The following research was completed with an understanding that there is much to know about women who use intravenous drugs (WUID). The extant literature about the lives of people who use intravenous drugs (PWID) is mostly quantitative, highly androcentric, and primarily focused on HIV transmission. What is needed is information about the culture of WUID and the circumstances contributing to their poor health both from drug use and the conditions in which they live. The ethnographic study involved (a) collecting artifacts, including photographs taken by the women, (b) observing participants during some of their daily activities and primary healthcare interactions, and (c) face-to-face interviews with WUID. The results portray a life that closely resembles that which is known, but also the findings enable a lens into (a) the vicious circle associated with obtaining drugs and survival, (b) the violence, both systemic and personal, that homeless, urban-living WUID in Canada endure, and (c) the importance of “being clean” that directs much of their activities and presentation. From a theoretical perspective, the study enabled a deepened understanding of the importance of the continuum of cleanliness and how it interfaces with what the women believe. In summary, WUID have received unjust opportunities to care for themselves given the current laws and stigmatization that forces them to remain hidden, perform illegal activities, avoid discrimination, and fend for themselves in a world that perpetuates the hegemony of white middle-class Western peoples. The results provide a direction for healthcare in terms of WUID. Primarily there is a need to engage WUID in establishing what would work for them and thus incorporating peers in the process of initiating and maintaining services. Clearly established is a need for drug use to be decriminalized to allow WUID to gain recognition, to avoid criminality, and to re-enter the world that belongs as much to them as any other.

Background: Women who inject drugs continue to represent a disproportionate percentage of new cases of HIV in Canada (PHAC, 2006). However, in Nova Scotia, HIV has still not been conceptualized as a major health issue, especially among women (Gahagan, Rehman & Baxter, 2006). At the same time, recent research findings suggest that female injection drug users in Nova Scotia are engaging in unsafe injection and sexual practices and often lack access to harm reduction-based programming and resources (Ploem, 2000; PHAC, 2006; Jackson et al., 2010; Parker et al., 2011; Hodder, 2011). In a provincial context of high prevalence of injection drug use and HIV risk behaviours, preventing increasing rates of HIV infection will depend on the development of proactive and gender-informed HIV prevention policies. Purpose: This study had two main aims. First, it aimed to chart the development of provincial HIV prevention and harm reduction policies and to identify how, and if, the policy development processes address the HIV prevention needs of women who inject drugs. Its second aim was to identify key barriers and facilitators to developing HIV prevention policy for women who inject drugs in Nova Scotia. Methods: This study involved a review of key HIV prevention and harm reduction policy documents as well as interviews with 27 key informants directly involved with HIV prevention and/or harm reduction policy decision-making. Findings/Discussion: The existing Nova Scotia-based policy development network, their policies, their processes and the context within which they have functioned over the past ten years do not appear to be supporting the development of HIV prevention and harm reduction policy which addresses the needs of women who inject drugs. Policy committee composition lacked inclusivity and organizations that work directly with women who inject drugs held less influence in policy processes. In addition, gender was not prioritized by decision-makers and therefore not comprehensively addressed in policy content. As a result, the needs of women who inject drugs have not been prioritized in policy processes and subsequently few targeted resources are going to the community-based organizations that provide services to these women.

<b>Background:</b> Women who inject drugs face vast disparities in health outcomes relative to their counterparts in the general population, most notably in HIV. Intimate partner violence (IPV) victimisation has a detrimental individual effect on women's HIV risk behaviour. Furthermore, IPV often co-occurs with substance use and poor mental health among women in high-income countries, but little is known about the cumulative and interactive effects of these conditions on women's HIV risk behaviour in low- and middle-income countries. This thesis applied an ecological approach guided primarily by syndemics theory to understand influences on women's HIV behavioural outcomes. It examined associations and mechanisms linking IPV, substance use, and depression, with HIV sexual and injecting risk outcomes in the first quantitative study of Indonesian women who inject drugs, the Women Speak Out study. <b>Methods:</b> This study combined community-based participatory approaches and extensive formative research with quantitative survey methods. 731 women, ≥18 years of age, and injecting illicit drugs in the preceding year were recruited using respondent-driven sampling (RDS) from urban settings in Greater Jakarta and Bandung, Indonesia. Network characteristics of the sample were assessed using the RDS software package for Stata 14. Data were analysed using multivariate logistic regressions, marginal effects models, and interaction analyses on the additive and multiplicative scales. The study was conducted in collaboration with the Indonesian Drug User Network. <b>Results:</b> Paper 1: Past-year IPV victimisation doubled the odds of engaging in one or more sexual HIV risk behaviours. Several covariates were associated with higher odds of sexual risk behaviour: HIV-positive status, non-injection crystal methamphetamine (crystal meth) use, low educational attainment, younger age, and being single. Co-occurrence of psychological, physical and/or injurious, and sexual forms of IPV had cumulative effects: sexual risk behaviour was reported by 62% of women who did not experience any form of IPV, but increased to 89% among those exposed to all three forms. Paper 2: Past-year IPV elevated women's odds of receptive syringe sharing. These effects remained after controlling for socio-demographic confounders. Two covariates, injecting illicit pharmaceuticals (vs heroin only) and housing instability and/or homelessness, remained associated with receptive syringe sharing in multivariate analyses. Paper 3: More than 1 in 4 women experienced concurrent IPV, depressive symptoms, and crystal meth use. All three exposures had independent negative effects on HIV sexual risk outcomes. The co-occurrence of all three factors produced a 4-fold increase in rates of survival sex work, 5-fold increase in STI symptomatology, and a 7-fold increase in inconsistent condom use. The joint effect of depressive symptoms and crystal meth use together was greater than the product of the estimated effects of each exposure alone on STI symptomatology, indicating an interaction on the multiplicative scale. Statistically-significant positive additive interaction was detected between IPV victimisation and crystal meth on inconsistent condom use; depression and crystal meth on STI symptomatology and on survival sex work; and IPV and depression on STI symptomatology and survival sex work. <b>Conclusion:</b> This thesis provides new evidence of the individual and cumulative effects of IPV, methamphetamine use, and depression on HIV risk outcomes among Indonesian women who inject drugs. The interaction analyses are the first to empirically test the assertion that these co-occurring conditions interact synergistically to increase drug-using women's HIV risk. This thesis furthers our understanding of how syndemics function within women who inject drugs to produce health disparities, and contributes to the problem theory for HIV risk behaviour in this population. The findings of this study have great public health significance and important implications for future longitudinal research, interventions, and policy.