The findings of this study indicate that the majority of IDUs who have sex with casual female partners do not use condoms consistently in these relationships, findings similar to those reported in studies elsewhere in India[12, 15]. The current study adds to this literature suggesting a significant association between IDUs' risky sexual practices with casual partners and non-condom use with regular sexual partners. Additionally, IDUs' who share injections/needles are more likely to engage in unprotected sex with their regular female partners, if they have such partners. These results provide evidence for the debate around the increase in HIV transmission to spouses from high-risk partners, for example, male IDUs in this study setting.
The finding that condom use practices are similar irrespective of sexual partner—IDUs who engage in unprotected sex with casual partners also report non-condom use with regular sexual partners—is of concern, as this could fuel the acquisition and transmission of HIV within these overlapping sexual networks. These findings are critical in light of recent estimates of new IDU epidemics emerging in selected states and districts of India and indicate the need for HIV prevention interventions to go beyond addressing the risks associated with IDUs' needle-sharing practices to also focus on reducing the risk of sexual transmission of HIV in drug use settings. Special efforts are needed to reduce the vulnerability of IDUs' sexual partners to HIV, particularly their regular sexual partners, the majority of whom presumably are low-risk non-injecting women[11, 18, 19], who are currently not reached by HIV prevention programs due to the lack of programmatic learnings around reaching IDUs' regular sexual partners.
As seen in this study, one quarter of IDUs engage in unsafe injecting practices and the majority reported unprotected sex with both casual paid/unpaid as well as regular sexual partners. IDUs' unprotected sexual practices with regular partners may be due to the low-risk perception of HIV acquisition or transmission in such partnerships[19, 25] or due to the fear of losing regular sexual partners if they disclose their risky injecting practices. Further research is needed to understand whether the regular female sexual partners of IDUs who engage in unsafe injecting practices have knowledge of HIV transmission and prevention. From the immediate programmatic perspective, peer educators need to counsel all IDUs on the risk of HIV transmission to regular sexual partners, if they do not adopt safe behaviors. A post hoc analysis suggests that about 3% of the total IDUs in the study districts not only shared injections and engaged in unprotected sex with casual paid/unpaid partners, but they also had sex with regular female partners. Every such respondent reported non-condom use in sex with regular female partners, indicating a high probability of HIV transmission within intimate partner relationships.
The results of this study also suggest that there are specific sub-groups of IDUs who engage in risky behaviors, including those in the younger age groups, not currently married, who inject frequently, and who had initiated injecting behaviors at a young age. Our findings on the characteristics of IDUs engaging in risky practices supports other published research studies, particularly regarding the early initiation into injecting drug use and frequency of injection increasing their HIV risk behaviors[17, 18, 26]. Efforts are needed to reach young, unmarried IDUs who are at high risk for HIV, through the use of young peer educators to encourage service utilization, and by organizing social activities that motivate young IDUs to take up risk reduction services.
Further, the results suggest the need to advance ongoing HIV prevention programs by identifying and reaching out to IDUs' regular sexual partners, to build awareness among such women about HIV risks and the ways to prevent infection. Available program resources for IDUs, such as the network of outreach workers, drop-in centers and voluntary counseling and testing centers, could be used to provide information and services to IDUs' regular sexual partners who are currently not covered by any HIV prevention programs. However, services may need to be appropriately designed to meet their needs. For example, drop-in centers for IDUs are perceived as providing services to high-risk males; as a result, IDUs' regular partners, who are mainly non-injecting women, may be reluctant to access these services for fear of being stigmatized; therefore, an effective strategy would be to set up female-friendly centers staffed entirely by women that provide a safe space for non-injecting women, which could also link women to other maternal health services. Similarly, harm reduction programs for male IDUs currently use male outreach workers and male peer educators to provide services; however, to reach IDUs' sexual partners, female outreach workers and peer educators could be employed.
Although the study findings have important implications for HIV prevention programs and research, they should be considered in light of certain limitations. First, the odds ratios in this paper were derived from unweighted estimates because RDSAT software, which is generally used to analyze RDS data, cannot calculate bivariate or multivariate statistics; therefore, STATA was used for all analysis. Second, the findings of the study are based on self-reported data, which may be subject to social desirability bias, and as a result, socially unacceptable behaviors may have been underreported. However, the use of trained field staff may have increased study participants' comfort level at the time of interview and reduced under-reporting. Finally, the study findings cannot be generalized to all IDUs across the country as injecting drug practices in India vary across states. However, these limitations do not compromise the internal validity of the data.
In conclusion, our findings show that IDUs who engage in risky behaviors such as unsafe injecting practices and unprotected sex with casual partners are more likely to engage in unsafe sex with regular female partners, suggesting the urgent need to address HIV transmission within regular sexual partnerships. Ongoing risk reduction programs for IDUs need to expand their focus to include communication about condom use in all relationships in addition to addressing IDUs' unsafe injection practices in an effort to achieve the goal of zero new infections. An alternative and effective means to reach low-risk women, who are partners of individuals at high HIV risk, could be by providing HIV prevention services through available maternal and child health programs in India and elsewhere at the community level.