HIV risk and preventive behaviours among the intimate partners of men who inject drugs in Malaysia

Background: People who inject drugs (PWID) comprise the highest percentage of diagnosed HIV cases in Malaysia. The female intimate partners of such men risk being infected with HIV through sexual contact. There has been no study in Malaysia, and few internationally that have examined the experiences of these women and how they protect themselves against HIV. Methods: A concurrent mixed-methods study comprising of a survey and interviews was conducted among the intimate female partners of men who inject drugs in the urban and rural areas around Kuala Lumpur and Selangor, Malaysia. Through respondent driven sampling and other sampling strategies, 221 women were recruited in the survey. A subsample of 22 women representing a range of ethnicities, marital status and localities were interviewed individually. The survey was analysed to examine factors associated with HIV preventive behaviour. The interviews were analysed using thematic analysis to identify recurring themes. Initial data analyses of the survey and interviews were done separately, after which they were combined and triangulated to address the research questions. Findings: The results found that these female intimate partners of PWID are vulnerable to HIV, reflected by the HIV prevalence (6.3%) reported among them being much higher than that in the general Malaysian population. While 7.7% of women reported having HIV positive partners, nearly half (45.7%) were not aware of their partner’s HIV status. Unprotected sex was common, with only 19.5% using condoms regularly with their partners. The high prevalence of HIV among their partners and the low use of condoms in their relationship shows the heightened risk faced by the women. There was a positive response to the possibility of using female-controlled HIV protective methods, with 69.0% agreeing they might use them if available. Nearly two thirds felt they need to ask their partner’s permission before doing so, with married women and Muslims more likely to report it important to ask their husband’s permission. From the interviews it was clear that HIV prevention practices were not easy for many of these women. While inability to negotiate condom use was the main issue, factors such as poor risk perception, relationship power imbalances, socio-cultural norms, inadequate knowledge of HIV prevention and socio-economic hardship synergistically increased their vulnerability to HIV. The challenges of consistent condom use within a long-term relationship call for other preventive strategies for HIV prevention among this population. These need to include strengthening the HIV screening of PWID and encouraging disclosure of HIV status to their partners, while at the same time empowering women by providing alternative prevention methods that women themselves could control. Conclusion: This thesis has unfolded the realities faced by female intimate partners of PWID in Malaysia, not just in the issue of HIV prevention but also the challenges in their daily lives. The alarming risk faced by the women and the complex nature of this issue demands a well-planned and comprehensive intervention that could improve the resilience of the women towards HIV. It is hoped that the findings from this thesis are able to reflect the women’s voices and provide the opportunity for their problems to surface for appropriate attention by the relevant bodies