Structural, everyday, and symbolic violence and the heightened vulnerability to HIV of women who use drugs in Tanzania.

Women who use drugs shoulder a disproportionate burden of the HIV epidemic in Tanzania. The mechanisms through which violence contributes to their excessively high rates of HIV have not been explored. In this paper, we use concepts of everyday, symbolic, and structural violence to critically examine the relationship between violence and heightened HIV vulnerability of women who use drugs in Dar es Salaam, Tanzania. We conducted cross-sectional surveys with 200 women who use drugs and follow-up, in-depth interviews with 30 survey participants who identified as living with HIV between November 2018 and March 2019. We drew from grounded theory methods to analyze qualitative data and complemented qualitative findings with survey results. Structural violence perpetuated constraints on women's economic opportunities and reduced their agency in sexual encounters manifesting in their disproportionately high rates of HIV. Nearly all women in our study engaged in sex work to meet basic needs and to support their drug use. Their involvement in overlapping drug use and sex work scenes exposed them to physical and sexual violence. Despite the pervasiveness of structural and everyday violence, some women reenacted agency by adopting strategies to maintain control and safety, and to exercise harm reduction. A multi-pronged, structural harm reduction strategy is critical to reducing violence experienced by women who use drugs and their ability to protect themselves from HIV.