frequency and amount
increased to maintain the stamina. With the extra money she earned with her sex work, she could easily support
and sustain her drug habit. For her, sex work was a way to earn extra money over and above what she earned from
dancing to take care of her son's medical treatment. Neelam's family is not aware of her involvement in either sex
work or her drug use. She can easily hide her drug habit as she hardly stays at home. She travels a lot for her dance
shows – during winters mostly in Punjab and to Delhi during other months where she dances in dance bars or in
private shows while attending to clients also. If she came home, she would stay for a maximum period of about 10
15 days at a stretch and would go to her friend's house to use drugs.
During one such stay at her home, the outreach staff of the women-centric harm reduction centre contacted her for
linking with various harm reduction services. Neelam has been in contact with the centre team for the past 18
months. She started with accessing services for testing HIV, hepatitis, and for STIs, and has been undergoing
repeat tests periodically. Through counselling she was made aware of the range of services available for women
who use drugs. She was also offered OST; however, she did not start on OST initially as she was not ready to quit
drugs fearing it would affect her earnings. When the COVID-19 related lockdown was imposed, she found it difficult
to access illicit drugs due to lack of availability and the price hike for heroin. The staff at the centre counselled her to
get started on OST for her withdrawal symptoms.
She is currently maintained on OST; Continuation of OST would be a challenge due to the nature of her work.
According to her, there is an urgent need to provide nutritional support and community support for women who use
drugs and are in sex work. As there is no alternate support or work for women who want to quit drugs or even sex
work, she feels that she has to continue dancing and sex work, for which then she needs drugs to survive. “I want to
quit sex work one day, I have a six-year-old child, but I don't want to be in sex work when he grows up. I don't want
him to know about this aspect of my life. But I am helpless right now as he is a child with special needs and I need
money to support him so he can have a good quality of life.” When asked about her vision for her future, she said
she required support wherein she can start her own work and leave sex work and drugs. “If I am in a white-collar job,
then he (her son) also will have a better future”, Neelam says with hope in her eyes.
18
IMPLEMENTATION OF ONE STOP INTEGRATED
MODEL FOR WOMEN WHO USE DRUGS
A. Project Initiation
Under the Global Fund supported Harm Reduction Advocacy in Asia (HRAsia) programme, Alliance India
planned to implement a demonstration project to address the comprehensive needs of the women who use
drugs. The objective of the site was to present a successful model which is comprehensive, cost-effective and
successful in terms of addressing the needs of women. It was planned that after successful implementation of
the project, advocacy efforts would be done by the programme with central government and other relevant
stakeholders for scaling up of the services to address the needs of the larger population of women who use
drugs.
The department of psychiatry in the Civil Hospital, Kapurthala was identified to implement the project at the
local site was identified. This was because the psychiatry department was implementing the various addiction
treatment programmes in the civil hospital, including the inpatient facility for women. The necessary technical
support to implement the project was provided by Alliance India staff managing the project. It was realized
from the beginning that there were two important missing elements in the provision of the integrated package
of services including harm reduction services for women who use drugs in Kapurthala. This includes 1)
identifying women who use drugs and reaching out to them with services, and 2) creating a common link
between the different service providers and the service recipients.
The project implementation began in January 2019.
B. Staff Roles and Responsibilities
In tune with the missing elements identified before the project inception, a dedicated team was provided
through the project which focused on outreach and creating networking and linkage with the various service
points. The consultant (psychiatry) served as the project coordinator for the project implementation. The
project staff included:
a) Project Manager
b) Counsellor
c) Nurse
d) Outreach worker
e) Peer educators
All the staff employed in the project were women so that the beneficiaries would feel comfortable in
communicating their needs and avail services from the project. The roles and responsibilities of each staff
were laid down as follows:
a) Project Manager
One Project Manager (PM) was appointed in the project. The PM was expected to work under the overall
supervision of the project coordinator. The expected knowledge and skills from the PM were:
Familiarity with government health policies and programmes
Strong communication skills
Ability to work in small teams, and flexible ways of working
Proficiency in data analysis, reporting writing, case study compilation
19
Overall management capacity to monitor, report and guide the team under her
The PM was the overall in-charge of the day-to-day management of the project. The roles/responsibilities of
the PM included:
Achievement of the project deliverables as per project targets.
Organize weekly review meeting and supervise work of all other staffs.
Establish linkages with other referral services, conduct stakeholder and advocacy meetings
Organize in-house capacity building of the other staff
Travel to the project areas/hotspots for overseeing the implementation of the programme and
supervision of Peer Educators (PE) / Outreach Workers (ORWs)
Analyse the progress of the project activities and share the same with action points in the monthly
project staff meeting.
Conduct weekly/monthly review meetings with project staff and PEs.
Timely submission of monthly program performance data in monthly progress report
Basic financial management including documentation related to finances
b) Counsellor
One counsellor was appointed in the project. The counsellor was expected to function under the supervision
of the PM. The roles/responsibilities of the counsellor included:
Conduct individual and group sessions on HIV/AIDS, Hepatitis, STI, safe sex and injecting practices,
prevention of abscesses, overdose prevention, drug treatment options, etc.
Conduct counselling for the family members of the clients
Motivate the clients for regular medical check-ups, testing for HIV and Hepatitis, visit STI clinic, ART
centre or other service points as needed
Orient the ORW on counselling techniques and coordinate outreach-based Behaviour Change
Communication (BCC) and psychosocial support
Identify individual or group motivators or inhibitors which require to be addressed for health seeking
behaviours, condom use, sharing the needles/syringes, domestic or group violence, etc.
Identify the hotspots or sites with low service uptake, increasing defaulters, and prepare outreach and
visit plan to conduct hotspot level meeting in coordination with the PM
Travel to the project area for providing services in the field
Engage with providers of social welfare services and facilitate linkage with social welfare services
c) Nurse
One nurse was appointed for the project. The minimum qualification required for the post was General
Nursing Mid-wife (GNM). The roles/responsibilities of the nurse were as follows:
Providing general nursing care to the clients in the field
Providing abscess care in the field
Conduct individual and group sessions on medical topics related to drug use, sexual and reproductive
health, treatment of addiction, etc.
Demonstrate condom use, and provide counselling on condom negotiation skills
Ensure the bio-medical waste management are followed as per the guidelines
d) Outreach Worker
One ORW was appointed for the project activities. The minimum qualification for an ORW education up to
class 10. She was expected to be from the local community and be well-versed with the local topography and
people and be able to work in team. The roles/responsibilities of the ORW were as follows:
Prepare micro-plans for each hotspot, monitoring the implementation of the plans and conduct periodic
20
review of the plans
Facilitate and build capacity of the PEs to implement the outreach activities as per the required norms of
the project
Prepare monthly action plan for each hotspot,
Ensure adequate supply of needles/syringes, and condoms for each hotspot.
Discuss with the counsellor monthly to understand the hotspots or sites with poor service uptake so that
necessary follow-up can be undertaken
Discuss with the community members and other stakeholders in preparing micro-plans
Ensure that field-level support is available for smooth implementation of the project
e) Peer Educators
Two PEs were appointed for carrying out the project activities. The PEs were required to be from the
community of women who use drugs – either currently using or used drugs in the past. They were to be literate
preferably with good knowledge of the local community. They had to be good community motivators and able
to connect with their community. The roles/responsibilities of the PEs were as follows:
Prepare micro-plans in consultation with the ORW
Calculate demand analysis of various commodities
Prepare weekly/monthly action plan for each hotspot
Ensure the supply of needles/syringes, other harm reduction materials, and condoms for each hotspot
Ensure follow up of STI cases, HIV positive cases, Hepatitis-C cases
Conduct home visit to those clients who have not turned up for Hepatitis-C or HIV testing or medical
check-up
Rope-in support of the stakeholders in smooth implementation of the programme in the allotted area
Support the ORW in maintaining records of free commodities
Most of the staff working in the project had experience in working with marginalised communities. One of the
PE was using drugs herself – she was chasing heroin and had stopped about one year before starting the
current work. The other PE had worked in the TI under the FSW component and had good knowledge of the
local community.
By twelve months of the project inception, some women who use drugs from the adjoining town of Phagwara
(located about 50 kilometres from Kapurthala) started coming to Kapurthala to access services from the
project. As a result, the project hired one more ORW and one PE to provide outreach services in Phagwara in
July 2020. A total of 42 clients out of the 226 clients registered in the project are from Phagwara.
C. Capacity building of the project staff
Various capacity building activities were conducted in the project lifecycle on various topics ranging from
basics of outreach to various services for women who use drugs. Other issues such as rights-based
approach, legal and policy issues, community mobilisation were also covered in the capacity-building
workshops.
21
S.
No
Month/Year
Topics Covered
Participants
1
Throughout
the life of the
project
· Concept of harm reduction (refresher meetings)
and related services
· Outreach planning and strategies
· Hotspot mapping
· Reporting and developing case studies
· Stakeholder identification and engagement
· SRHR
· Gender-based violence
· Formation and development of drug users forum
Project staff
2
May 2019
· Health, Rights and Financing Priorities for people
who use drugs
· Key barriers to comprehensive HIV prevention and
care among women who inject drugs in India
· Development of an action plan on advocacy for
WWUDs
· Development of an action plan for addressing
capacity-building needs for WWUDs
Project staff
Potential members for
the drug user forum in
Punjab
3
Dec 2019
· Community System Strengthening for People Who
Use Drugs with a special focus on Women Who
Use Drugs
· Legal and Policy Concerns linked with Service
Provision
· Extend, Trends and Patterns of Drug Use in India:
Problems and Responses
· Resource Mobilization for Harm Reduct ion
· Leadership, Governance and Management
Project staff
Potential members for
the drug user forum in
Punjab
4
Dec 2019
· Role of Punjab Government in addressing drug
use
· Addressing risks, vulnerabilities and unmet needs
of Women Who Use/Inject Drugs:
§ Gender-Based Violence and SRH
§ Drug Dependence Treatment
§ Prison interventions
§ Community engagement
· Opportunities for WUD community-led advocacy
for policy reform, implementation, resource
mobilization and sustainability
· Advocacy and stakeholder engagement:
Elaborating on public health financing
· Development of an action plan for addressing
capacity-building needs for WWIDs and
strengthening WUD networks
Project staff
Potential members for
the drug user forum in
Punjab
5
July 2020
· Importance of community collectivisation
· Key barriers to comprehensive health and rights -
based programs on prevention and care among
women who inject drugs in India
· Discussion on work plan and way forward for
Punjab Women Drug User Forum
Project staff
Potential members for
the drug user forum in
Punjab
6
Oct 2020
· Drug user forum network development -
importance and role
· Advocacy approaches for drug user forum or
networks
Potential members for
the drug user forum in
Punjab
22
D. Identifying and reaching out to the potential beneficiaries
The PEs were knowledgeable about the community of women who use drugs due to their previous jobs.
The team strategized on potential places where women who use drugs could be contacted. One potential
avenue was existing clients on opioid agonist treatment in the OST clinic, OOAT clinic and the DTC.
Similarly, another avenue was contacting FSWs in Kapurthala who could provide information on drug
users among them. Yet another place was the group of girls/women who work as dancers during
occasions. Through these networks, the outreach team was able to get initial clients. These initial set of
clients then provided further link to other women who use drugs. The outreach team followed the
strategies usually followed in a Targeted Intervention project for outreach. This included – hotspot
mapping, assessing risks and vulnerabilities of each individual client, individual tracking, etc.
The project targeted not only women who inject drugs, but non-
injecting opioid users as well. The team was able to reach out to
and register 226 clients in the two-year period of the project.
The month-wise registration of the clients can be seen in the chart below:
Figure 1: Month-wise registration of clients in the project from January 2019 to November 2020
23
E. Services provided for women who use drugs
Once a client was contacted by the team in the community during outreach, she was then registered
in the project. The project smartly utilised existing services in the community to provide needed
services to their clients. The 'direct' services provided through the project was mainly 'outreach' and
counselling. Other services were provided through linkage with existing service points in the
community.
Counselling
Individual and group counselling was provided to the clients. The counsellor and the outreach
worker were mainly involved in the counselling. The areas in which the clients were counselled
included: drug use including available treatment options, HIV-related issues including the need for
testing and treatment, Hepatitis-C, sexual and reproductive health, safe injecting and sex practices,
overdose prevention and management, mental health issues, etc. Counselling was carried out in
the field as well as in the De-addiction Centre for women.
HIV testing
Each client was tested for HIV twice in a year. The integrated counselling and testing centre (ICTC)
of the civil hospital was used for getting the testing done. The clients were counselled for HIV before
and after the HIV tests.
HIV treatment
Those clients who were tested positive were then registered in the ART clinic in the civil hospital.
Those who were on ART were tracked regularly to ensure that they are regularly taking their ART
medicines.
Hepatitis-C testing and treatment
The Government of Punjab provides free-of-cost testing and treatment of Hepatitis-C in the
government hospitals throughout the state. Each client was tested for Hepatitis-C in the civil
24
hospital twice a year. Those found positive were then encouraged for treatment in the medicine
department of the civil hospital.
Tuberculosis testing and treatment
Each client was screened for tuberculosis. Those who had any of the symptoms suggestive of TB
were counselled to get tested for TB in the civil hospital, and those found positive were treated for
TB.
Gynaecological problems
Those clients reporting gynaecological problems were referred to the gynaecology department for
treatment
Mental health problems
Those clients who had mental health problems were referred to the consultant psychiatrist who was
the project coordinator of the project for treatment.
Treatment of addiction
The clients were counselled for treatment of their opioid use problem. Those willing were given the
choice of treatment available in the civil hospital ranging from inpatient detoxification to outpatient-
based buprenorphine or methadone maintenance treatment. The clients were referred to the
facilities as per their choice.
25
Provision of HIV prevention commodities
The project tied up with local TI to provide HIV prevention commodities such as Needle-Syringes
and condoms.
To enable easy access to these services, the project staff conducted advocacy with the other service
providers. In these advocacy meetings, the staff provided information about the project and the
importance of improving access of these services to women who use drugs.
26
With regards to vocational training, many women expressed that they would like to get trained in stitching
clothes. For this, the project staff advocated with the Red Cross Society of Kapurthala and succeeded in
convincing the authorities to provide sewing machines for training the women. The Red Cross society
donated 10 sewing machines to the centre. The training centre was opened in Nav Kiran Kendra, the De-
addiction Centre for women, and the interested clients were trained in stitching. During the ongoing
COVID-19 pandemic, the project staff provided clothes and got masks stitched to be distributed among
the service recipients and the hospital staff. Similarly, some clients were linked with the department of
employment generation and training where they got trained in courses such as beautician and web-
designing. Some also got employed after getting such training.
Linkage to social protection schemes and vocational training
The project staff also assessed the needs of the clients for getting access to social protection schemes. In
case any client expressed such a need, the counsellor would make further assessments and then the
project would help the client in linking up with the necessary social protection schemes. The project staff
would advocate with the appropriate department/government agency to help them access the scheme.
The table below provides the list of various schemes that the women benefitted from with help of the
project.
Table 1: Number of Women accessing social protection schemes and entitlement
Sr.No
Social Protection Schemes
Number of
Women
1
Stitching & Tailoring Training scheme
75
2
Female Widow Pension
4
3
Female Handicap Child Pension
2
4
Assistance for getting UID (Aadhaar) Card
5
5
Child handicap Certificate
1
6
Sakhi One stop Centre Scheme
6
7
Skill Building and Training Programme
6
8
Linkage to Department of Employment Generation and
Training (such as beautician and graphic designing courses)
5
Total
104
27
Addressing Gender-based violence
“My boyfriend pushed me into sex work. He would beat me if I did not give him money to buy
drugs. He often calls our drug peddler to our home and forces me to have sex with him. If I resist,
both beat me black and blue. I left my parents place when I was 17 years old to be with him.
Initially, everything was good, then we both started doing drugs and my life became a hell.
These black spots on my face are because, once he hit me with his cricket bat.”
(A 25-year old women who had experienced intimate partner violence)
28
The information collected during initial registration as well as regular interaction of the project staff with
the women who use drugs showed that violence is a common phenomenon in this population sub-group.
Often the perpetrators are the family members of the women. To equip the project staff with the
knowledge and skills on how to manage gender-based violence (GBV), one-day training on “Addressing
GBV/IPV and SRH issues amongst women who use drugs” was organised for the staff members and
members of the Punjab State Drug Users Forum including program manager, ORWs, PEs and
counsellor of the project. The training was aimed at enhancing the knowledge of the participants on GBV,
and to build the capacity of the participants on developing individual safety plan on the reduction of GBV
and identifying SRH needs among the women who use drugs. The participants were oriented on the
steps of developing and implementation of the safety plan for those experiencing GBV.
F. Cost implications
The project has invested mostly in staff salaries. The other commodities were provided through linkages
with existing services in the community. The table below shows the six-month budget for project-related
activities. The budget does not include project monitoring support by the Alliance India team.
Table-2: Annual budget for carrying out project-related activities
Activity
Unit cost
(INR)
Units
Amount (INR)
(For twelve
months)
Honorarium to Coordinator
8,400
1
1,00,800
Hiring of Project Manager
15,750
1
1,89,000
Hiring of Female Outreach Worker
7,875
2
1,89,000
Hiring of Female Counsellor
12,600
1
1,51,200
Hiring of Female Peer Counsellor
5,250
2
1,26,000
Hiring of Staff Nurse (Part Time)
12,600
1
1,51,200
Local conveyance for Staff
5,150
1
61,800
Office Cost and utilities
5,000
1
60,000
Total cost of implementation (for 12 months
in INR)
10,29,000
29
PROGRAMME MONITORING REPORT ANALYSIS
The project tracked basic indicators to monitor the performance of the project monthly. A Microsoft Excel
Sheet was prepared for this purpose, which the project staff was expected to fill up at the end of the month
and transmit it to Alliance India. The achievements of the project on the indicators tracked by 30
November 2020 are provided in Table-3.
In its two years of implementation, the project was able to identify and register more than 200 clients
and provide various services that they had set out to do at the inception of the project.
The project was able to get almost all the clients tested for HIV, Hepatitis-C and Tuberculosis (for
those requiring TB testing). They were able to link most of those found positive to their respective
treatment.
Almost every second client was linked to the opioid agonist treatment programme, which can be
considered as a high coverage on OST.
Those requiring or desirous of inpatient treatment for addiction were treated at Navkiran Kendra,
the women-specific De-addiction Centre.
Table-3: Cumulative achievement of the project on tracked indicators by November 2020
SL.
No.
Indicator
Achievement
(Number)
Achievement
(Percentage of
those registered)
1
Number of Women who use drugs registered
226
2
Number who received counselling services
226
100%
3
Number who were enrolled in Opioid Agonist
Treatment (OAT) with Buprenorphine
85 (75 in
OOAT clinic,
and 10 in OST
clinic)
38%
4
Number who were enrolled in OAT with
Methadone
18
8%
5
Total Number of Women who were enrolled
in OAT (with Buprenorphine/Methadone)
103
46%
6
Number who were on OAT in the reporting
month
72
32%
7
Number referred to De -Addiction Centre
44
19%
8
Number who received NSP services
37
16%
30
Another important offshoot of the project implementation in Kapurthala has been the
initiation of a drug users forum for women in Punjab.
SL.
No.
Indicator
Achievement
(Number)
Achievement
(Percentage of
those registered)
9
Number tested for HIV
197
87%
10
Number found HIV positive (among those
tested for HIV)
16
8%
11
Number registered for ART (among those
found to be HIV positive)
14
87%
12
Number currently on ART (among those
found to be HIV positive)
14
87%
13
Number tested for Hepatitis -C
194
86%
14
Number found to be Hepatitis -C Positive
(among those found to be Hepatitis -C
positive)
46
24%
15
Number referred for Hepatitis -C treatment
(among those found to be Hepatitis -C
positive)
43
93%
16
Number completed Hepatitis -C treatment
(among those found to be Hepatitis -C
positive)
14
32%
17
Number referred for TB testing
101
45%
18
Number found TB positive (among those
referred for TB testing)
1
1%
19
Number on TB treatment (among those found
positive for TB)
1
100%
20
Number completed TB treatment
0
0
21
Number of overdose cases reported
0
0
22
Number of violence and/or crisis cases
reported
4
2%
23
Number of violence and/or crisis cases
reported addressed
4
100%
31
Punjab State Drug Users Forum
The Punjab State Drug Users Forum (SDUF) for women was planned with an intent to collectivise the
community of women who use drugs and help them raise their voice for getting services and be treated
with dignity and respect without stigma and discrimination. The Punjab SDUF was formed in July 2020,
and has 92 women who use drugs as members, at present. Various training and meetings have been held
for the members to build their capacity to run a drug users forum. Some of the achievements in this brief
period of five months include:
A couple of sensitisation meetings were conducted for the member of the group on services for
women and the formation of support groups for various services.
The Punjab SDUF coordinator reached out to the employment office in Kapurthala and applied for
the employment for WUD registered with them. The employment office has agreed to provide a
training course to 10-15 women on beautician. One major achievement of the Punjab SDUF was
getting their four members selected for the job by the ICICI foundation for training and employment.
The SDUF also visited the Viral Hepatitis Interventions of Kapurthala and met the senior officials.
The main agenda is on making testing available for the women who use drugs on weekends the
women face difficulty to visit the testing centre due to their work schedules. A request letter was
submitted to the officer-in-charge of the Viral Hepatitis Centre in November 2020.
A meeting with “Sakhi” One Stop Centre Kapurthala under Ministry of Women and Child
Development was held in October 2020 and issues related to sexual and reproductive health were
discussed.
32
Mrs P (name changed), a 20 year old lady who is a resident of Kapurthala came for admission to the Nav
Kiran Kendra, the women-only De-addiction Centre in Civil Hospital, Kapurthala. P's parents were daily
wage earners. As P was good in studies, she joined a computer course after her 12th standard. In the
computer institute, she met a boy who befriended her. Gradually, she fell in love with the boy and got
married to him with the parent's consent before they could complete their graduation.
After marriage, she got to know that her husband is using drugs – he was chasing heroin daily and was
addicted to heroin. The husband's drug use led to constant arguments and conflicts between the
couple. The husband would also resort to physical and verbal abuse under intoxication. All these made
her angry and sad. She then thought of using heroin herself under the impression that he will stop using
if she starts using the drug. However, she liked the intoxicating effect the drug produced. Now, she
started using it on occasions of stress and anger, as she felt relieved of her stress and became calm.
Soon, she started getting withdrawals on stopping heroin use and felt like taking the drug everyday and
became addicted to heroin within a few months of trying it for the first time.
The couple continued to use together for some months with the husband arranging for the drug by
selling it on the streets. After a year or so, the husband decided that both of them should stop using
drugs. He convinced her to undergo detoxification for heroin. Mrs P underwent treatment from a private
centre as OPD patient, while her husband admitted himself in Navjeevan Kendra, Civil Hospital,
Kapurthala. She got to know that she is three-months pregnant while undergoing treatment in the
private centre. She could not resist craving even after getting detoxified and restarted using heroin. This
was the case with her husband too. Her husband was arrested and booked under NDPS as he was
caught peddling drugs to support his livelihood and drug. Their home was also sealed by the police.
Stranded and helpless, she approached her parents, but they refused to let her stay at their home. She
had no option but to start living on the streets without support from anyone; to make matter worse, she
also was six-month pregnant. Rinku (name changed), a sex worker, met her and took her home after
listening to her story. Though she was kind and helpful, Mrs P had to take up sex work to sustain her drug
use and basic needs. Rinku knew about her pregnancy, and to avoid further complications she
motivated Mrs P to seek treatment at Navkiran Kendra, the Government De-addiction Centre for
women in Civil Hospital, Kapurthala. However, Mrs P was reluctant to seek treatment as she felt she will
be ill-treated inside the centre, a myth amongst many women who use drugs. With Rinku's assurance
and persuasion, finally, Mrs P decided to get admitted at Nav Kiran Kendra.
After admission, she was pleasantly surprised to find the centre so welcoming towards patients. She
saw that she was treated as a patient with respect. She became comfortable with the facilities provided
in the centre and actively took part in all the activities conducted in the centre. She decided to stay longer
in the centre and delivered her baby in the civil hospital itself with the support of the centre staff and the
hospital administration. Seeing these changes and her commitment to getting better, her parents who
were contacted by the project staff also came forward to support her. Her husband is also out of the
prison on bail and promises to remain drug-free and support Mrs P and their son.
33
REFLECTIONS AND LESSONS LEARNT
The project on comprehensive harm reduction package of services for women who use drugs was
launched in January 2019 and has completed two years of its implementation. The project primarily
focused on outreach services and linking the clients to various services existing in the community. In
these two years of implementation, the project has had some remarkable achievements.
The most important achievement is the fact that the project has been able to identify more than 200
clients in the two-year period and provide various services. Most clients have been provided basic
harm reduction services, including testing and treatment of HIV as well as of Hepatitis-C. Various
issues specific to women such as SRH services, gynaecological and child-care services, addressing
GBV, etc. have been provided through the project. Last, but not the least, is the constitution of the
Punjab SDUF for women.
One can draw various lessons and reflections from the project implementation and project outcome
that can be important for replicating similar projects for women who use drugs in India or similar other
countries.
Women who use drugs in India are a vulnerable lot. One-third of the women registered in the
project reported to be injecting opioids. The husbands of almost half of them were also using
drugs. More than half of the registered women identified themselves as sex workers. HIV
positivity and Hepatitis-C positivity in this group was very high. There is a clear need to look at
this population as a separate sub-group of people who use drugs and plan interventions for this
sub-group. Otherwise, the SDG goal of ending AIDS by 2030 cannot be achieved.
Even though Kapurthala had all the interventions necessary for women who use drugs, very few
women were availing services from these service points. This was true even for the women-only
inpatient addiction treatment facility. This shows that having a static service point is not enough.
An outreach team is needed that can reach out to the women in their milieu, inform them about
the services and help them access these services.
Presence of any outreach is not enough, be it FSW or PWID. Kapurthala had a core-composite
TI that was providing services to PWID as well as to FSWs. Yet very few women who use drugs,
including WID, availed services through this TI. It seems that women who use drugs fall through
the cracks of the male-centric implementation model of TI for PWID or of sex-centric
implementation model of TI for FSW. Having outreach specifically for women who use drugs is
important. Such an implementation model used in this project has proved to be useful – the
number of women who use drugs identified and registered in a relatively short span of two years
is a testimony to this fact.
34
The project provided harm reduction services to injecting as well as non-injecting users. This
may be important to consider in the harm reduction and HIV prevention projects. It is well known
that women who use drugs (especially opioids) through injecting and non-injecting route are
closely interlinked. Some of the findings from the project also show that there is a close link
between sex work and drug use. In such a scenario, it may be important to consider women who
use drugs, especially opioids, as one sub-group who share similar risks and vulnerabilities.
Future HIV prevention and harm reduction projects may look at women who use drugs
(irrespective of their injecting status) as one sub-population and provide interventions to them
together.
Almost all the TIs in India are run by non-governmental organisations (NGOs). There are
definite advantages of an NGO implementing TI, including greater flexibility required for
outreach activities. However, the project showed that outreach teams can also be attached to a
government hospital under the day-to-day supervision of a project manager and overall
supervision of the doctor working in the hospital. This is also true for women-centric addiction
treatment facilities. Even if such addiction treatment facilities are in Government hospitals, an
outreach team can greatly help in identifying potential service recipients and link them to
addiction treatment.
The project was also able to mobilise the group of beneficiaries to collectivise themselves into a
drug user forum in the short span of the project duration. The benefits of such collectivisation
are yet to be borne as the SDUF is only six months old. However, the benefits of such
collectivisation have been documented for other groups and in other countries. Such a group
can act as influencers and reach out to similar women, and act as advocates for services and
their rights.
There are still gaps in the services provided through the project. Some female-specific services
such as sanitary napkins, childcare services, etc. were not provided during the project
implementation. Research and implementation experience in other parts of the world have
shown that such services greatly help in attracting more women to avail harm reduction and
addiction treatment services.
The project incurred a modest implementation cost. Majority of the cost was on account of salaries
for the staff. Thus, cost should not come in the way of scaling-up this model. One may argue that this
project was successful only because so many services existed in the community. It should, however,
be remembered that many districts in the country would also have a similar milieu of services
existing. The project was able to utilise the full potential of the existing services in the community; this
helps in replicating the model to other parts of the country as well.
35
CONCLUSIONS
The project on comprehensive harm reduction package of services for women who use drugs has
successfully completed two years of implementation. The project focused on outreach activities and
linking the clients to existing services in the community. The project addressed both non-injecting
and injecting forms of drug use. The project had modest implementation cost mainly spent on
salaries of the outreach team. Within a short span of two years, the project was able to reach out to
more than 200 women and provide comprehensive harm reduction and addiction treatment services
to this population group. The experience accumulated in a short time shows that this project needs to
be sustained in future. The learnings from the project can prove useful in scaling-up harm reduction
services for women who use drugs in India and similar countries in the region.
36
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... While the vast majority of PWID in India are men, several studies, including our prior research in India have delineated the unique vulnerabilities and challenges that women who inject drugs experience for receipt of substance use treatment 36,40,[58][59][60] . Although service delivery models exclusively for women have been piloted 61 , dedicated studies are needed to understand and ameliorate the gaps that women experience in buprenorphine treatment receipt and retention. Finally, grouping ICCs by region may have obscured site-specific differences, and findings are not generalizable to other cities. ...
Preprint
Background India is facing an alarming rise in the injection of opioids leading to burgeoning HIV epidemics among people who inject drugs (PWID) in several cities. Integrated Care Centers (ICCs) provide free single-venue HIV services and substance use treatment to PWID and have been established across 8 Indian cities. We evaluated engagement of PWID in buprenorphine treatment at ICCs to inform interventions. Methods We retrospectively analyzed 1-year follow-up data for PWID initiating buprenorphine between 1 January – 31 December 2018 across 7 ICCs. We used descriptive statistics to evaluate buprenorphine uptake, receipt frequency, treatment interruptions (no buprenorphine receipt for 60 consecutive days but with subsequent re-engagement in treatment), and treatment drop-out (no buprenorphine receipt for 60 consecutive days without subsequent re-engagement), and explore differences between historical opioid epidemic regions (i.e., Northeast cities (NEC)) and emerging opioid epidemic regions (i.e., North/Central/Northwest cities (NCC)). We used a multivariable logistic regression model to determine predictors of treatment drop-out by 6 months. Results 1312 PWID initiated buprenorphine (76% NCC vs. 24% NEC). 31% of PWID in NCC, and 25% in NEC experienced ≥ 1 treatment interruption. About a third (34%) of PWID in NCC vs. half (50%) in NEC dropped-out by 6 months (p<0.0001). Over 6 months, 48% of PWID in NCC vs. 60% in NEC received buprenorphine ≤2 times/week on average (p<0.0001). In multivariable models, living in NEC was associated with increased odds of treatment drop-out while receipt of counseling was associated with decreased odds of treatment drop-out. Conclusions PWID at ICCs, particularly those in NEC have low buprenorphine receipt and retention. Patient-centered interventions adapted to regional contexts are urgently needed to ameliorate these gaps.
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