title: The syndemic of HIV, HIV-related risk and multiple co-morbidities among women who use drugs in Malaysia: Important targets for intervention.
abstract: BACKGROUND
  Substance use and HIV are syndemic public health problems in Malaysia. Harm reduction efforts to reduce HIV transmission have primarily focused on men with substance use disorders.
  
  
  OBJECTIVE
  To explore HIV risk behaviors, substance use, and social factors associated with poor health outcomes among women who use drugs in Malaysia.
  
  
  METHODS
  A cross-sectional survey of 103 drug-using women in Kuala Lumpur, Malaysia were recruited to assess their medical, psychiatric and social comorbidity as well as their engagement in nationally recommended HIV testing and monitoring activities.
  
  
  RESULTS
  One-third reported having ever injected drugs, with most (68.2%) having recently shared injection paraphernalia. Sex work (44.7%) and infrequent condom use (42.4%) were common as was underlying psychiatric illness and physical and sexual violence during childhood and adulthood. Most women (62.1%) had unstable living situations and suffered from an unmet need for social support and health services. HIV prevalence was high (20%) with only two thirds of women eligible for antiretroviral therapy having received it. Suboptimal HIV testing and/or monitoring was positively associated with interpersonal violence (AOR 2.73; 95% CI 1.04-7.14) and negatively associated with drug injection (AOR 0.28; 95% CI 0.10-0.77).
  
  
  CONCLUSIONS
  Women who use drugs in Malaysia demonstrate considerable medical, psychiatric and social co-morbidity, which negatively contributes to optimal and crucial engagement in HIV treatment-as-prevention strategies. Mental health and social support may be key targets for future public health interventions aimed at drug-using women in Malaysia.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA; Yale University School of Public Health, New Haven, CT, USA.
authors.forename: Kelsey B
authors.initials: KB
authors.lastname: Loeliger
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Ruthanne
authors.initials: R
authors.lastname: Marcus
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Wickersham
authors.affiliation: Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Veena
authors.initials: V
authors.lastname: Pillai
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Adeeba
authors.initials: A
authors.lastname: Kamarulzaman
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA; Yale University School of Public Health, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address: frederick.altice@yale.edu.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D000328:Adult; D015897:Comorbidity; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000523:psychology; D006801:Humans; D008296:Malaysia; D015995:Prevalence; D012309:Risk-Taking; D012742:Sex Offenses / Q000523:psychology / Q000706:statistics & numerical data; D011477:Sex Work / Q000523:psychology / Q000706:statistics & numerical data; D012725:Sexual Behavior / Q000523:psychology / Q000706:statistics & numerical data; D015819:Substance Abuse, Intravenous / Q000453:epidemiology / Q000523:psychology; D019966:Substance-Related Disorders / Q000453:epidemiology* / Q000523:psychology; D016387:Women's Health
keywords: HIV; Malaysia; Sex work; Substance abuse; Violence; Women