Keeping these points in mind, this essay attempts to compile relevant information concerning women's risk behaviour and areas of exposure to HIV, and women's educational, emotional and physiological needs in respect of HIV infection. For reasons of conciseness, I have used a case history as a point of focus, in order to relate theory to practice, and to set natural boundaries to an otherwise vast subject.

Case Study
Laura is 20 years old, unemployed, but has a vocational qualification in carpentry. She has been injecting opiates for two years. She now avoids sharing injecting equipment, but has done so in the past when withdrawing from drugs or when her supply of drugs ran out. She has been in contact with a drug agency for the last 12 months, and thinks she is 4 months pregnant. She is worried about telling anybody, including her partner (who is an HIV positive injecting drug user). She is worried about the baby's health and HIV status when born.

I have hypothesized that Laura is a compliant client. She joined a drug agency after only one year of injecting drugs, and now avoids sharing equipment. Pregnancy is an ideal time to intervene with women, whether in drug treatment or HIV prevention. "We can take advantage of the 'maternal instinct' and help two for the price of one." (Weissman, 1991)

a) HIV infection transmission in female drug users:
Over 50% of reported Aids cases among women are attributed to injecting drug users (Finnegan, 1993). The second most common risk category for HIV infection is heterosexual intercourse with an HIV-infected male. Most drug-injecting women have more than one risk factor. Like Laura, they tend to be sex partners of injecting drug users, and they might share non-sterile injection equipment with their partners and/or others. Although Laura has stated that she is no longer sharing equipment, she has been practising unprotected sex with an HIV-infected person which resulted in a pregnancy. Most studies indicate that intravenous drug users are more likely to change injection behaviour than sexual risk behaviour (Finnegan, 1993).

Heterosexual transmission risks are greater for women than for men, as HIV is likely to be more concentrated in semen than in vaginal secretions. Furthermore, the female genital tract is conductive to passage of virions through tissue to CD4+ cell receptors. Other factors include undiagnosed STD's; amongst sex-workers, higher pay can be expected for unprotected vaginal intercourse. However the greatest risk remains repeated unprotected sex with an infected injecting drug user (Finnegan, 1993). Condom use often occurs with casual sex partners, but rarely with primary sex partners.

Thus Laura belongs to a 'High Risk' group, and it is of paramount importance to relate this to her. The first priority for her program of education concerns avoiding infection through sexual intercourse.

b) Sexual risk reduction - a possible minefield
Laura has acknowledged that sharing injecting equipment poses a high risk for contracting HIV. (We need to make sure that she has not only stopped sharing with others, but also with her partner! As an extra safeguard, we would teach her how to clean her works effectively.)

A Health Worker or Counsellor working with Laura would bring across the 'Safe Sex' message more effectively by improving her initial motivation. This could acknowledge that she has shown determination to change her life by a) implementing safer drug use, b) staying in contact with a drug agency for the past 12 months and c) actually coming to see him. She will need all the encouragement she can get; for many women the overwhelming problem in reduction in sexual risk of HIV is male control over safer sex practices such as condoms. Laura has mentioned that she is worried about telling her partner about her pregnancy. This may indicate a number of problems: a) She might have been providing her partner with drugs (occasional work in her profession, prostitution or other illegal activities) and pregnancy would certainly 'get in the way' of most of these activities. b) She may fear dissolution of the partnership, violence or feel a general lack of ability to communicate with him altogether. Thus she might find it very difficult to negotiate safer sex with him. Nevertheless, by educating her, we would at least give her the chance of making an informed decision about her future. She would need to know that anal and vaginal sex should be avoided without the use of condoms. Even if we assumed that infection had already occurred, she would be best advised to stick to the above rules, in order to avoid subsequent reinfection or infection with other STD's, which could worsen the progression of HIV illnesses (Patton, 1994). Finally we would need to point out to her that a new infection with HIV at this stage would make her more infectious (during the first 3-6 months after infection occurs one is more infectious than during the subsequent 'latent' period) and thus might make transmission of the virus to her baby more probable.

Bearing in mind that she will find it very difficult to implement this advice, the counsellor also has an obligation to offer assertiveness training, couple counselling, and wherever possible refer Laura to a self-help group where she meets women in similar circumstances. The 'Safe Sex' message is best repeated in regular intervals. It might also help to give her basic written instructions about 'Safe Sex - why and how' to take home and possibly share with her partner (e.g. Course Handout 'Sex - What is Safe?').

Having started the counselling process with factual information about HIV prevention, we have entered simultaneously the arena of Pre- and Post-HIV Test Counselling.

c) Pre- and Post-HIV Test Counselling
Laura has indicated that she is worried about her baby's HIV status. She may think it possible for the baby to get directly infected through the father's semen, and not have considered her own status concerning infection. We have to make her aware that the baby could only get infected if she herself was. This will bring home her own vulnerability once more. If she thus was to request a test we would have to point out the test's implications.

*We would need to provide information about the test itself, how it is performed and how long she would have to wait for the result (which would only be revealed to her in person, face to face).

*We would need to promote health education, identify and change behaviours which would put her at risk (see above, point a.).

*We would need to assess her risk of exposure to HIV, which is likely to be high.

*We would need to explore with Laura what a positive test-result would mean to her. How would she cope? Whom would she tell about it? Practical implications such as insurance, mortgage and future jobs (she has a vocational qualification in carpentry, which she may want to take up later on) would also need to be mentioned.

We should remember that, once a person has been told that she is positive, she will never be the same again. Subsequent anxiety and depression is almost inevitable. Would Laura really benefit from knowing? It is certainly advisable that, as a high risk client, she should treat herself as positive and take the recommended precautions (see above, point a.). But not knowing for certain may leave her with this bit of hope she will need if she wants to keep the baby. Certainly, if she wants to breastfeed, she would benefit from knowing whether she is positive or not. Breastfeeding can transmit the virus, and should be avoided by HIV-positive women (particularly in the west, where they can have access to sterile water and bottlefeeding equipment). Furthermore, doctors may use AZT in a positive woman to combat infection in the baby. AZT reduces perinatal transmission by 67%, reported David Erskine, Pharmacist at Chelsea & Westminster Hospital at a lecture at the Centre for Research on Drugs and Health Behaviour on Feb. 24th 1995.

Healthcare workers (dentists, doctors, nurses etc.) would probably prefer to know Laura's status. However, precautions should be applied universally anyway.

A negative test result would be tremendously good news for Laura, but could also prove to be counterproductive. It might give her a false sense of security and encourage further 'high risk' behaviour.

Testing is a two-edged sword, for the tensions it causes barely outweigh the benefits: "Most clients can handle death itself better than the anxiety about death." (Lockley, 1989)

Laura may however insist on having the test. After all, she thinks she is pregnant. Interestingly enough, less than 50% of HIV-infected women who are aware of their HIV antibody status haven chosen to terminate their pregnancy. There seems to be no statistically significant difference in the frequency of elective termination between HIV-seropositive and seronegative women (Selwyn, 1993). Laura may want to consider treatment of the baby with AZT, and to breastfeed should she be antibody free. Thus had she decided to opt for being tested, she should also receive Post- Test Counselling.

Centres offering testing have developed protocols for giving results. Results are now rarely given on a Friday, as few agencies are available over the weekend to give support. Any result will be related to the tested person face to face. Should the result be negative, one needs to explain the concept of a 'window period' to the client. If it is three months or more since the last exposure to infection, there is more certainty about the result. The opportunity must be used to re-emphasize the need for behaviour change at this point, for a negative result can change any day.

Counselling following a positive result must include plenty of time for the person to absorb the news. The client is likely to be in shock (grief over the loss of health), which can often block them from absorbing information. So even should they want to know information about the disease, treatment and prognosis, all information needs to be repeated on several later occasions and backed up with handouts. It is of utmost importance at this juncture that the client feels you are a confidante and helper. Only then will you be able to continue a counselling relationship which will encourage her to change and improve her life.

Laura will certainly need practical help concerning her welfare & financial matters, her housing, her general medical status and involving her partner, family and friends as additional support. Treatment programmes should adopt a flexible and integrated model, acknowledging all needs and addressing them holistically (Finnegan, 1993). As Laura thinks she is 4 months pregnant, and shows concern for her baby, I continue to assume that she has committed herself to having this child. It is now important to introduce her to those services that will help her with ante-natal care and drug-control.

d) Drug Use, HIV & Pregnancy
As long as Laura remains asymptomatic she needs no special medical services during pregnancy, other than ante-natal care and drug-management. The latter may comprise treatment of infections and abscesses and maintenance therapy. Detoxification during pregnancy may be hazardous for the foetus. A reduction of drug intake is however generally recommended, to avoid the baby going into withdrawal after birth.

Laura has to understand that it is of utmost importance to her and her baby's health to attend ante-natal check ups and her maintenance program regularly. These should ideally be correlated to make it easier for her. The case worker (counsellor) could try to contact the various agencies involved, and help to set up a time-management plan for Laura. She would benefit from learning skills in dealing with medical personnel and social workers, and avoiding misunderstandings and confrontations. Ideally all the required services would be set up under one roof to be easily accessible.

Laura's initial motivation has to be maintained. Thus we would need to remind her that she has demonstrated her concern for the baby by coming for help, for which she deserves respect and praise.

She also needs to receive basic information of the effect drugs have on the baby's development. Foetal tissues metabolise drugs poorly; what is excreted into the amniotic fluid will be re-ingested and increases the concentration of drugs in foetal tissues in comparison to maternal tissue. Opiate use often leads to lack of appetite and an irregular life-style. Malnutrition of the mother can be one of several reasons leading to low birth weight and weaker babies.

Hence it is believed to be beneficial to the mother to be prescribed a substitute drug during pregnancy. She would receive this drug in regular intervals, in regular amounts (according to her needs) and could thus be observed regularly. She would no longer need to 'find' street-drugs and avoid infections and withdrawal. In practice, methadone tends to be the substitute medication offered. It has benefits to the unborn baby, since it has shown to decrease foetal wastage and improve intrauterine growth (Mulleady, 1992). This may, however, be due to stabilising the mother's life-style.

The prescribed amount will vary from person to person, but women commonly increase their dose during pregnancy due to greater stress. Sometimes an increase in methadone is required during the third trimester of pregnancy, due to tissue binding and metabolism of the drug (Mulleady, 1992). We should definitely help her to avoid topping up with street drugs, for an infrequent dose of heroin presents a special risk of poisoning or overdose to the foetus. Should she however consider detoxification, this would best be conducted during the second three months of pregnancy as this minimises the risk of abortion and premature labour. In Glasgow, the Possilpark Clinic has reported anecdotally that over 50 women have withdrawn from heroin without substituting another drug and without harming the baby (ISDD, 1995).

For those with a history of regular opiate use extending over several years, partial detoxification followed by maintenance on a low fixed dose of methadone (eg. 15 mg daily) has limited effects on the foetus, and may be an ideal compromise solution. The evidence shows that at 15mg or less babies rarely withdraw.

Laura also has to be made aware that the initial relationship between her and the baby may be difficult. If the baby was to withdraw, it would be more irritable and difficult to manage, eg. feed, than other babies. Laura would need to be reassured that this had nothing to do with her mothering. The baby might need to stay behind for several weeks for withdrawal or observation, which would make breast-feeding very difficult indeed. Unless she was to live nearby, come in for feeds or use a breast-pump, a proper milk supply would not be established very easily.

If HIV-infection of the mother was suspected or apparent, breast-feeding should not be encouraged, to avoid transmission of the virus to the baby. The other two roads to transmission from mother to baby are across the placenta (in utero) and during delivery, through contact with the cervix, amniotic fluid and the birth canal. Thus Laura should be encouraged to have as normal a labour as possible, without forceps, episiotomy or other interventions.

Laura can then be assured that, even if she was HIV-positive, her chance of transmitting the virus to the baby would be no more than approximately 15%. As all babies are born with their mother's anti-bodies, all children born to HIV-positive females will at birth be HIV-positive themselves. It can take up to 18 months before the HIV status of a baby can be accurately determined (Mulleady, 1992).

During this time of waiting the mother will need a lot of emotional support to avoid relapse and disintegration of the established order in her life. A drug user on a maintenance program does not necessarily risk having her baby taken away by the social services, as long as the environment the baby is being brought up in is considered as relatively stable.

"Finally, it must be remembered not only that the pregnant woman is a whole person and not just an uterus, but that pregnancy is only one part - and usually a very small part - of any woman's life." (Weissman, 1991)

e) Application to my own work as a counsellor
Recently one of my clients asked for advice, as a close relative, whose partner was HIV-positive, had fallen pregnant. My client was beside herself with grief and worry. The only solution she could see at this point was abortion.

Two areas had to be addressed. First of all it was important for my client to accept that whatever decision her relative was to take, it was her relative's decision and not hers. A difficult one to swallow for somebody with a strong streak of perfectionism. She could however chose to take on a supportive role in her relative's life.

Secondly she needed education on HIV and pregnancy, drug use not being involved in this case. She had believed that the baby would invariably be infected through the father's semen. I advised her that this was in fact impossible. I continued to give her information on the probability of infection in babies of HIV-positive mothers, and she was very to relieved to learn that it was believed to be no more than 15%. Furthermore it had to be ascertained whether or not her relative was actually infected. I proceeded to explain to her the three different ways of transmission from mother to child, and the importance of 'Safer Sex' to avoid future infections. I explained further that newly infected people are most infectious. Finally I left her with a bunch of information covering the discussed topic, but also addresses of specialised agencies that can help. She thanked me for my 'down to earth approach' - supplying her with factual information was just what she needed.

Conclusion
My aim has been to highlight important issues dealing with women drug-users, pregnancy and HIV-infection. Due to space constraints I had to limit my analysis to western women, not taking into special consideration questions of race or developing countries. Of particular importance to me was the realisation that women will only chose to use services which they perceive as meeting their needs. Thus ideally we would want to offer a "sympathetic, supportive, non-judgmental, multi-disciplinary one-door approach, which addresses the whole range of problems, both medical and non-medical, encountered by women and their families." (Hepburn, 1990)

BIBLIOGRAPHY:

ISDD Drugs, Pregnancy & Childcare, A Guide for Professionals, ISDD, London, 1995

L.P. Finnegan et al. Drug use in HIV-infected women in: HIV Infection inWoman, ed. M.A. Johnson & F.D. Johnstone Churchill Livingstone, Edinburgh, 1993

M. Hepburn Obstetrics, Women and Drug Use in the context of HIV, in: Women, HIV and Drugs, ed. S. Henderson, ISDD, London, 1990

P. Lockley Social Work Counselling for Aids Virus Positive Drug Addicts, unpublished, the author (Ninewalls Hospital, Dundee), 1989

L. Mandelbrot & R. Henrion Does Pregnancy accelerate Disease Progression in HIV-infected women? in: HIV Infection inWoman, ed. M.A. Johnson & F.D. Johnstone Churchill Livingstone, Edinburgh,1993

G. Mulleady Counselling Drug Users about HIV and Aids, Blackwell Scientific Publ., Oxford, London, 1992

C. Patton Last Served? Gendering the HIV Pandemic, Taylor & Francis Ltd., London, 1994

P.A. Selwyn & P. Antoniello Reproductive decision-making among women with HIV-infection in: HIV Infection in Woman, ed. M.A. Johnson & F.D. Johnstone Churchill Livingstone, Edinburgh, 1993

C. Shepherd HIV Infection in Pregnancy, Books for Midwives Press, Haigh & Hochland Pbl., Cheshire, 1994

F. Suffet and R. Brotman A Comprehensive Care Program for Pregnant Addicts: Obstetrical, Neonatal, and Child Development Outcomes, The International Journal of the Addictions, 19 (2), 1984, pp. 199-219

G. Weissman Working with Pregnant Women at high risk for HIV Infection: Outreach and Intervention, Bull NY Acad. Med., 1991, pp. 291-300

A. Williams When the Client is Pregnant: Information for Counsellors, Journal of Substance Abuse Treatment, USA 1985, Vol. 2, pp. 27-34

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