Women who use drugs, HIV and Hepatitis

Social stigma attached to WUD and HIV can represent a huge barrier to their access to harm reduction services, drug treatment, HIV treatment, sexual and reproductive health care and other medical services. Many programs for drug users do not respond to the specific needs of women.

HIV testing and counselling (HTC) is the initial connection to HIV prevention, treatment and care services for PLHIV and should be offered to WUD at least annually. Testing and counselling services prove to be effective when they succeed in reducing barriers for WUD’s access to antiretroviral therapy (ART) and in providing referrals to WUD-friendly HIV clinics that have good experience in working with women who use drugs. It is important that they adhere to the “5 Cs” principles—consent, confidentiality, counseling, correct test results and connection to follow-up services, and that they deliver services respectfully and without coercion, judgment, stigma or discrimination. Comprehensive pre-test counselling for WUD who are or may become pregnant should foresee information on the risks of transmitting HIV to the child and on how to reduce such risks (including antiretroviral prophylaxis and counselling on infant feeding), and the benefits to the child of early diagnosis of HIV.

WUD can successfully adhere to ART and many WUD living with HIV decide to initiate and sustain treatment where ART is accessible, affordable, and available. This important step should not be blocked by misguided laws and policies stating that drug use and/or OST are not compatible with ART.

Antiretroviral prophylaxis and infant feeding counselling are important interventions for the prevention of mother- to-child transmission (PMTCT). Some harm reduction services include ways to directly provide or organize the provision of ART for pregnant and nursing WUD living with HIV either on-site or through referrals. Provider-initiated HIV testing and counsellingis recommended for WUD who are pregnant or living with TB or hepatitis C, ensuring it is in no way coercive. HIV-negative WUD should be tested at the beginning of each new pregnancy and should be recommend another test late in pregnancy. Counselling on gender-based violence is recommended as part of post-test counselling.

WHO recommends four approaches for a comprehensive PMTCT strategy:

1. Primary prevention of HIV infection among women of childbearing age;
2. Preventing unintended pregnancies among women living with HIV;
3. Preventing HIV transmission from women living with HIV to their infants (including HTC, ART, safe delivery,
4. safer infant feeding, post-partum interventions in the context of ongoing ART);
5. Providing appropriate treatment, care and support to mothers living with HIV, their children and families.

Therefore, WUD living with HIV should receive special, multidisciplinary care, especially when they learn about their HIV status during pregnancy and face multiple problems. The following services should be put in place to support them:

• specific counselling and possibly peer support on HIV related issues, in order to sustain adjustment and coping with the new condition in a delicate phase of their lives;
• interventions to reduce risk of vertical transmission from mother to child;
• counselling and support for treatment adherence, correct nutrition, parental training, stabilization of drug use and OST;
• antenatal and intrapartum ART with ART for the newborn;
• delivery by Caesarean Section in selected cases.

HEPATITIS AND VACCINATION

Pregnancy is not discouraged for women living with hepatitis C. The risk of maternal-fetal transmission of viral hepatitis during pregnancy is relatively low. It is essential to note that the risk greatly increases if the mother is co-infected with HIV. Hepatitis B virus (HBV) vertical transmission rates are around 10–20% for most women co-infected with HIV. The screening for Hepatitis B - (HBV) surface antigen identifies women who are infectious; the immunization of newborns prevents vertical transmission of HBV from the mother to her baby. WUD should be offered combined immunization against HBV (Hepatitis B) and HAV (Hepatitis A), since immunization is safe during pregnancy. An accelerated vaccination regime is recommended – vaccinating at 0, 1 and 2 months or even 0, 7 and 21 days. After the accelerated regime, another booster dose is required at month 12.

HBV vaccine is beneficial for all babies and, provided that the baby is immunized at birth, breastfeeding is not contraindicated. Although the hepatitis B and C viruses have been found in breast milk, HCV is not transmitted through breast milk. Most experts agree that it is safe for women with hepatitis C to breastfeed their babies if specific precautions are followed. For example, if the mother has cracked and bleeding nipples, breastfeeding should be stopped until the nipples have healed and bleeding has ceased.

As yet there is no vaccine available for HIV or HCV.