Manifestations of Gender Inequality and Its Influence on Health Service Use Among Female Injecting Drug Users - A Study in Champai, Mizoram

Gender inequalities affect women’s access to and experience of HIV/AIDS programmes and services. The current study focused on Female Injecting Drug Users with human immunodeficiency virus positive status, residing in Champai district of Mizoram - known as transit hub for illegal drugs. Drug use and drug peddling beset the district and injecting drug use and sharing of injecting equipment among males and females caused the rising HIV infection among users. In Mizoram, the human immunodeficiency virus infection has topped the list of States with prevalence rate of 2.04%. The study was conducted with the aim of exploring the needs and social contexts of Female injecting drug users. We embarked at understanding how FIDUs experience gender inequality and discrimination and the impacts the same have on their abilities to access health services. This study was performed in August 2019 and conducted among Female HIV positive intravenous drug users of Champai. The qualitative study also used content analysis. The data were collected through individual interviews with Key Informants involved in health service delivery; and focus groups with HIV positive FIDUs. Given the hidden nature of FIDUs, snowball sampling was attempted to recruit participants. Qualitative data analysis was conducted using the framework approach and informed by theories of risk environments. A summary of socio-demographic with drug use and HIV positive status of participants was generated using Microsoft Excel systems. Transcripts were analyzed through QAD MINAR software and codes were generated. The findings suggest systemic interventions that reduce community deprivation and social disorder likely to yield important benefits. This study identified important structural and contextual factors that affect the uptake of the preventive health services by FIDUs of Champai and other vulnerable districts of Mizoram state.

Results-This study identified important structural and contextual factors that affect the uptake of the preventive health services by FIDUs of Champai and other vulnerable districts of Mizoram state.
Conclusion-The findings suggest systemic interventions that reduce community deprivation and social disorder likely to yield important benefits.

Introduction-
The Human Immunodeficiency Virus infection is on the rise among women in some states of India, probably due to complex social and cultural issues affecting women (1). HIV-positive women in India continue to face inequalities with health, social and economic ramifications (2).
In the North-Eastern states, Mizoram tops with the virus "strike rate" and HIV prevalence rate of 2.04% (3). Data compiled by the Mizoram State AIDS Control Society show that 67.21% of the positive cases from 2006 to March 2019 have been transmitted sexually, with infected needles shared by intravenous drug users accounting for 28.12% (4). This Christian-majority State bordering Bangladesh and Myanmar has battled drug trafficking and abuse for a long time. According to the 2019 study, Mizoram is estimated to have more than 28 thousand people injecting drugs for non-medical purposes (5). The HIV prevalence of 19.8 % was considered stable to rising epidemic as per HSS 2017 (6). Notably, female morbidity is higher in Mizoram than male morbidity levels. Contrary to morbidity levels, the rate of hospitalization among sick is higher for males as compared to females and the average out-of-pocket expenses is also substantially higher for males. (7) This is perhaps an indicator of inherent bias in the society's perception of women's health wherein sickness among males is given more importance and substantially more money is spent on the treatment of men compared to that of women.
The current study attempts to focus Female Injecting Drug Users of Champai district. As per the study in 2017, heroin addiction among young people of Champai stood at 81.7% and injecting drug use affected 96.2% young males and females with 61.2% sharing of injecting paraphernalia reported for the district (4). Notably, a comprehensive package of harm reduction interventions is being implemented by National AIDS Control Organization through the State AIDS Control Societies in India. But the major service components of harm reduction program remain inaccessible to FIDUs of Champai, as observed.
We conducted the qualitative study and used content analysis with the broad aim of understanding the ways in which FIDUs experience inequality and discrimination and the impacts the same have on their abilities to access health services.

Study design-
This study, performed in August 2019, was conducted among Female HIV positive intravenous drug users registered in the Champai ART centre for more than two years. The data were collected through focus groups with PLHIV FIDUs and individual interviews with Key Informants involved in providing services to this population. Two focus groups were conducted with experienced local moderator and note takers conversing in Mizo tawng language with participants. The interviews

Settings:
The focus groups were conducted at participants' convenient location near to New Hope Society in Champai; among 14 FIDUs who were HIV positive.

Participant selection and recruitment:
In the current study a person who has injected at least once in the last three months is categorized as an IDU in keeping with the definition followed in the National AIDS Control Programme. She should be above 18  Qualitative data analysis was conducted using the framework approach (8,9). Taking cue from Rhodes' conceptualization of 'risk environment framework', we conceived that the interactions between the various types of environment and level of environmental influence the harm reduction praxis. (10) Data analysis was guided by the 'risk environment' framework' accordingly.
All focus groups lasted between 60-75 minutes. A summary of socio-demographic with drug use and HIV positive status of participants was generated using Microsoft Excel systems. Transcripts were analyzed through QAD MINAR software and codes were generated.

Results-
The socio-demographic profile of participants (n= 14) and years of IV drug use, PLHIV status and ART regimen are summarized in Table-1. Desk review of literates and documents led to the understanding that manifestations of gender inequality in Mizo society are rather diverse. Those can be grouped into four conditional groupsmodern, transitional, conservative and traditional (9) The modern type being mild, is respectful toward women's individuality, but the level of her autonomy and freedom is, however, an issue of negotiation with a man. In the transitional type the inequality is more highlighted and in which man takes woman's opinion into consideration, often helps her in housework, however, the main decision maker in the family is the man. In conservative type customary division of roles with highlighted male dominance becomes highlighting factor, though involvement of women in decision making and their respectful treatment are typical attributes. Violence is not spread but cannot be ruled out theoretically. In the fourth-traditional type-gender inequality is traditionbased relationship. The tradition endows a man to dominate and women to follow submission roles. Some forms of violence are witness in this type. One important aspect of this study is that in all the stated types woman's sexuality restriction are innate as she is perceived in the roles of mother only. This means that woman's sexuality is valued in the context of reproduction, rather than her individual happiness. One vital side of the stated types is that woman's sex restriction is innate as she is perceived within the roles of mother solely. This suggests that woman's sexuality is valued within the context of reproduction, instead of her individual happiness.
Four major themes emerged through the analysis that are in keeping with the risk environment approach. These themes are enumerated as follows. Most of the KIs cited lack women-specific service rendering in the harm reduction programme.
While female KIs opined that women's position in Mizo society was weak and therefore their needs were not considered by policy makers. Champai's geographical location proximate to porous international border and influx of Chins tribe folks of Myanmar, giving elevate to quandaries of drug trafficking and human trafficking. (11).
In all of the FGDs, participants noted that many young people got involved in the sale and distribution of trafficked drugs as a means of financial survival. According to one KI, "easy

accessibility of illicit heroin pushed young males and females to narcotic use, and the benefits made from smuggling the precursors, provided them the financial support. [KII-CSC functionary]
The accredited social organization as Young Mizo Association or the Churches in north-east were either bereft of suitable knowledge on harm reduction and HIV or adopted narrow moral angle that added to the stigma manifestation [ 12].
Most of the FGD participants stated that these contextual factors diminished their desire to seek treatment. Many KIs recognized these high levels of social disorder. The FIDU participants in our study were literate, all above middle school education level, yet found lacking in the negotiation power with men, either as partner or in conjugal life. They are socially excluded from opportunities to reduce their HIV risks through education, employment, or access to health services by virtue of their gender and drug use.
Our findings show that lack of income opportunities fosters an environment where negative social capital flourishes. This led to the emergence of trafficking of human and illegal drugs that run an underground economy and provide community members with a source of income. Due to high levels of social disorder that accompany the drug trafficking, young women, either directly or at the behest of male partners, get involved in drug peddling and consequent drug chasing or injecting practices under peer influence. They are compelled into sex for money or drugs. These findings suggest the potential value of community-based interventions for supporting women in their attempts to reduce their risk behaviours and encouraged to use health services.
In addition to these contextual interventions, structural and systemic interventions are needed to ensure that the health system is responsive to the needs of women drug users. The National AIDS Control Organization has in place a strong gender sensitive interventions guideline, but slow implementation at the ground levels in different states and not suitably integrated with large National programmes of health, education and social security have not yielded the desired outcomes, so far.
Despite overwhelming evidence of the structural and contextual factors that drive women's risky use of drugs, the KIs thought that young women had personal agency and could overcome their circumstances and context if familial and social support are meted to them.

Limitations and future direction-
Several limitations of our findings should be noted. Firstly, our FGDs involved FIDU participants who were receiving antiretroviral therapy, and linked to a care and support NGO under NACP.
Their accounts and experiences of stigma and inequality may differ from other women. It is indeed possible that our study may be underestimating the impact of gender inequality among female injecting drug users, because our purposively sampled participants were already accessing some psychosocial and ART services. Secondly, we were unable to assess the strength of the relationship between their encountered barriers and service utilisation. Consequently, future quantitative studies are needed to examine the relationship between these variables and service use.