Abstract
Background:
Drug-dependent women are the vulnerable population deprived of access to health services and also have particular relevance to public health perspective because they are important bridge population for driving HIV/AIDS epidemic. This qualitative study aimed to explore the perception of drug-dependent women regarding HIV testing.
Methods:
In this qualitative study, we approached 23 women with substance use disorders in 2 of the selected drop-in centers in the south Tehran. Focus group discussion, face-to-face semistructured interviews, and field notes were used to collect the data. Qualitative content analysis was used to extract the explanatory model of women’s perceptions about HIV testing.
Results:
Four main themes emerged from the data: forgotten health during use, having misconception, and sharing of sexual partner in secrecy and concerns. Seven subthemes were extracted, including not being sex worker, point of ruin, voluntary selection and concerns about fear of abandonment and fear of loss and death, double concern, and future of children.
Conclusion:
Beliefs and values of drug-dependent women can be positive points leading them to do an HIV test, and misconceptions of these women would be corrected by using safe behavioral skills training.
Introduction
Women are more likely than men to use drugs and become dependent on substances and engage in more HIV risk behaviors in relation to substance use. 1 Drug-dependent women are deprived of access to health services. In addition, this population of women has particular importance from a public health perspective. They are considered as important bridge population in increasing the HIV/AIDS epidemic. 2 Increase in HIV trend among women have been indicated among people living with HIV. 3 In Iran, the number of involved people with HIV were 30 183, and 15% of them were women; the most common route of HIV transmission was injection (67%). Sexual relationship and unknown mode have been diagnosed in18% and 12%, respectively, in 2015. 4 Currently, Iranian studies indicate that in Iran 9.6% of the drug-dependent people are women representing increased tendency to substance abuse in Iran. 5 Substance abuse increases the transmission risk of HIV through the risk behaviors it engenders and influences people’s judgment leading to unsafe sex behaviors including inconsistent condom use, trading sex for drug, money, or shelter as well as unsafe injection practices such as sharing used syringes. 6 Results of a study in Iran showed that women start substance abuse in young ages with drugs of less detrimental effects such as hashish. Then, they abuse heroin gradually. Co-use of heroin crack with methamphetamine has more detrimental effect on health. 7 Evidence shows that the use of stimulant substances may be associated with high-risk sexual behaviors, which put people at risk of sexually transmitted diseases and HIV. 8 Methamphetamine use may trigger the growing HIV/AIDS epidemic. Therefore, it is important to encourage drug users to perform HIV test. 9 In India, like Iran, women who inject drug can be referred to drop-in centers (DICs), particularly nongovernmental organizations, for treatment of sexually transmitted disease and distribution of syringe and condom. 10 Nevertheless, there may be barriers to female abusers to go for testing and counseling sexually transmitted diseases. Stigma and discrimination are the main factors increasing susceptibility to HIV infection by reducing access to HIV testing. 11 Given that prevention of high-risk behaviors depends on increased knowledge and improvement in attitude and beliefs, 12,13 qualitative research will help to collect rich data. Role of feeling, attitude, belief, and values of this group of women is important for preventive measures. 14 Thus, the unique subjects concerning intention and performance of high-risk behaviors can be explained, and preventive strategies be clarified through the qualitative research because there are many unclear questions as to how drug-dependent female with high-risk behavior think about getting a sexually transmitted diseases or HIV? What are their experiences of healthy behaviors such as testing and counseling? The current study aimed to understand perception of Iranian drug-dependent females with high-risk behaviors for HIV/AIDS.
Methods
This study was a qualitative study and employed content analysis approach. 14,15
Sample/Participant
We approached the participants in the selected DICs, comprising 23 females who used drugs. We included those who were sexually active and above 18 years with substance use disorders. We explained the objectives of the study and obtained the verbal and written consent prior to data collection. Long-term and continual attendance of the researcher (M.J. and E.M.K.) as a midwife and sexual health specialist in these centers had facilitated rapport and familiarity with the context and clients and assisted recruitment. Women used to refer to the researcher to receive information and seek for help about their reproductive and sexual health issues. Volunteer women attended the selected DICs to participate in our study.
Data Collection
The ethics committee of the Shahroud University of Medical Sciences approved the study. This study was carried out from December 2014 to May 2015. We could have access to the maximum variation from a number of female drug users. Women (n = 21) attended 4 focus group discussions (FGDs) with 5 or 7 participants in each group. Individual interviews were also conducted with 2 women who didn’t attend FGDs because of unwillingness. Demographic characteristics of drug abuse women are shown in Table 1.
Demographic Characteristics of Drug Abuse Women With Risky Sexual Behavior.
Semistructured and in-depth interviews were conducted in private and descriptive writings, and notes were taken. All interviews were audio recorded and transcribed verbatim by the research team.
The FGDs were held to further explore current drug problems of women and their sexual experiences. The interviews and group discussions began with a general question as the interview guide and were carried out flexibly with open-ended, descriptive questions. The main questions were “how will you feel if you find out that you are HIV positive?” and “what are your reasons for HIV testing or not?” Also, more probing questions were asked such as “Can you give an example? Can you more explain? and Do you mean that?” (see Table 2). Each group or individual interview lasted between 60 and 90 minutes. The purpose of the FGDs, which it helped in creating data, 15 was to further explore the drug-dependent women’s perception toward HIV testing and their experiences of doing that.
The Main and Probing Questions in Interviews.
Data Analysis
All handwritings and tapes were marked with codes that specified the order of interview. Substantive statements were identified using the principles of content analysis and emerging patterns noted. 16
To open semantic layers of life, experiences, and beliefs, conventional content analysis was employed as the best approach that emphasizes on creation and development of categories and interpretation of text with inductive method. In this type of analysis, categories are extracted directly from textual data. Hidden contents and models can be clarified from the content. 14,16,17 Furthermore, we compared our own initial analysis with the key informants to confirm the overall agreement on the substantive statements. All interview transcripts were read word by word several times to extract codes. Texts were encoded during the interviews. Partial codes were classified as a subset in more general titles.
The unmarked transcript of the first FGD and 2 of the individual interviews were reviewed by the research supervisor and a colleague from other discipline for identification of the patterns and substantive statements because the researcher’s own judgments could be rechecked. The performed activities and its stages were recorded accurately to ensure confirmability. Continual engagement of the researchers (M.J. and E.M.K.) with the field and the participants increased the data reliability. To enhance transferability, 2 substance user women who were not the study participants were asked about adaptation of findings to their experiences. Throughout the entire research process, we used pseudonyms as an essential step to protect permanently the participants’ identities.
Results
Four main themes emerged from the data: forgotten health during use, having misconception, sharing of sexual partner in secrecy, and concerns. Seven subthemes were extracted, they included not being a sex worker; point of ruin; voluntary selection and concerns about fear of abandonment, fear of loss, and death; double concern; and future of children.
Forgotten Health During Use
Based on the participants' narratives, women felt desperate for drug as well as money in an extent that they hardly pay attention to their overall health. Women volunteered to HIV and hepatitis testing when they thought to quit drug. They were referred to DICs to receive methadone and sometimes seek for screening of sexually transmitted disease. As participant no. 3, (FGD2), a 40-year-old who had used methamphetamine for 16 years, said: No one has motivation at time of drug use because she can’t pay for it or has no hope for life and can’t go for test. She doesn’t pay attention to her appearance and dress and she doesn’t like to go testing. That is why I went to testing after I wanted to quit drug.
Having Misconception
Most participants in this study had myth and misconceptions about HIV and hepatitis.
Not being sex worker
They believed that only sex work caused HIV transmission. For them, an injecting drug use history was a perceived threat. In other words, they assumed a very low probability of HIV infection in the absence of these 2 factors.
The participants’ narratives showed that although they had multiple sexual partners in their lives, they were not in concurrent sexual relationships and they did not consider themselves as sex worker. The participants believed that the presence of 1 partner as a peer in drug use, their equal level of socioeconomic class, emotional support and commitment to each other, and lack of extrarelational sex with someone else could be barriers for getting HIV. Based on this perception and feeling, they did not view themselves at risk.
As participant no. 1 (FGD 3), a 44- year-old, 31-year drug user mentioned: After my first husband, I lived with someone for two years. Then, I had a boyfriend. I didn’t have any relations with someone else at the same time. My second husband and my boyfriend were prisoner previously for drug and didn’t have HIV and Hepatitis tests. I am afraid of AIDS, but I think why I should get HIV because I had not been sexual relation with more than one man. I have tried to have one friend…. I had a relation with the man who I liked. I had several sexual partners, but I had sex with just one person at one time and when I separated from him after a while, I became familiar with other person. For the woman who has sex for money may be important to use condom but I was only smoker and I hadn’t sex to earn money. That is why I didn’t insist on the use of condom. I did an HIV test one time but my sexual partner didn’t test up to now. I knew that he might have sex with other women.
Point of Ruin
Most participants stated if they become infected with HIV, they would continue risky behaviors by increasing drug dose, relapsing to substance use while being cleaned, or choosing to inject substance because they believed that becoming infected with HIV meant that their lives have ended.
Participant no. 3 (FGD4), 39 years old, 20-year drug user, mentioned: I tried to quit drug. I decided to do HIV and other testing. I told one of my friends that I would return to use meth if the test result becomes positive and I get hepatitis. I feared a lot. The women who find out that they are infected, don’t care to use condom because they think that their lives has ended and that if they are supposed to live in this way [with HIV] for 4 years, it makes no difference whether they live for 2 years or less because what good is living with HIV in a dirty dorm.
Voluntary Selection
In this study, there were not any sex worker women who accepted it as a profession. Despite sex act in exchange for money and drug, our participants believed that this exchange did not mean sex work. The participants perceived high threat when they were raped by a strange man.
As participant no. 5 (FGD3), 42-year-old who had used methamphetamine for 16 years, said: I did not inject yet and had no sex with anyone. I lived in street for a while…I thought myself that someone might have been sex with me when I were unconsciousness. For this reason, I feared that I might be infectious. They may be HIV positive and transmit it to me. When you use crystal or methamphetamine, you become unconscious because it makes you awake for some days and when you use low dosage, become bothered. I had such an experience once and when I woke up, I saw that I was unclothed in a solitude place lonely.
Sharing of Sexual Partner in Secrecy
Sharing of sexual partner in secrecy was another issue obtained from the findings. Most women declared only when counselor or laboratory team asked them to introduce a familiar person for informing about HIV test result and they nominated their sexual partners as the first reliable person. They preferred to inform their sexual partners about their sero-status as the first person and intended to hide their HIV status from their families.
Participant no. 2 (FGD1), 30 years old, 18 years of substance user, declared: When I wanted to do hepatitis and AIDS test, they asked me if I like to inform my close relatives if the result is positive. I answered that I preferred to inform the man who I am with him because I thought that he supported me and I didn’t have anyone else to inform my mother or sister.
Concerns
For some reasons, most participants mentioned that for them voluntary HIV testing was associated with fears and concerns about getting positive test result. The emerging themes confirm this claim.
Fear of Abandonment
Some participants were worried that they could not afford to treat their disease due to high-cost medications and their low economic status. In addition, lack of shelter made them very much worried.
Participant no. 2 (FGD4) said: We haven’t got any money. It is very bad because tests and drugs are very expensive. If we get HIV, we will become helpless. It is very important where a person dies because we haven’t got any shelter and lives in street. It is fearful. My friends don’t get close to me and I fear that I lose the people who are close to me.
Fear of loss and death
In addition to the participants’ concerns about social deficiencies and health problems related to the disease which played important role in quality of life, female substance abusers thought that they would lose their hopes and wishes in their lives.
Some participants feared that their mental health would be affected by HIV disease. Participant no. 4 (FGD1) says that It is very important for me not to lose my spirit.
As participant no. 1 (FGD 3) said: It [HIV] leads to bad death.
Double concern
While the drug use was a main concern for the drug-dependent women, and supply of drug was an issue that engaged their minds all the time, the concern about HIV infection was also added to their concerns. In fact, affliction by HIV was superimposed on life difficulties, and chaos resulting from addiction caused a double concern for the women.
Participant no. 2 (FGD1) said in this regard: If it is positive, I can’t do anything. I only know that a misfortune will be added to my misfortunes. My misfortunes will increase hundredfold. I’ll reproach myself for not being careful.
Future of Children
Attitude of society toward identity of children with HIV-infected mothers was a disturbing issue for the drug abuse women. The participants believed that if they share their incurable disease with their children, their children will be exposed to social stigma and have limited attendance in the society, resulting in isolation of children. Some participants pointed out that although they didn’t live with their children, they were worried about the future of their children being affected due to their HIV status.
Participant no. 1 (FGD1), a 32-year-old, 17-year drug user (FGD1), said: When I got divorced, my husband took care of my daughter and I no longer saw her. She is now 16 years old and when she found me, I fear that she wishes: I wish I hadn’t found my mother. If I have such a disease, I will feel ashamed of my daughter because she will be damaged in society. If I become HIV positive one day, I will be embarrassed, though I wasn’t sad when I heard that I got hepatitis. I don’t want anyone to tell my children that your mother died due to AIDS. It is a dishonor. Getting HIV is too bad for my friends and relatives. I don’t want my children to be embarrassed of living in society because of my HIV status.
Discussion
The themes emerging from our study show that concurrent with drug use, women didn’t have any perceptions and motivations for HIV/hepatitis testing before introduction and referral to DIC, but most of them had been tested voluntarily when referred to these centers. Women’ perceptions and their experiences of performing test and waiting for test result were described as their thoughts about the possibility of positive result similar to the other study in Rhode Island. 18 In a study, the perception of disease risk was the main motivation for voluntary requests of testing. The other factors such as previous negative results, long-term treatment for quitting substance use, and type of educational intervention were the reasons for HIV testing, 19 while the main reason of our participants for testing was their perceptions of their health status. They requested for testing because of the suspicion of being infected with HIV due to drug abuse and rape.
One of the other emerging themes was belief of women in that HIV infection just occurs in sex workers due to their high-risk behaviors, especially having sex without condom. Our participants did not consider themselves as a sex worker. Although most of them had exchanged sex for money, shelter, and drug, they were emotionally dependent on their partners and stayed with them for a while. Therefore, because of not having multiple partners at the same time, the participants did not perceive them to be at risk of HIV infection. Despite receiving information about HIV and its transmission ways, the education programs seem to be insufficient. Consistent with our finding, van Empelen et al found that women were aware of strategies to decrease the chance of HIV risk, but they had misperception about their safe sex behaviors. 20 Given that the education programs on safe sex and preventive behaviors were provided in our DICs, our participants knew that extrarelational sex with multiple partners for money as a profession and drug injection are two important factors for the transmission of HIV/STD, but they did not consider themselves to be susceptible to HIV infection. In this regard, Ajzen writes, intentions to perform behaviors can be predicted with positive or negative attitudes toward the behavior, perceived behavioral control, and subjective norms along with social pressures, and these intentions play a role in actual behavior. 21 The women in the present study seem to have low perceived susceptibility to HIV and lack of decision-making power toward their subjective norms such as giving priority to the needs of men than women. A study in Middle East and North Africa (MENA) showed that half of 500 000 people living with HIV were female, and many of them were married. The women did not think that they were susceptible to HIV. However, there were some cultural practices such as the relationship between traditional gender roles and risks that could increase women’s risk of HIV. In this region, women socialized to be responsive to men’s request, with focus on partners’ needs, while men socialized to start and expect sex. 22 The other study in southeast of America showed that one of the barriers to HIV testing was lack of perceived susceptibility to HIV in women. T did not recognize their behaviors as risky because they were neither injection drug abuser nor sex worker. 23 In India, a study also showed that the women were at the potential risk of HIV infection due to their husbands’ drinking and extramarital sexual activities as well as women’s tendency for pregnancy and inability to negotiate safer sex behaviors. The complexity of gender relations and the sociocultural status of these women seemed to act as barriers to preventing HIV. 24
This qualitative study showed that the drug-dependent women were concerned about the future of their children if their test results were positive. They did not want their children to be stigmatized in the society. This issue could be a both positive and negative point. On the one hand, women might avoid the risky behaviors, and on the other hand, they conceal their HIV sero-positivity from their families, such as siblings, children, and parents.
Findings of a study in China showed that disclosure of parental HIV infection to children had both positive and negative effects. Positive effects included children’s opportunity to support their parents and strengthening their relationships, opportunity to receive information about HIV transmission, and increase adjustment with their parents’ illness and death. The negative effects related to nondisclosure were feelings of anger in children and their misconception about HIV. 25
In the present study, women’s narratives revealed that the most of them disclosed their sero-status to their sexual partners as intimate persons, while they concealed this condition from their close relatives such as sister, mother, and friends. Women viewed their partners as the person who supports them, and our participants emotionally depended on their partners. In a study, the participants mentioned that they first would inform their family members and friends to be supported by them. 26 In another study, women mentioned that one of the barriers to testing was stigma and discrimination that might be experienced by their families. 27 The participants who were HIV positive reported refusal of treatment for a while. They deny their affliction with HIV. It could be an alarm for risks. Our participants believed that the possibility of a positive HIV test result would discourage them from life. In addition, consistent with other studies, people felt being close to death after receiving a positive test result. All around the world, people living with HIV experience closeness to death. 28,29 A study has reported that 1 in 4 people with a positive test result had attempted suicide. 23
In Iran, like most countries of the world, there were concerns about taboo, discrimination, rejection, and stigma with HIV and hepatitis, although our participants stated that it was not a barrier to HIV/STD testing in the present study The reason for voluntary testing was the concern about health status and doubt about consequences of past behaviors because over 90% of our participants used crystal amphetamine that might increase risky behaviors such as physical and sexual violence, unprotected sex, and sharing pipe. 30 While in the other study, women mentioned the tabooing of HIV as one of the barriers to testing, 18 our participants concerned about the possible positive result because of the high costs of treatment, lack of place for care and treatment, and inabilities resulting from serious AIDS-related complications.
Conclusion
Based on the emerging themes, most efforts to prevent HIV in the women with risky behaviors can be focused on their current lifestyle along with dynamic advocacy. The participants did not seek testing and health care when they use drugs that might expose women to sexually transmitted disease at this period. For access to them, peers and street outreach as a community-based program can be effective. Peers can lead these women to centers that provide HIV/STD testing and counseling. 31
Our results revealed that the drug-dependent women did not perceive themselves to be at risk of sexually transmitted diseases. Although they were aware of risk factors for HIV transmission such as “injection of drug” and “sex worker,” they had low HIV risk perception. They assumed their partners as their husbands, since they were in love with them for a while, and this emotional attachment and feeling caused most women not to consider themselves as a sex worker.
It is necessary to perform comprehensive training and interventions, which increase condom use with negotiation skills. Our study has some limitations. First, participants were selected from the DICs and had been trained regarding HIV/STD. So, our results cannot be generalized to the perceptions and experiences of women in drug rehabilitation and methadone maintenance clinics. Second, none of the drug users were involved in sex work. Third, the present study had 2 HIV-positive drug users, and the findings of our study cannot be generalized to this group of women.
The results of this qualitative study may add to the information regarding the perceptions of female drug users toward HIV testing, and the results are not generalized to all drug-dependent women. One of the main limitations of this study is that we used the perceptions of those referred to 2 DICs in south Tehran. However, we tried to consider maximum variation in sampling.
Footnotes
Acknowledgments
The authors would like to thank all the participants and the Family Health Association and the State Welfare Organization of Iran. This study was performed in 2 centers related to 2 aforementioned organizations.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The present study was supported by Sharoud University of Medical Sciences as a PhD thesis (No. 930/14). The present article was supported by a grant no. 9320 from Sharoud University of Medical Sciences.