This qualitative study among women drug and alcohol users in two Northeast Indian states highlights the problem of both drug and alcohol use and dependence among women, and the very clear ways in which this places them at risk of HIV infection. While descriptions of HIV risks associated with drug use are not an unexpected finding, the strong focus given to the link between sexual risk behaviours and alcohol consumption in the context of relatively high HIV prevalence is an important finding that has implications for HIV prevention programs.
The findings also highlight the extent to which the women’s situations and issues varied by state. The women in Nagaland were mainly struggling with the consequences of alcohol use and dependence, and an absence of accessible services. Their HIV vulnerability was mostly related to the lack of control they had during sexual encounters due to their intoxicated state (and no doubt the intoxicated state of the men involved as well). The women in Manipur were also struggling somewhat with the consequences of alcohol use, but the most problematic substance in this state was heroin. Their HIV vulnerability was mainly associated with the need to frequently engage in sex work in order to raise money to purchase heroin. The observed differences between the two states could arguably be attributed to the non-representative sampling, but these differences are consistent with the experience of staff working in local HIV prevention and care services, and with other research .
The stated reasons for using drugs and alcohol overlapped with what has been reported elsewhere in the literature  and included widowhood, suppressing emotional pain, pleasure, avoiding the symptoms of withdrawal, and overcoming the shame of sex work. Even though the Northeast region of India is culturally, linguistically and ethnically distinct from the rest of the country, widowhood and divorce place women in situations of personal, social and financial hardship, similar to other parts of India. While some of these women may have been divorced due to their substance use, others were using substances to cope with being widowed or divorced.
Some of the women reported drinking alcohol primarily to avoid the symptoms of withdrawal. Unfortunately there are limited viable treatment options currently available for alcohol-dependent women. To the best of our knowledge, alcohol detoxification treatment for women is not available in either of these two states, and even if it were, many of the women would not have the money or family support required to access such a program. Similarly, there is no chapter of Alcoholics Anonymous for women in these states. Consequently, these women are effectively trapped in a cycle of alcohol dependence, which is challenging enough to recover from even when appropriate resources are available and accessible. Somewhat in contrast, those women who were dependent on injectable opioids such as heroin and Spasmoproxyvon have the option of registering to receive opioid substitution therapy (OST) as treatment for their opioid dependence, and there is at least one drug detoxification and rehabilitation centre that caters for women specifically. The literature indicates that women dependent on substances are less likely, over their lifetime, to enter treatment compared to men, but gender does not predict treatment retention, completion, or outcome if given the opportunity of treatment . The participants in this study frequently emphasized the desperate need for women-only and women-friendly drug and alcohol detoxification and rehabilitation centres that are low cost and can accommodate children .
HIV risks for female drug and alcohol users
The relationship between HIV risk behaviours and alcohol use has not received as much attention as the risks associated with injecting drug use and sex work , even though sex and alcohol use are frequently co-occurring behaviours all over the world. In a large study of women and substance use in India, Murthy noted that 60% of female substance users believed that substance use makes sex more enjoyable and less painful . A survey among migrant FSWs in fourteen districts of four high HIV prevalence states (Andhra Pradesh, Karnataka, Tamil Nadu and Maharashtra) found that 54% consumed alcohol prior to sex, and that alcohol use was associated with inconsistent condom use . Many of the FSW participants in our study said that they used alcohol in order to overcome the shame of engaging in sex work, and to cope with having sex with their clients. Thus it may be difficult for FSWs to reduce their alcohol use in the absence of alternative sources of income, and this has consequences for their ability to negotiate safe sex, and therefore their risk of HIV infection.
A link between alcohol use and unsafe sex is an important one, particularly in the state of Nagaland where the evidence suggests that sexual transmission of HIV is probably the major driver of the epidemic, which is somewhat different from the neighbouring state of Manipur where HIV transmission through unsafe injecting is still making a major contribution to the epidemic. Women who are injecting drug users can access a range of services through HIV prevention NGOs including STI management, needle & syringe and condom distribution, abscess management and basic health care. In contrast, women who are dependent on alcohol are not eligible for services provided by these NGOs unless they are engaging in sex work, as the NGOs are mostly funded to target HIV prevention services to specific high-risk groups (IDUs, FSWs, or men who have sex with men). It is likely that fear of discrimination because of their alcohol dependence would inhibit these women from accessing any mainstream health care services, even though many of them experience a range of health problems .
As alcohol is an illicit substance in Manipur and Nagaland, its consumption is inherently risky. The quality and serving of alcohol is totally unregulated, and venues that sell alcohol, while commonplace, are nevertheless trading outside of the law. Young women entering this world are vulnerable to a range of hazards including STIs, HIV, substance dependence, and violence . While the (female) participants in this study provided vivid descriptions of unsafe sex linked to their own alcohol use, it is probable that alcohol use by men is also making a substantial and direct contribution to the occurrence of unsafe sex and sexual violence, and therefore a contribution to the prevalence of HIV and other STIs in these two states. Therefore, interventions to minimise the harms caused by alcohol use should target both women and men.
These study findings raise a number of key questions that need to be answered if the situation of women drug and alcohol users in Manipur and Nagaland is to be improved: How can HIV prevention NGO programs reach vulnerable women (non-injecting) drug users and alcohol users when they are only funded to target key population groups that do not generally include such women? If the NGO programs are not able to reach these women, who can/will? Women drug and alcohol users in India generally prefer to receive health care services through NGOs , so it would be beneficial if the HIV prevention NGO services currently offered to female IDUs and FSWs were extended to include other vulnerable women such as (non-injecting) drug users and alcohol users. This especially applies to safe sex promotion (including the distribution of condoms) and STI clinic services. Some of the participants mentioned that they were HIV infected, and it is highly likely that others are unknowingly HIV infected. The negative effects of alcohol on the progression of HIV disease are well recognised , so infected women need to be identified, offered treatment, and provided with relevant health promoting information.
This study has a number of limitations that should be considered when interpreting the findings. There could be some selection bias because the FGD participants were recruited through the NGO networks, but this is somewhat offset by the fact that the NGO workers deliberately recruited participants who were not recipients of their services. It is also possible that the women participating in the study are at the more chronic end of the drug and alcohol dependence spectrum, and therefore more conspicuous for recruitment into the study. Given the sensitive nature of the questions about socially taboo behaviours of women, some participants may have been inclined to provide more socially acceptable responses, at the expense of valid responses, resulting in bias. It is a qualitative investigation so findings cannot be generalized to all women drug and alcohol users in Manipur and Nagaland. A follow-up survey with a representatively sampled group of women would strengthen the findings.