Features- Female drug users on the rise

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Female drug use on the rise in Manipur
By Namaram Kishalaya

The population of female drug users in the state of Manipur has risen to an
alarming proportion. This was indicated in a report prepared by H Dineshwar of the The Kripa Society, Imphal and Mukta Sharma of the London School of Economics. The latter was an external consultant. The report was part of the UNESCO's "Five-City RSA" study. The Kripa Society or popularly known as "Kristy" conducted and implemented the "Rapid Situation Assessment (RSA) of drug use in Imphal" in collaboration with Sharan, New Delhi.

According to the report, most female drug users are from the age-group of 25 to 29 years, which account for 43%. Age-group of 30years and above consist of 30% of the users, 10% belong to the 15 to 19 years age-group and the 20 to 24 years age-group comprise 17%.

A majority of female drug users are from north AOC, Lamphel, Old Lambulane, Checkon and Deulahland areas of Imphal. Most female drug-users had migrated from different districts of Manipur particularly after the ethnic clashes between the Nagas and the Kukis.

Out of the total RSA sample the highest 40% of the female drug-users are married and 30% are unmarried, 27% are divorced and 3% are widows. Most female drug-users are either engaged in drug peddling or sex work as their main occupations. In the RSA sample, 51% of the females are peddling drugs and 27% are engaged in commercial sex work and 13% are running small businesses as fish mongers, tea vendor and pan-shop owners. Female drug users engaged in commercial sex work (CSW) earn around Rs 900 to Rs 1500 a day. It has been observed that most female drug-users work as CSW and earn around Rs 9000 a month minimum.

Heroin is the most common drug in use amongst the female drug-users in Imphal. The study shows that a majority 80% of the female drug-users used Heroin as their primary drug in the last month and 7% used Spasmo-Proxyvon capsules, pills and alcohol at 3% each respectively. Injection of non-injectable capsules (Spasmo-Proxyvon) have also increased among female drug users. 73% of female drug users are injectors and 27% are non-injectors. While a total of 27% of the female drug-users started directly with Heroin, 60% of the female drug users started with alcohol.

The report said, curiosity and frustration are the most common reasons for starting drug use among the female users (33% and 30% respectively). Pleasure and peer influence are also other important factors for using drugs at 23% and 10% respectively. It has also been found that most female users started using drugs due to depression, family problems and influence by their drug-using husbands. Out of the total RSA sample, a majority 66% of the female drug-users used drugs with members of the opposite sex followed by 34% of them who had not used drugs with members of the opposite sex.

While a total of 87% of the female drug-users had experienced sexual
intercourse, only 13% responded that they never had experienced sexual intercourse. All respondents had sexual intercourse for the first time with their boyfriends. Most female drug-users have their first sexual intercourse between the ages of 12 to 20 years. The report also pointed out that 37% of the female drug-users had 2 to 3 partners in the last one year. Twenty-six per cent of them had only one partner in the last one year. It has also been found that female drug-users cum CSW had 3 or 4 sex partners in a day to meet their daily requirements. A majority 80% of the female drug-users had sex with other than their spouses. It is evident that there is a high rate of extra-marital sex among the female drug-users.

The level of knowledge about HIV/AIDS among female drug-users is very poor even though many of them have heard about it, the report said. It pointed out that 10% of the female drug-users have never heard of HIV/AIDS. Besides very few of them have the correct information about HIV/AIDS. In the RSA sample, only 17% have complete knowledge (on HIV/AIDS), 75% have incomplete knowledge, while 8% of them have no knowledge at all. It indicates that various HIV/AIDS awareness programs conducted in the state rarely reach the female drug users.

Most female users have the knowledge about condoms and its importance in protecting various kinds of sexually transmitted diseases. However, due to individual circumstances and other social factors, male sex partners rarely use condoms. Seventy-five per cent of the sex partners of female drug-users do not use condom while having sex, only 25% of the partners use condom. Twenty per cent of the female drug-users suffered from diarrhea more than once in a month and 17% suffered from fever in the same period. Pus and burning with urination is 17% each respectively. Ten per cent suffered from loss of body weight and ulcer over the genitalia and 3% suffered from TB, jaundice and growth over genitalia respectively. Forty percent of the female drug-users go to private practitioners while 60% administer self-medication for treatment.

Most female drug-users prefer to go for home detoxification. RSA report shows that 30% of them preferred home-detoxification while 10% of them prefer substitution therapy. Ninety-three per cent of the female drug users have never been to jail and 7% of them had been to jail. Out of the RSA sample, two female drug users managed to get drugs inside the jail. The female users have little knowledge about treatment centers and other services provided for drug problems in the city.

The report pointed out that 56% of the female drug-users have incomplete knowledge about the treatment centers available and 43% of them have
no knowledge of the treatment centers. Only 1% of them have complete knowledge of the treatment centers. The report also said, while harm reduction is an effective public health strategy particularly in the context of HIV/AIDS and other blood borne infections related to injecting drug use, the authors of this study feel that there is a real role for supply reduction and demand reduction as well. Supply reduction strategies need to be put in place not only vis-à-vis Heroin No. 4, but also for pharmaceutical drugs that are available too easily over the counter. These have been identified previously in this document.

Strategies for the prevention of initiation into drug use and initiation into injecting are areas that need to be strengthened and reviewed. Treatment strategies inside treatment centers are overwhelmingly abstinence-focused. This excludes drug-users who are unable to or do not wish to give up drugs completely from access to services. We recommend that alternative approaches such as maintenance therapy be given a balanced and pragmatic hearing in this context. Treatment is inaccessible for many drug-users because it is expensive, too time consuming and overwhelmingly focused in Imphal.

Treatment services must be geared to providing maximum access to as many drug-users as possible. Qualities of services are variable and are not frequently user-friendly. Treatment centers still continue the methods adopted more than a decade ago. There is serious need to review and modify the treatment models to be able to cope with the ever-changing trend and pattern of drug use.

Outreach and follow up services need to be strengthened particularly in the case of treatment for drug abuse. Outreach services for prevention of HIV in the delivery of interventions such as NSEPs are crucial and must be accorded prime importance. Imphal has a considerable number of drug users, many of whom are also involved in sex work. Treatment services for them are inadequate. Where they exist, they have a biblical and moralistic approach. This simply is not an effective treatment strategy as when women leave these institutions they are unaware of interventions such as NSEPs, STD prevention and condom use and how to access them effectively.

HIV/AIDS prevention services in the state as delivered by RIAC do not have adequate coverage. Elsewhere in the developed and developing world, it has been established that at least 70 to 80 percent of the target risk group must be covered. This is simply not being achieved in Imphal. The number of needles and syringes being circulated within the IDU population needs to be increased dramatically.

At the moment less that 1 percent of all injections is covered by a new needle and syringe. Sexual-behavior-change strategies and delivery of required services are also very poor. Most IDUs who are offered condoms as part of the RIAC program simply refuse to accept them as quality and packaging are unappealing.

Majorities of the male drug-users are aware of how HIV/AIDS is transmitted but continued to practice unsafe sex. Hence, it is necessary to empower the women to negotiate safe sex with their partners. Further, education should also be focused more on female spouses and girlfriends.

There is a desperate need for creating an enabling environment for nurturing safe injecting and sexual practices. Punitive measures and incarceration of drug-users by both law enforcement agencies and local insurgent groups pushes drug-users underground. Therefore they are unable to access services, and even when they are able to access them, their effectiveness is considerably reduced.

To this end we call for a review of paraphernalia law and intensive community awareness campaigns covering all stake- holders. While most people have heard of HIV/AIDS, a much smaller proportion has comprehensive knowledge of prevention and transmission of the disease. The RSA team urged the governmental and non-governmental sector to refocus some of their prevention strategies in this area. There is no proper documentation of various activities undertaken by the governmental and non-governmental sectors. This hinders evaluation and research. It also leads to the loss learning from programs that have been effective and could be replicated elsewhere.

Training and capacity building activities need to be ongoing. The model of
training seen most frequently is workshop and seminar based. This does not allow the incremental process of skill development. Counseling services are very weak. Four counselors are available for pre and post- test counseling during office hours. This has a very detrimental impact on voluntary testing and information/knowledge levels of people who may be interested in accessing services and adopting behavior change strategies.

There is severe resource constraints- both financial and human-in the fight
against drug abuse and HIV/AIDS in the city. Delays in release of funds and lack of continuity and leadership in the program have intensified this problem.
A policy and strategy on proper & systematic disposal of old used needle & syringe is urgently required as drug-users carelessly and randomly dispose their used N/S thereby creating a problem in the community. Though the Manipur Government endorsed harm reduction and NSEP, there is still need for policy makers, LEA and the communities in the city to be sensitized to the issues related to drug use, its public implication and its harmful consequences. The non- governmental sector and community resources must be utilized by the government to engage in advocacy and service-delivery activities.

Most drug-users have had no prison experience.There is a need for drug and HIV/AIDS education, particularly on safe practice. It is seriously and urgently required for the prison inmates as many prison inmates indulge in risky behavior such as injecting and male homosexuality.

The care component is quite inadequate with the rate of people developing
opportunistic infection and the ever-increasing demand for this service. There are two care workers available in each NGOs implementing RIAC project in the state. No service of a professional doctor or nurse is available. There are two hospices with a ten-bed capacity in the state with one each at Churachandpur and Imphal.

Failure in the governance and administration of the state is also an immense
obstacle in prevention and intervention programs on drug abuse and HIV/AIDS. Political instability, insurgency and current financial situation of the state all contribute to the ineffectiveness of various programs. Total breakdown of law and order in the state, frequent bandhs, strikes, curfews, road blockade, counter insurgency operations, etc. make the people less concerned about the problem of drug abuse and HIV/AIDS.

Community people are more concerned about the decades-old insurgency problem and its related consequences, such as involuntary disappearance and killing. With current state of affairs in Manipur both political and financial, the community people have little interest in the issue of drug abuse and HIV/AIDS.

Most people consider HIV/AIDS and drug abuse as a moral issue and there is very little chance of community people owning up this issue. The concerned governmental and NGO sectors need to review their community approaches and its effectiveness.

Stigmatization of people with HIV/AIDS and of drug-users is still very strong in the community. Drug-users are still harassed and humiliated in the public if
caught or arrested. Till today local newspapers continue to publish the pictures of drug-users and peddlers caught or arrested in the paper along with the details. Such attitude prevailing in the community make drug-users difficult to access to various intervention services offered such as, NSEP, maintenance, condom, etc.

Some of the recommendations cited in the report were:

Improving quality of services to risk-groups and increasing coverage of services to at least 70 per cent of those at risk. Increase allocation of resources and ensure steady flow of the same in areas of HIV/AIDS prevention and drug treatment services. Develop suitable IEC materials in different local languages and audio-visual media, which address the issues of drug use and HIV/AIDS. Packaging and quality of condoms distributed free as part of various sexual health interventions need to be improved to make them more attractive to users. Sexual health counseling and user-friendly treatment services, especially for adolescents and women need to be strengthened and expanded.

Drug treatment:

Treatment should be a comprehensive package, which includes abstinence, education/information of HIV/AIDS, harm minimization and adequate referral services to harm minimization centers. Duration of treatment must be flexible to address needs of the individual client. Expand existing levels of treatment slots offering alternative models of treatment. To develop community based programs with a view to long-term sustainability.

Capacity building/training and advocacy:

Upgrading of counseling skills to address the changing patterns of drug/alcohol use. Train staff to undertake documentation, evaluation and research. The government and non-government sectors should engage in advocacy on different levels encompassing policy makers, law enforcement, community and pressure groups. Advocacy should include discussion of legal and ethical aspects pertaining to human rights of those living with HIV/AIDS and drug users and their spouses.

Prison:

Sexual health intervention program. Condom distribution and appropriate IEC materials related to HIV/AIDS must be implemented in jail. Referral to outside agencies for drug use treatment and its related complications. Minimizing marginalization of drug-users within the jail and Self Help group meetings in prison should be conducted.

Gender:

Services for women users should be women friendly providing comprehensive continuum of services with alternative approach including effective sexual interventions, non-formal education as also means of sustainable livelihood by formation of co-operatives and micro-credit facilities.

Counseling:

Increase in the number of professional & trained counselors who are able to provide specialized counseling on drugs & HIV/AIDS. Rotation of counselors to prevent stress and burn-out and if possible develop exchange programs between Imphal and other cities of India.

(ManipurOnline Media Services)

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