Emerging evidence suggests that violence perpetrated against women who use and inject drugs may be worse than previously expected. In our recent investigation, “Violence Against Women Who Inject Drugs,” published in JAMA Network Open in March, my colleagues and I found that experiencing violence was nearly universal for women who inject drugs in Melbourne, Australia. Eighty-two percent had been assaulted at some time. Nearly 2 in 5 women had been sexually assaulted. 

Australia is often seen as a world leader in harm reduction, with strong systems to reduce drug-related harm and social supports that can help people access income, housing, and services for domestic and family violence. However, as with many high-income countries, women who use drugs are invisibilized in policies to end violence against women. Despite facing much higher risk of abuse than other marginalized groups, they are not recognized as a key priority population in Australia’s 10-year plan to end violence against women and children.

Women described major barriers to engaging in care. They feared stigma from their health care provider—or, more frightening still, that their children would be put at risk of removal.

While much violence is suffered alone and women are often reluctant to access medical care in the aftermath, nearly one in four women who inject drugs, according to our paper, presented to the emergency department due to assault over a 10-year period. Most of these women had severe enough injuries to be admitted to hospital. 

Only one in three women reported accessing medical health care after an assault, however, and this was typically contact with a counselor. In in-depth interviews, women described major barriers to engaging in care for their assault. They feared stigma from their health care provider about their drug use, for example—or, more frightening still, that their children would be put at risk of removal. 

Women who inject drugs are also often marginalized in other ways, and sometimes lack access to a phone or money for transport to engage with violence services that they need. 

This all heightens vulnerability when drug acquisition in unregulated markets and use under prohibition can be weaponized against women as a method of control. In these circumstances, control of access to methamphetamine, which is commonly smoked in Australia, may play a particularly sinister role in sexual coercion, according to past research.

My colleagues and I have been following up on these issues. In research examining violence against people who smoke meth, which has not yet been published, we found that two in three women reported recent assault over an 8.5-year period—at an average of six separate occasions of recent violence. Nearly one-third of women reported that the person who used violence against them was a current or ex-partner. One in six of the women had presented to an emergency department after being assaulted.  

Women who use substances rarely conform to society’s perspective of the “perfect victim.” Public and institutional ideals about who is believable, deserving of sympathy or worthy of protection are often shaped by entrenched stigma towards people who use drugs. 

In many countries, responses to violence against women still fail to account for how stigma, substance use, and gendered power intersect.

When a woman is known to use drugs, signs of abuse can be dismissed, minimized or interpreted through criminality and disorder, rather than vulnerability. Consequently, violence towards this population is somehow seen as expected or even deserved. Alternatively, women are at risk of being misidentified as the primary aggressor in an abusive situation.

For many women, children become a powerful tool of coercive control. Partners can threaten to report drug use and manipulate child protection or custody fears. Women may stay in dangerous relationships, avoid health care or withdraw from support services not because they do not need help, but because seeking it, or disclosing the complete context of their situation, can be too high-risk.

The invisibilization of women who use drugs is also reflected in drug and violence policy. Resourcing and attention are more likely to be paid to those groups identifiable within formal policy documents and commitments. In Australia, harm reduction policy does not adequately address the issue of violence and ending-violence policy does not adequately identify people who use substances. And Australia is unlikely to be unique. 

In many countries, responses to violence against women still fail to account for how stigma, substance use and gendered power intersect, leaving some of the most vulnerable women outside of public discourse, unsupported and alone.

Photograph (adapted) via the CDC

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People who inject drugs (PWID) are some of the most marginalized people in society, and vulnerable to myriad harms. Widespread stigma, discriminatory drug policies and criminalization are calamitous for social health. PWID face systemic barriers to accessing health care, leading to prolonged suffering, delayed treatment, and ill health. They frequently face police abuses and long-term ensnarement in criminal-justice systems. And drug prohibition fosters riskier drug supplies and practices, costing many lives.

People injecting drugs are particularly concentrated in North America and Eastern Europe. In both regions, more than one in every 100 people inject drugs.

It is vital that we understand people who inject drugs better in order to work for a more equitable world. To this end, my colleagues and I conducted an international study of this population, which we published in The Lancet Global Health earlier this year.

People injecting drugs are particularly concentrated in North America and Eastern Europe. In both regions, more than one in every 100 people inject drugs. Estimates of PWID in the world’s regions are as follows:

* East and Southeast Asia: 3.8 million people (0.24 percent of the adult population)

* North America: 3.3 million people (1.38 percent)

* Eastern Europe: 2.3 million people (1.08 percent)

* South Asia: 1.8 million people (0.14 percent)

* Sub-Saharan Africa: 1.3 million people (0.21 percent)

* Western Europe: 1 million people (0.35 percent)

* Latin America: 600,000 people  (0.15 percent)

* Middle East and North Africa: 320,000 people (0.10 percent)

* Central Asia: 240,000 people (0.51 percent)

* Australasia: 120,000 people (0.62 percent)

* Caribbean: 96,000 people (0.31 percent)

According to our data, this global population is overwhelmingly male; about one-fifth of people who inject drugs are women. Compared to the general population, there is slightly higher reported prevalence of sexuality diversity, with more people identifying as gay, lesbian or bisexual. Unfortunately, there is a dearth of evidence on sexuality and gender identity among PWID, with barriers to disclosure in many places. While we investigated transgender identity among PWID, few countries had available data.

Almost one-third of people who inject have been incarcerated in the past year. In both Sub-Saharan Africa and Eastern Europe, 60 percent of PWID have been recently arrested.

People who inject drugs are often living in circumstances that make good health untenable and perpetuate a cycle of marginalization. Unstable housing or homelessness is alarmingly high among PWID in North America, for example, with recent experiences reported by over half of the population. PWID in South Africa and Czechia reported similarly high prevalence.

When responses to illicit drug use are highly punitive in most countries, it is unsurprising that almost one-third of people who inject have been incarcerated in the past year. In both Sub-Saharan Africa and Eastern Europe, 60 percent of PWID have been recently arrested.

Marginalized populations often overlap substantially, and vulnerabilities to certain clinical harms and trauma can be compounded. For instance, 15 percent of PWID worldwide report engaging in sex work—which is also widely criminalized—and many more report exchanging sex for drugs. This is more pronounced in countries where paid work, social security, or other methods of funding drug use are harder to obtain. In Sierra Leone and Ghana, local studies suggest that nearly everyone who injects drugs is involved in sex work.

In Russia and Estonia, every second person who injects drugs is living with HIV—equating to well over half a million people.

Despite a global expansion of HIV testing and treatment and harm reduction service availability, we have only seen a modest reduction in HIV prevalence among people who inject drugs. Worldwide, 2.3 million PWID are currently living with HIV.

Over one-third of this group lives in Eastern Europe. PWID in Belarus, Moldova and Ukraine all bear a shockingly high burden of HIV, with prevalence ranging from 20-30 percent. More alarming still is the burden in Russia and Estonia, where every second person who injects drugs is living with HIV—equating to well over half a million people. Harsh drug laws, lack of available treatment, and restrictions on harm reduction services and information make it near-impossible for Russia to reduce this prevalence.

Additionally, nearly 6 million people who inject drugs are living with the hepatitis C virus. Untreated hepatitis C can cause fatal liver damage and cancer over 15 to 20 years, but it can also compromise the immune system, leaving people unable to fight other infections. This is critical, when injecting may expose the body to bacteria or fungi that can become septic or result in other invasive and life-threatening infections. Just in the past year, one-third of PWID reported an injecting-related skin or soft tissue infection, and evidence suggests that these infections and others are rapidly increasing.

Many of the China’s 2.5 million PWID are subjected to mandatory drug treatment, entailing human rights abuses.

Given the circumstances many face, it is unsurprising that people who inject drugs often experience complex mental health disorders—issues that often go untended. In China, more than 90 percent of PWID have clinical depression. Many of the country’s 2.5 million PWID are subjected to mandatory drug treatment, entailing human rights abuses. A significant proportion of this population dies by suicide, contributing to one of China’s leading causes of death.

Globally, more than 80 percent of people who inject drugs mainly use opioids. We know that methadone and buprenorphine treatment greatly reduce chances of opioid overdose, and of contracting HIV, hepatitis C and other infections. Access to these medications also improves quality of life, mental health, and other factors that create stability for people. In the United States, medications for opioid use disorder (MOUD) are associated with savings of up to $105,000 per person in health-care and other costs.

Yet less than half of countries have these medications available, we found in our companion study of global harm reduction interventions, also published in The Lancet Global Health this year. For every 100 people injecting opioids globally, only 21 are accessing MOUD. In Central Asia, Eastern Europe, Latin America and Sub-Saharan Africa, only one out of every 100 people injecting opioids is accessing MOUD.

Globally, syringe service programs only distributed around 35 needles per person who injected in 2021—less than one needle a week.

We also know that syringe service programs (SSP) greatly reduce people’s chances of blood-borne diseases, overdose, infections and other harms. As well as syringes, they provide people with other harm reduction supplies, also connecting them with social and wider health services. We found that there are now 94 countries that have implemented such programs.

But globally, SSP only distributed around 35 needles per person who injected in 2021—less than one needle a week. Most people inject daily or more frequently, and a lack of access to sterile syringes leaves many needing to share or to re-use blunted equipment.

Only a few Latin American countries had operating SSP in 2017, and since then most of them have been shut down. National officials claim that this is due to a lack of injecting drug use; in reality, this leaves more than half a million people without sterile equipment and other harm reduction resources.

At the same time, the changing political landscape in Latin America has seen increasing enforcement of punitive drug policies. Even in Uruguay, where cannabis has been legalized for some time and the prevalence of injecting drug use is estimated to be 0.26 percent (equivalent to the global level), there is no access to SSP or MOUD.

Relatively speaking, Australia is a harm reduction haven for people who inject drugs. It’s one of five countries that are implementing both MOUD programs and SSP at a high level, according to the World Health Organization—the others are Austria, Canada, the Netherlands and Norway.

In Australia, the equivalent of 508 needles per person injecting were distributed in 2021. Besides all the health harms prevented, from 2000 to 2010, these efforts saved the country up to $140 million (US) in health care costs. Australia also offers drug-checking services, take-home naloxone, and some access to safe consumption sites. Yet we know that people in remote settings and from marginalized backgrounds still face gaping inequities. There’s also a lack of treatment options and harm reduction provisions for people injecting methamphetamine, who constitute more than half of PWID in Australia.

There is a lack of political will in many countries to provide basic overdose prevention measures. That brings us back to the costs of stigma.

Globally, very few countries have introduced overdose-prevention services such as safe consumption sites or take-home naloxone distribution. These services save lives, improve quality of life, and reduce strain on hospital and health-care department resources. Despite hundreds of thousands of people experiencing overdose (both fatal and non-fatal) each year, there is a lack of political will in many countries to provide basic prevention measures. That brings us back to the costs of stigma.

That it took more than two decades of increasing overdose fatalities, and more than 1 million lives lost, for the United States to open any safe consumption sites tells us of a devastating inertia when it comes to harm reduction.

Evidence is critical for bolstering advocacy. Global monitoring is essential in understanding the world’s harm reduction landscape and its glaring implementation gaps; it gives us clearer understanding of the complex social and structural barriers to health.

It is critical that we recognize the imperative of strongly evidenced interventions that empower people who inject drugs and mitigate suffering, bolstering community, support and compassion. Harm reduction—serving the wider goal of promoting health, justice and humanity—must be central to our global response to drug use.

Image of world cities at night via NARA & DVIDS Public Domain Archive

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