This study found that about a quarter of FSWs in Dimapur district of Nagaland reported having ever used illicit drugs. The drug-using FSWs substantially differed from their non-drug-using peers in terms of their demographic profile, sexual risk profile and burden of sexually transmitted diseases.
Younger FSWs were less likely to have ever used drugs, which may reflect a true declining trend of drug use. It is also possible that those who remain in sex work for longer are more likely to have been exposed to drugs, and to have begun to use them as a means of coping with the challenges inherent in being an FSW in this context. An earlier study of FSWs in Dimapur noted an increase in the proportion of FSWs regularly using alcohol and other drugs after the commencement of sex work [16
]. In terms of marital status, we found that those FSWs who were or had been married were more likely to report drug use compared to those who had never married. Furthermore, among the married FSWs those who were widowed were more vulnerable to drug use. The probability of using drugs among the married group remained elevated even in the multivariate model indicating an independent relationship. The drug use of husbands’ seems to play an important role in the development of drug use among married women in India [24
]. A higher rate of drug use among widows may be related to the influence of their husband’s drug use, as many young widows in Nagaland are in this situation due to the drug-related death of their husbands [25
]. Drug use by one or both marital partners contributes to family disharmony, and can lead to separation or divorce [24
]. These drug-using women may be forced into sex work in order to sustain their livelihood and their drug use [4
]. In this study, drug-using FSWs and non-drug-using FSWs did not differ from one another in terms of their educational status. Our results are contrary to previous reports from this region that indicated a strong link between illiteracy and substance use for women [26
This study also found that alcohol use among drug-using FSWs was more common compared with non-drug-using FSWs. This finding is consistent with previous reports, which showed that co-use of alcohol and illicit drugs was very common among drug users in northeast India, including female drug users [4
]. Consuming alcoholic drinks at least once weekly was independently associated with having ever used drugs among FSWs in this study. Panda et al. (2006) reported that 98% female drug users consumed alcohol prior to use of illicit drug in Manipur [4
]. This is certainly a cause for concern because concomitant use of drugs and alcohol are synergistic risk factors for transmission of HIV and other STIs [31
]. Probably, alcohol use can be used as a behavioural marker for identifying suspected illicit drug users as illicit drug use is a more stigmatized and socially unacceptable behaviour particularly among women in comparison to alcohol use. FSWs may not be hesitant to disclose their habit of consuming culturally acceptable home brewed alcohol.
Studies in this region indicate that many female drug users resort to sex work to obtain drugs from their sexual partners or to earn money for purchasing drugs [4
]. The drug-using FSWs in our study were more likely to report sexual interactions with clients who had ever injected or shared injecting drugs, and they also reported a higher volume of clients compared with non-drug-using FSWs. Volume of clients was found to be independently associated with being a drug-using FSW. Overall, our data indicate that drug-using FSWs are more likely to be exposed to HIV and other STIs due to their higher volume of clients and more sexual interactions with male drug users.
Contrary to previous reports, in our study drug-using FSWs compared to non-drug-using FSWs were more likely to report using condoms consistently or most of the time with both regular and occasional clients [9
]. But, such results should be interpreted with caution since studies have shown that sex work conducted under the influence of drugs is associated with lower rates of condom use in other settings [32
]. One possible explanation for the higher rate of condom use among drug-using FSWs in the context of Nagaland may be their greater awareness about the importance of condom use, since drug users have been a major target group for HIV prevention programmes in this region for a long time. In fact, we also found that prior knowledge of HIV was strongly associated with being a drug-using FSW. The venue for having sex with clients was significantly associated with having ever used illicit drugs in the univariate analysis. We found that drug-using FSWs were more likely to operate from lodges/hotels and least likely to be street-based. Probably lodges/hotels were used clandestinely for the dual purposes of drug use and sex by FSWs.
In our previous report from this study, we showed that both injecting and oral drug use were significantly associated with HIV among FSWs in Dimapur [14
]. Prevalence of HIV was almost three times higher among drug-using FSWs compared to non-drug using group [14
]. This analysis throws further light on the relationship between drug use and other STIs among FSWs. We could not establish a significant multivariate association between drug use and individual STIs in this study, but prevalences of individual STIs were generally higher among drug-using FSWs. Similarly, the overall prevalence of one or more STIs was almost two times higher among drug-using FSWs compared to non-drug-using FSWs (59% vs. 33.5%) indicating their greater vulnerability to STIs. Even after exclusion of the IDUs from the drug-using group, prevalence of one or more STIs was significantly higher among life time illicit drug users compared with non-drug-using FSWs (results not shown) highlighting the importance of illicit drug consumption in the epidemiology of HIV and other STIs among FSWs in this region. These findings suggest that the drug-using FSWs need to be targeted by the prevention programs with greater urgency to make the HIV and STI prevention programs more successful.
This study has certain limitations. Firstly, RDS was used to recruit FSWs in the study because random selection of the target population was not a possibility according to our pre-survey assessment. However, RDS can be considered as the best sampling option to obtain better representative samples of a target population where random sampling is not feasible. The statistical theory upon which RDS is based suggests that if peer recruitment proceeds through a sufficiently large number of waves, the composition of the sample will stabilize, becoming independent of the seeds from which recruitment began, and thereby overcoming any bias the nonrandom choice of seeds may have introduced [35
]. This stable sample composition is termed the “equilibrium”. Therefore, it is after the point of equilibrium that the sample becomes representative of the study population [36
]. In this study, we could achieve equilibrium for most of the key characteristics after 5th
waves. Secondly, we relied on self-reported data regarding sensitive personal information such as use of illicit drugs and sexual behaviours, hence the results are subject to social acceptability bias. To improve the veracity of the self-reported data, participants were assured of anonymity, and told that there would be no adverse consequences for disclosing this information to the interviewers. Further, it is difficult from a cross-sectional study to establish temporal relationships between dependent and independent variables. Lastly, only data regarding ever drug use was collected in this study. Therefore, we are unable to describe the extent and pattern of current drug use among FSWs in Dimapur, and the relationship between these variables, their sexual risk behaviours, and infection with HIV and STIs.