Background information on participants
Demographic information of all FGD participants are summarized in Table . The proportion of widowed and divorced women was very high considering the relatively young age of the participants (64% in Manipur and 35% in Nagaland), highlighting the particular vulnerability of these women across India, including the Northeast.
Demographic information for FGD participants
Drug and alcohol use among the women
The patterns of drug and alcohol use were different in each of the states. Most of the women from Nagaland were alcohol users, a small number used Spasmoproxyvon, and none were using heroin. The Nagaland study participants consistently reported that injecting drug use among women in their state was previously observed but is now very uncommon, and although women used Spasmoproxyvon orally, the most problematic substance for women in Nagaland was alcohol.
According to the study participants, even though Nagaland is a dry state, alcohol is widely available. Young women (as young as mid-teens) are employed in numerous booze joints that are commonplace, particularly in Dimapur (the commercial capital). These women are employed to attract male customers who are then encouraged to purchase alcohol not only for themselves but also for the young women, thereby increasing sales. Women drink mostly manufactured beer, locally brewed rice beer, and spirits. Over time some women become dependant on alcohol as indicated by the fact that they are drinking all day every day, and describe symptoms of alcohol withdrawal if not able to access alcohol.
"P: (participant): Sometimes even if we sell 8–9 cases of drinks, we still get a scolding from the owner of the joint… They tell us that we don’t have good communication skills, or we have not accompanied our customers well, and therefore to avoid this confrontation we force our customers to drink more and more by accompanying them, and we get drunk. (Focus Group Discussion (FGD)3 Dimapur, Nagaland)"
While the booze joints were the most frequently described context for alcohol consumption by women, some participants said that small groups of women congregate in drinking ‘hotspots’ or in the home of one of the women in order to drink. Additionally, some women, especially those who are married, drink alone at home where privacy can be maintained and social opprobrium avoided. However, this is only possible for women who have enough money to purchase a supply of alcohol to take home; many others are dependent on men in booze joints who purchase alcohol for them.
Alcohol use was similarly popular among the Manipuri women, but almost two-thirds were using heroin (No.4) and one-quarter Spasmoproxyvon. The women who used heroin tended to do so alone in quiet places, or at the peddler’s place. Most of the women using heroin injected it, but some were ‘chasing’ (inhaling) heroin.
There was widespread acknowledgement that women begin and continue to drink and take drugs for a complex range of reasons including poverty, family conflict, divorce or widowhood, pleasure, to deal with stress and suppress emotional pain, to overcome shyness and shame associated with sex work, and finally to avoid the symptoms of withdrawal.
"P: We drink and do drugs for different reasons. Some do so because of lots of stress in their lives, while some have a friend who drinks, and so she gives into peer pressure and goes astray… Some break off a serious relationship with their boyfriend and to ease the heartache, they get into drinking or do drugs. I am a married woman who looks after a booze joint, and so thinking of my [absent] children, I drink away, get drunk and then go to sleep. I wake up fresh [sober] and wash myself and then start drinking and go to sleep drunk. (FGD3 Dimapur, Nagaland)"
Table provides examples of quotes that highlight the main reasons why women in Manipur and Nagaland use drugs and alcohol (as identified by the participants).
Quotes reflecting some of the reasons women in Manipur and Nagaland use drugs and alcohol
The women in this study were vulnerable to HIV infection in a range of ways that differed somewhat by state. For some of the participants, especially for those from Manipur who were heroin dependent, involvement in sex work was an obvious risk for sexual transmission of STIs including HIV. However, identifying as a sex worker also meant that they were able to access HIV prevention services that provided needles & syringes, condoms, and STI treatment. While some of the women indicated that they needed to engage in sex work in order to support their drug and alcohol use, it was also the case that some needed to use drugs and alcohol in order to engage in sex work.
The FGD participants from both states said that condoms were used some of the time, but not all the time. The failure to use condoms was sometimes because the men insisted on sex without a condom or paid extra money for it (in relation to sex work), but the intoxicated state of the woman was also commonly identified as a reason for condom-free sex, both in the context of sex work and outside of it.
"P1: Sometimes, men tell us that they will not use condoms even though we insist, and so sometimes we give in and do have sex without condoms. We also don’t know whether they are infected or not - they might be or they might not be… Men give us whatever amount of money we ask but on the grounds that we have sex without condoms. We do say no to them, but they get angry and tell us that they will not pay… We use sometimes, and sometimes we don’t. (FGD1 Dimapur, Nagaland)"
The risk of HIV infection secondary to injecting drug use tended to be a focus of the KIs more than the women, although some of the women who injected drugs acknowledged this possibility, and a few mentioned that they were HIV infected.
"P: These days as we can get free syringes from NGOs we use our own, and sharing of syringes is much less. However when we have severe withdrawal, as we do not always carry our own syringes we do not mind sharing, even if we know the HIV status of that person. This way it is easier for drug users [to be infected]. (FGD3 Churachandpur, Manipur)"
In both states, but particularly in Nagaland, the HIV risks for women dependent on alcohol were very evident. Many participants described situations that placed women alcohol users at high risk for infection with HIV. The consumption of alcohol by women was frequently linked to sex, mostly unprotected sex. Sometimes the women were raped when very drunk, sometimes by groups of men, and had limited recall for the event.
"P: As for me I started drinking after my husband died. I stayed with my brother who used to run a booze joint. Then whisky was known as bagpiper - it’s so strong - it was my first time. I drank this and got all drunk. I found myself naked in the morning after drinking. I didn’t remember anything about what had happened. My sister in law clothed me with mekhela [skirt]. She told me not to drink it [whisky] ever again… I started drinking beer and MC [rum]. We even go out with men without knowing how to put on a condom. Many of us women are like this. We are not even aware of whether we are going around naked or clothed. Most of the times we women drink because of problems faced with husbands. We even go looking for customers and have sex without condoms. (FGD3 Dimapur, Nagaland)"
"P1: It happens always. After we are drunk we don’t even care whether the guys we are with are sick or not. Sometimes we also find ourselves not properly clothed. I sleep at the booze joints."
"P2: Sometimes male friends group together and perform group sex with the girl. (FGD2 Dimapur, Nagaland)."