Drug use and sexual behaviors among women who inject drugs and use a syringe services program; Miami, Florida.

Background: Women who inject drugs (WWID) face disproportionately higher risks of infectious diseases, reproductive health challenges, and gendered social and structural vulnerabilities compared to men. Despite these elevated risks, most harm reduction programs do not tailor their services to meet the needs of WWID. In Florida, where syringe service programs are relatively new and implemented at the county-level, access remains limited. These gaps are especially pronounced for WWID, who face additional barriers due to restrictive reproductive policies and limited access to gender-responsive care. This study examined gender-related risks among people who inject drugs (PWID) accessing a SSP in Miami, Florida to inform harm reduction service delivery and intervention needs.

Methods: This study analyzed enrollment data from the first legal SSP in Florida collected from its December 2016 inception through July 2022 (N = 1660). In bivariate analyses, we used chi-square tests to describe differences in sociodemographic, injection drug use (IDU) and sexual behaviors, and infectious disease prevalence between men and women. We used multivariable logistic regression models to estimate associations between gender and IDU behaviors, sexual behaviors, and HIV/HCV prevalence, adjusting for age, race/ethnicity, housing status, and enrollment year.

Results: Our sample included 1660 participants (26% women). Compared to men, WWID had significantly higher odds of sharing syringes (adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI], 1.23-2.10), injecting over five times per day (aOR = 1.33, CI 95%, 1.05-1.70), injecting opioids only (aOR = 1.79, 95% CI 1.35-2.38), and opioid/stimulant co-injection versus stimulant-only injection use (aOR = 1.46, CI 95%, 1.03-2.6). WWID also had higher odds of engaging in recent sexual activity (aOR = 1.75, 95% CI, 1.25-2.45), exchanging sex for money/resources (aOR = 6.60, 95% CI, 4.12-10.57), and testing reactive for HCV antibody at time of enrollment (aOR = 1.41, 95% CI, 1.10-1.80).

Conclusion: Drawing on real-world programmatic data from routine SSP intake, this study highlights the. elevated injection and sexual health risks faced by WWID accessing a SSP. Findings support the need for gender-responsive harm reduction strategies, including bundled, trauma-informed services that integrate safer injection supplies, overdose prevention, reproductive and sexual healthcare, and peer-led education initiatives that also address the social and structural determinants of health-such as trauma, poverty, housing instability, stigma, criminalization, and relational dynamics. These findings directly informed the development of a women-centered harm reduction clinic at the IDEA Miami SSP. This model may inform responsive service design in similar settings.