Female partners of injection-drug-using men in the Republic of Georgia are at high risk for contracting HIV and HCV. This is the first study that describes the prevalence of HIV and HCV among this recently identified high-risk group of illicit-drug-free female partners of opioid-injecting men in the Republic of Georgia, almost all of whom were married.
When asked about their HIV status only one woman reported that she was HIV-positive, half said they were HIV negative, and more than one third stated they were never tested. A small number of women reported being infected with HCV, almost two-thirds said they were HCV-negative, and close to one in four stated they were unaware of their status. It has been reported that stigma against and fear of discrimination has led many people in Georgia to conceal a positive HIV status. This situation might be the case for some of the women in the present study as well, and may extend to revealing HCV status. Kirtadze et al. examined the attitudes and beliefs of 34 health service providers in Georgia who had contact with injection-drug-using women. These providers indicated less tolerance towards such women, believing they were failures as a good mother, wife, or child. The authors concluded that drug-using women in Georgian culture were “twice stigmatized” – as failed mothers/wives/daughters, and as less acceptable than men, even drug-using men.
In addition, the parent study records suggest that male participants refused HIV testing due to the fear of being diagnosed positive (e.g., “It is better if I do not know if I am infected”), and refused HCV testing due to lack of available treatment options (e.g., “even if I am positive there is no treatment that I can afford”). This might well explain low motivation of participants, both, males and females, to know their health status.
Half the women reported not being worried about contracting HIV/AIDS and less than one in five reported being considerably or extremely worried about being infected with HIV/AIDS. The low prevalence of concern is surprising since a majority of women with HIV in Georgia have been infected from a partner who injects drugs. The limited understanding of and attitude towards HIV/AIDS in Georgia suggests that there may be a serious lack of available information about risk factors for HIV infection. Alternately, there may be a taboo among Georgian women to express worry about contracting HIV/HCV, due to the heavy social stigma associated with these infections. Moreover, the fear of being arrested and a lack of trust in health care providers contribute to the fact that only about 5% of injection-drug-using adults in Georgia are tested for HIV on a regular basis. Therefore, it may be the case that the prevalence of HIV is notably higher among injection-drug-using adults than what has been estimated.
Moreover, despite a low average sex risk score, only 1 in 10 women reported that her partner used a condom most of the time. The women may be influenced by the widespread belief among Georgian women that if they are not injecting drugs or are sex workers, they are not at risk of HIV or HCV infection. Safe sex would be a protective factor against HIV and HCV for the women. However, other studies have also found that sexually active women in Georgia rarely use or discuss using condoms with their partners. More than a third of the women reported not having had sex during the last 30 days. These results merit further research to determine the extent that low rates of sexual activity are related to the slow spread of HIV and HCV among women in the Republic of Georgia. Previous research has revealed a low level of knowledge of HIV risk factors and high prevalence of unsafe sex among the general population in Georgia. Inadequate knowledge of HIV risk factors and methods for HIV risk reduction seem to be a widespread problem in Georgia. Results of the present study would suggest that unsafe sex frequently occurs in an extremely high-risk population, non-drug-using female partners of injection-drug-using men.
High-risk injection practices are common in the Republic of Georgia. Previous research reported that in some subgroups more than four out of five opioid-injecting drug-using men in Georgia are sharing needles with others[26, 27]. Thus, even if the opioid-injecting male partners of illicit-drug-free females are not having sex with other women or men, the male partner remains at high risk of getting infected with HIV and HCV and passing these infections to his female partner through sexual contact.
The women generally perceived themselves as supportive of their partners’ efforts to reach and maintain abstinence.
Seventeen women (43%) had experienced physical abuse by their partner within the last year prior to the interview and close to half reported feeling unsafe in their current relationship. In a study including more than 1,000 women in the general population in Georgia, 6% reported experiencing physical violence and 11% sexual violence during the last five years. This study measured all physical and sexual violence, not just violence by partner. Another study including close to 8,000 women in Georgia reported that 2% had experienced physical abuse and 3% sexual abuse by a partner during the last 12 months. Females in a relationship with an opioid-injection drug-using male partner seem to be at increased risk of experiencing interpersonal violence compared to the general population of women in Georgia. Another health risk is that the drug-injecting man will initiate his partner into drug use. Women commonly start using drugs because of their partner[29, 30]. Preventing female partners of opioid-injecting men from initiating drug use is a critically important goal. Including these women in their partner’s treatment program might enable them to improve their relationship with their partner, learn how to resist the use of illicit drugs, and better support their partner in his rehabilitation.
First, the sample size of the present study was relatively small. Therefore, the findings need to be interpreted with restraint. Second, selection bias that attracted motivated males in a stable relationship with an interest in treatment might have operated to yield a sample of men who are more likely to engage in safe sex practices. It is difficult to determine the extent to which this statement might be true, given the high non-response rate regarding HIV and HCV infection for the male as well as the female participants. Selection bias may have been further compounded by attrition. Thus, the small sample size and the impact of both selection bias and attrition may have adversely impacted the ability to determine precise estimates of HIV and HCV in the population of non-substance-using female partners of injection-drug-using men. Third, a relatively large number of men who expressed an interest in participation in the parent study failed to enter the study: 19/74 (26%) failed to show up for their intake appointment, and 15/74 (20%) were determined to be ineligible. Because information on the women in the present study is gathered from the female partners of the male participants, such a relatively high rate of participant loss potentially limits the generalizability of the findings. However, the rate of non-participation is not unexpected, because the parent study focused on attracting non-treatment-seeking men into treatment. Fourth, stigma and the attendant fear of disclosure may have operated to restrict the range of responding and increase the chances of socially desirable responding, also limiting our ability to generalize our findings. Fifth, HIV and HCV status was based on self-report measures. Thus, the reliability of such data depends on truthful answers from respondents. Sixth, there was a relatively large amount of missing data on for the questions regarding HIV and HCV status, because the women failed to answer these questions. Being either HIV-positive or HCV-positive is associated with considerable stigma in Georgia, and fear of stigmatization may have influenced some respondents to refuse to answer these questions – or, potentially to answer in socially desirable ways. Finally, information on sexual violence or abuse independent of physical violence was not collected.
Strengths of the study
Research on non-opioid-injecting female partners of opioid-injecting men is scarce, both in the Republic of Georgia and elsewhere. Information about HIV status, HCV status, sex risk behavior, concern about getting HIV and interpersonal violence may prove invaluable for designing HIV interventions for injection-drug-using men and their female partners. We can envision that public health efforts should be focused in two directions. First, efforts need to be made to provide additional information to potentially sexually active Georgian women – particularly female partners of injection-drug-using men – that barrier protection methods are the best protection against HIV and and HCV infection. Second, providing couples therapy in some form, even if only for 2–3 sessions, may allow for direct outreach and education of both members of the couple on the risks of HIV and HCV infection.