Analysis of risky behavior, HIV and HCV related knowledge and testing practice among PWIDs partipating in Needle and Syringe Program in 10 cities of Georgia: Tbilisi, Rustavi, Gori, Batumi, Kutaisi, Zugdidi, Ozurgeti, Samtredia, Poti, Telavi
Study Report
Georgian Harm Reduction Network
Tbilisi 2017 Acknowledgements
This project is a product of unremitting work, research and dedication. Nevertheless, it could not be implemented without financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Special attention is to be given to the Harm Reduction Service Centers participating in the study-active involvement and cooperation from the side of the heads of the Centers for Needle and Syringe Program: Psycho-Social Information and Consultation Center “New Way” (Tbilisi, Kutaisi, Samtredia), the Union “New Vector” (Tbilisi), “Imedi” (Batumi), the Union “Step To The Future” (Gori, Telavi), the Association of National Development of Education, Social Rehabilitation and Historic Values Protection “Ordu” (Poti), and the Association of Young Psychologists and Doctors “Xenon” (Zugdidi). We express our gratitude to those beneficiaries who allowed time and gave their consent for participation in the study. Without trust and contribution of each respondent, beneficiary and the personnel of the Needle and Syringe Program it hardly seems credible to implement this study.
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Table of Contents
ABREVIATIONS 4
INTRODUCTION 5
HARM REDUCTION PROGRAMS INDUCED BY INJECTION DRUG USE 5 HARM REDUCTION SERVICES IN GEORGIA 6 STUDY PURPOSES 7 STUDY TASKS 7
METHODOLOGY 8
STUDY DESIGN 8 ETHICAL ISSUE OF THE STUDY ERROR! BOOKMARK NOT DEFINED. INSTRUMENT 9 SAMPLING 9 STUDY PARTICPANTS’ SCREENING AND INCLUSION CRITERIA 10 DATA COLLECTION AND ANALYSIS 10 STUDY LIMITATIONS 11
STUDY RESULTS 11
DEMOGRAPHIC DATA 11 INJECTION DRUG USE PRACTICE 18 RISK ASSESSMENT BATTERY 22 SERVICES ASSESSMENT ERROR! BOOKMARK NOT DEFINED. ASSESSMENT OF KNOWLEDGE ON TRANSMISSION OF HIV INFECTION 32 ASSESSMENT OF KNOWLEDGE ON TRANSMISSION OF HEPATITIS C 33
BASIC FINDINGS 38
RECOMMENDATIONS 39
BIBLIOGRAPHY ERROR! BOOKMARK NOT DEFINED.
ANNEX ERROR! BOOKMARK NOT DEFINED.
ANNEX #1 ETHIC COMMISION REPORT ERROR! BOOKMARK NOT DEFINED. ANNEX #2 STUDY QUESTIONAIRRE ERROR! BOOKMARK NOT DEFINED. ANNEX #3 INFORMED CONSENT ERROR! BOOKMARK NOT DEFINED.
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Abbreviations
NSP Needle and Syringe Program PWID Injection drug user HIV Human Immunodeficiency Virus OST Opioid Substitution Therapy AIDS Acquired Immune Deficiency Syndrome VCT Voluntary Counselling and Testing WHO World Health Organization GHRN Georgian Harm Reduction Network SPSS Statistical package for social sciences STI Sexually Transmitted Infections CI Confidence Interval OR Odds Ratio SD Standard Deviation
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Introduction
Harm Reduction Services Induced by Injection Drug Use
Prevention practice for HIV and other blood-borne infections worldwide is based on the evidences and the experience collected during the last 30-40 years. According to the joint consolidated guideline of the World Health Organization, the Joint United National Program on HIV-AIDS (UNAIDS) and the United Nations Office on Drugs and Crime, introduction1, of 9 main interventions have been recommended, which are operating in Georgia and available for PWID population:
1. Needle and Syringe Program (NSP); 2. Opioids Subsitution Therapy (OST) and other treatment methods for drug dependence; 3. Voluntary Counselling and Testing (VCT); 4. Antiretroviral therapy (ARV therapy); 5. Prevention and treatment of sexually transmitted infections (STI prevention and treatment); 6. Condom distubution program for PWID and their partners; 7. Targeted information and communication-educational program for PWID and their partners; 8. Prevention, vaccination, diagnostic and treatement of viral hepatitis; 9. Tuberculosis prevention, diagnostic and treatement.
Harm reduction as a feedback response to drug abuse problems represents an important component of public health and national drug policy and is based on the human rights principles. According to harm reduction approach, those people, who use drugs, not all of them can or wish to stop drugs. At the same time, proceeding from the hazard related to HIV infection, hepatitis B/C and blood-borne other infections and overdose, bio-psychological-social and legal support is required. According to the statement2 of the International Harm Reduction Organization, harm reduction for the PWID includes: “strategies, programs, and practices directed to reduce health, social and economic harm induced by legal or illegal psychoactive substances and it is not necessary to have a goal for reduction of those substances. Harm reduction has the benefit for both PWUD and their families and the society”. The harm reduction programs worldwide involve: 1) Needle and Syringe Program, 2) Opioids Substitution Therapy, 3) Substitution with morphine of long-term effect, 4) safe injection rooms 5) overdose prevention, and 6) treatment of other types of drug dependency.
1 WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users – 2012 revision. 2 Harm reduction International www.ihra.net
5 Needle and Syringe Program is the most important component of harm reduction involving voluntary counselling and testing. It includes providing sterile injection material (needles, syringes, transfusion devices in small veins), filters, spoons, cudgels, alcoholic tampons injection water, ascorbic acid, vein protection means (ointments, antiseptic and disinfection solutions).
During the last 10 years number of problematic3 users of psychoactive substances has grown4 and accounted for 49,000; consequently prevalence within 18-64 aged group of the Georgian population is approximately 2.02%, but calculating on general population it is 1,33%. Therefore, health and social harm associated with use of psychoactive substances have increased. With this regard growth of incidents of blood-borne infection diseases (HIV/AIDS, hepatitis C) is essential. Based on the 2016 data of AIDS center, 46.5% of cumulative number of HIV-AIDS infected people is from drug user’s community. Harm Reduction Services in Georgia
Harm Reduction Programs were introduced in Georgia within the period of 1999-2000 by the US and the Georgian Office of Open Society Georgian Foundation of the Open Society Institute. Since 2001 a non-governmental organization ‘Sasoeba” started implementation of the Needle and Syringe Program in Tbilisi, Georgia (through financial support of the Open Society Foundation), and in Batumi the first service of NSP was provided by the Department of Public Health of the Ministry of Health of the Autonomic Republic of Adjara5.
Since 2005 geographical access to the Harm Reduction Centers in Georgia has being increased, management of those centers is carried out by the Georgian Harm Reduction Network since 2008. In 2015 a mobile ambulatory service was introduced and currently, eight mobile ambulatories have been operated. By 2017, harm reduction programs have been implemented by the 10 non-governmental member organizations of the Georgian Harm Reduction Network through 14 service centers in 11 cities of Georgia (Tbilisi, Gori, Telavi, Kutaisi, Samtredia, Poti, Zugdidi, Ozurgeti, Batumi, Sokhumi and Rustavi), geographical coverage of those programs with the support of mobile ambulatories is extended to 55 cities and to the adjacent villages. Nowadays, harm reduction program in Georgia offers complex, diverse services oriented on beneficiaries’ needs that involve:
3 PWID of Illegal psychoactive substances The European Monitoring Centre for Drugs and Drug Addiction, http://www.emcdda.europa.eu/activities/hrdu 4 Sirbiladze, T., Tavzarashvili, L., Chikovani, I., Shengelia, N., & Sulaberidze, L. (2015). Population Size Estimation of People who Inject Drugs in Georgia 2014. Tbilisi. Retrieved from http://curatiofoundation.org/wp-content/uploads/2016/05/PWIDs-PSE-Report-2015_ENG.pdf
5 Wilson, D. P., Zhang, L., Kerr, C., Kwon, A., Hoare, A., Otiashvili, D., … Williams-Sherlock, M. (2011). Evaluating the Cost-Effectiveness of Needle-Syringe Exchange Programs in Georgia. Retrieved from http://altgeorgia.ge/2012/myfiles/UNAIDS_reporrt_eng.pdf
6 • provision of PWID with needles, syringes, various sterile devices, condoms and educational materials in hospital service centers via outreach and mobile ambulatories; • pre and post counselling and screening testing of PWID on HIV/AIDS as well as testing on hepatitis B and C and syphilis by fast simple tests; • coordination with Hepatitis C Eliminaton Programme and well-timed referral of beneficiaries with positive screening result for further diagnostic and treatment; • provision of informational-educational meetings for peers. • implementation of case management intervention in harm reduction centers; • provision of consultations with doctors-specialists (therapeutist, surgeon, infectious speciliast, gynecologist, STI specialist, urologist) and psychologist and lawyer for PWID • prevention of HIV distribution by peers (PDI – Peer Driven Intervention)6, among PWID that should draw new beneficiaries for the program, their coverage by minimum HIV prevention package and educational work with them; • provision of services oriented for sexual partners of PWIDs, their counselling, offering services intended for reproductive health (gynecological consultation and other medical services); • PWIDs screening for TB detection early, referring them to TB diagnostic/specialized treatement clinics and provision of educational work on the issues of TB prevention and well-timed diagnostics; • Treatment of syphilis for PWID and their sexual partners
Study Purposes
Based on the aforesaid, for highly vulnerable group, such as PWID, operation of harm reduction programs, increase of geographical area for service, improvement of service quality and increase in accessibility, consideration of needs for PWID population and management of services focused on them represent a significant component for harm reduction programmes. For this purpose enquiries of beneficiaries is regularly made in the Service centers, through which current situation is assessed and the needs are revealed, which may be taken into account for the future programs. Consequently, the purpose of the study is to review beneficiaries’ behavior related to drug use, the level of knowledge in hepatitis C and HIV-AIDS in PWID and assesses behaviors implying sexual and injection risk. The results of the mentioned study give the opportunity to reveal the needs and
6 Broadhead, R. S., Heckathorn, D. D., Altice, F. L., E El Van Hulst, Y., Carbone, M., Friedland, G. H., … Selwyn, P. A. (2002). Increasing drug users’ adherence to HIV treatment: results of a peer-driven intervention feasibility study. Social Science & Medicine, 55, 235–246. Retrieved from http://chipcontent.chip.uconn.edu/chipweb/pdfs/Broadhead et al., 2002.PDF
7 respond to them in an adequate manner, taking into account evidence-based data, namely, to plan and introduce the relevant changes for PWID within the frame of HIV-AIDS prevention program Study Tasks
The study tasks are:
o to study injection and sexual risky/hazardous behaviors for beneficiaries included in PDI; o to study social-economic level of drug users; o to assess level of knowledge for HIV-AIDS and hepatitis C; o to study behaviors related to overdose; o to assess frequently applied harm reduction services; o to assess needs through various desirable services.
Methodology
Study Design
Within the frame of cross-sectional7 study, direct questioning of beneficiaries by interviewers has been performed. The questioning was done within the period from 1st February 2017 till 30rd August 2017 period (7 months). Targeted population of the study was a beneficiary, provided with NSP services in the 14 Harm Reduction Service Centers.
Ethical Issues of the Study
The protocol, questionnaire (administered by an interviewer) and informed consent form to be submitted to the commission of bioethical issues -Health Research Union (HRU, IRB 00009520), address: #47, Tashkenti street, Tbilisi) for consideration of the study participants rights. The ethic commission of Health Research Union is registered in the Registry of Human Tights Ethics Commission8. The Ethic Commission discussed the study application submitted and issued a right to conduct study pursuant to all rules (see annex 1).
7 Setia, M. S. (2016). Methodology Series Module 3: Cross-sectional Studies. Indian Journal of Dermatology, 61(3), 261–264. http://doi.org/10.4103/0019-5154.182410 8 http://ohrp.cit.nih.gov/search/irbsearch.aspx
8 Instrument
The structured questionnaire used by the Harm Reduction Network for data collection in the previous years has been applied as well as standardized risk assessment battery9, which is well- adapted in that population for performing study in Georgia10 and in addition, the questions on C hepatitis dissemination were used. The final instrument was composed of the following sections: demographic data (17 questions), PWID practice (28 questions), risk assessment battery (29 questions), service assessment (3 questions), verifying knowledge for HIV infection dissemination (5 questions), hepatitis C (19 questions). Most of the questions were simple with the possibility to select one answer, however, questions to select multiple answers and ranking sequence of answers were also provided (see annex 2).
For respondents nonjudgmental environment was created and the main criterion was voluntary participation in the study. Confidentiality of study participants was ensured (no name, surname or personal number was mentioned), seven-digit and 15-digit codes were only applied (they had been used upon administering harm reduction programs).
Sampling
Non-probable, easily of access sampling design11 was applied, which means questioning those beneficiaries that were available for the service center, within the period of conducting study and agreed to participate in the study. Questioning proceeded until the desirable number was gathered. Calculation of the sampling size is carried out taking into account the following parameters: • targeted population size - 49,70012; • supposed percentage number of the persons being in touch with study event is defined as 40% (according to the 2016 data of the Georgian Harm Reduciton Network, the services are provided for 35000-38000 PWID, but for the study, based on minimum calculations, just 20,000 was used);
9 Metzger DS, et al. The Risk Assessment Battery: Validity and Reliability; Paper presented at the 6th Annual Meeting of National Cooperative Vaccine Development Group for AIDS.Nov, 1993. 10 Otiashvili, D., Piralishvili, G., Sikharulidze, Z., Kamkamidze, G., Poole, S., & Woody, G. E. (2013). Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use, and reducing HIV risk behavior – Outcomes of a Randomized Trial. Drug and Alcohol Dependence, 133(2), 10.1016/j.drugalcdep.2013.06.024. http://doi.org/10.1016/j.drugalcdep.2013.06.024 11 Tyrer, S., & Heyman, B. (2016). Sampling in epidemiological research: issues, hazards and pitfalls. BJPsych Bulletin, 40(2), 57–60. http://doi.org/10.1192/pb.bp.114.050203 12 Sirbiladze, T., & Tavzarashvili, L. (2014). Estimating the Prevalence of Injection Drug Use in Georgia. Tbilisi: Bemoni Public Union.
9 • Margin of error is defined as 2.85; • Confidence interval is defined as 95%.
x=Z(c/100)2r(100-r) n=N x/((N-1)E2 + x) E=Sqrt[(N - n)x/n(N-1)]
Based on those parameters, 1110 respondents were determined as improbable comfortable sampling size that was divided into the 14 service centers with 70-100 value of coverage within the study period.
Study Participant Screening and Inclusion Criteria
The information on the study was provided on the wall of all service centers and moreover, outreach personnel offered beneficiaries to participate in the study. A person who agreed to participate was screened and the procedure for obtaining consent to participate was performed. For this purpose an interviewer explained all potential participant the goal of the study and introduced informed consent form for participation in the study (annex 3). Study inclusion criteria were: • A participant must be adult (at the age of 18 and above); • Participation in the study is to be volunatary; • The mandatory requirement was minimum 6-month experience of being invoved/benefited from the Needle and Syringe Program; • A study participant should not the problems related to mental health, thinking and speech which can impede him/her in participation in the study.
Data Collection and Analysis
Data collection was carried out through questionnaires, which was entered by an interviewer in excel file in advance. Via excel cells validation, within the data entry process, making errors was minimized. Afterwards the base was filtered for discrepancies and imported for preliminarily prepared Statistical Package for the Social Science (Statistical Package for the Social Science v.21)13 where whole base was counter checked by applying frequencies and cross-tabulations. Two open
13 Dembe, A. E., Partridge, J. S., & Geist, L. C. (2011). Statistical software applications used in health services research: analysis of published studies in the U.S. BMC Health Services Research, 11, 252. http://doi.org/10.1186/1472-6963-11-252
10 questions were provided in the questionnaire, which appeared into the database via grouping of similar answers and relevant coding.
Univariate analysis was performed-frequencies, middle and median values were calculated, but under bi and multivariate analysis (category variable cross-tabulation, comparison of average values, t-test, ANOVA) interconnections among variables (differences, associations and correlations) were revealed.
Study Limitations
The study is based on collection of observations from the side of beneficiaries who are gaining benefit from the services. This study has created the general picture for injection and sexual risk-behavior of beneficiaries, but as all studies, this one has certain limitations. First-rate limitation can be considered applied non-probable, easy to access selection, as well as mobilization of study participants with the support of social workers, which in some cases could attract such beneficiaries who gave positive answers or answers which were acceptable for social workers. Also limitation may be considered the circumstance when service provider itself (in this case VCT consultant) performed questioning of beneficiaries. Consequently, taking into account those circumstances we became somehow restricted from the opportunity to generalize completely the findings, however, we are able to have a presentation on certain behaviors distributed in that population.
Study Results
Demographic Data
The study was conducted in 10 cities of Georgia (Tbilisi, Telavi, Batumi, Gori, Kutaisi, Rustavi, Ozurgeti, Samtredia, Zugdidi, and Poti). Totally 1178 screenings were performed, 13 of them did not meet the criteria, 59 refused to participate in the study and the data of 1106 respondents were placed in the final database. Majority of the questioned respondents are in Tbilisi because of 4 service centers operating in the capital of Georgia (32.6^; 361 respondents), please see diagram 1. Most of participants are men (1068 respondents) and little part –women (34 respondents), information on gender for 4 respondents is unknown. On the question “How would you describe yourself? Heterosexual, gay, bi or homosexual –totally 3 answers were received, from where only one pointed out gender-woman and two-men. There is no statistically significant difference among cities, in terms of women drug users, however, in some cities women were not questioned at all (see diagram #2). .
11 DIAGRAM 1. DISTRIBUTION OF STUDY PARTICIPANTS’ NUMBER ACCORDING TO THE CITIES
400 361 350 300 250 200 150 101 101 100 82 100 70 70 71 70 80 50 0
DIAGRAM 2. GENDER DISTRIBUTION ACCORDING TO THE CITIES
Zugdidi Poti Samtredia Kutaisi Ozurgeti Batumi Gori Rustavi Tbilisi Telavi
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
women men
Age distribution of study participants gets closer to normal distribution (diagram #3), average age of participants is 40.77, and median age is 40.
DIAGRAM 3. HISTOGRAM OF AGED DISTRIBUTION ACCORDING TO NORMAL DISTRIBUTION CURVE
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Average age of the women respondents is 41.41 (CI 95% 38.77-44.55, SD 8.9) with minimum age of 25 and maximum-58, but average age of men was 40.72 (CI 95% 40.20-41.24, SD 8.6), with minimum age of 18 and maximum of 72. By comparing the level of respondents education, professional educational level in women is higher compared to men, which provides statistically authentic difference χ2 (5) 12.708, p=0.026 (see diagram 4).
DIAGRAM 4. EDUCATIONAL LEVEL ACCORDING TO GENDER
refrain from answering 0.3%
higher-completed 17.2%
higher-incompleted 18.9%
professional 11.4%
secondary-complete 46.9%
secondary-incomplete 5.3%
men women
13 High rate of unemployement is revealed in total sampling (46.9%), which exceeds self-employement (26%) and temporary employement (15.2%) rates in total. In terms of employment more men are employed than women that also gives statistically authentic difference χ2 (5) = 59.621, p = 0.000 (see diagram 5).
DAIGRAM 5. RATE OF EMPLOYEMNT AMONG RESPONDENTS
1.3% refrain from answering 17.6%
0.5% pensioner disabled person 2.9%
9.6% full time worker 8.8%
14.8% temporary worker 26.5%
26.1% self-employed 20.6%
47.7% unemployed 23.5%
men women
Despite those differences in education and employment, difference in personal incomes received in last month is not revealed (in total selection average is 398 GEL14), however, 172 respondents (15.6%) refrain from answering. The representatives of both gender mentioned equal amount of personal incomes in average: average income for women is 588.24 GEL (minimum is 100 GEL and maximum - 1500), average income for men is 423.04 GEL (minimum is 0 GEL and maximum is 15000), t (1100) =1.550, p=0.121, consequently, the given difference is not considered as statistically important. In whole selection, distribution of median values of amounts are provided on diagram 6 showing that for the majority of the respondents 100-500 GEL is available (n= 645, 69%). Among the sources for income employment is prioritized, and amounts borrowed or gifted from friends, relatives and others took the second place (21%), please see the details on diagram 7.
36% of the respondents (n= 645, 69%) pointed out that during the last 30 days they spent up to 100 GEL for drugs, 59% (n = 644) -500 GEL, the rest 60 respondents (5%) from 500-2500GEL. On the
14 Ignoring of very different value took place while calculation of this value (outlier), totally 5 cases, which significantly exceed 3000 GEL.
14 last day of whole selection, average value for spending on drugs is 260 (median 200, SD 219.373), minimum 0 GEL and maximum 2500 GEL (diagram 8). 120 respondents refrain from giving answers that amounted to 11% in total sampling. Based on the answers received, majority of the respondents (n = 719, 65%) pointed out that they used drugs in the last month by taking debt within the amount of 100 GEL, 255 (23%) respondents used drugs within the amount of 500GEL, and the rest -12 participants (1%) spent the biggest amount-3000GEL.
DIAGRAM 6. DISTRIBUTION OF PERSONAL INCOME RECEIVED DURING THE LAST 30 DAYS IN TOTAL SELECTION
501-1000 GEL
1001-3000 GEL
up to 101-500 3001 and more GEL
up to 100 GEL
DIAGRAM 7. SOURCE OF INCOME DURING THE LAST 30 DAYS
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employement 6% amount obtained from renting or selling 7% 3% amount given by friend, partner, relative, borrowed 5% 40% money social support, or pension
illegal income 21%
money won (casino, totalizator, others) 18% refrain from answering
DIAGRAM 8. DISTRIBUTION OF AMOUNTS SPENT ON DRUGS DURING THE LAST 30 DAYS
Majority of the respondents live with their parents, friends, partners or relatives (n = 533, 48%); 43% (n = 472) of the respondents have own flats, the rest (n = 95; 9%) is homeless, live in shelters or in rented/mortgaged houses/flats (diagram #9). Statistically authentic difference was revealed between housing and gender, namely; owners of flats are more men than women, the latest ones live with their parents, friends, partners or relatives χ2 (5) = 34.103, p = 0.000.
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DIAGRAM 9. HOUSING OF THE RESPONDENTS
others-shelter, homeless, rented/mortgaged
with parents/relative/friend's flat
own flat
men women
The respondents pointed out that they live together with 3 members (SEM = 0.42; CI 2.70 – 2.87), excluding adults, in this regard statistically significant difference is not revealed between women and men (diagram 10). The majority (917, 82.9%) specified that persons they live with, no one is a drug user; however, 108 respondents (9.8%) mentioned that they live with some drug users, other 81 respondents (7.3%) refrain to answer. In this terms statistically significant difference in gender is detected, more men pointed out to live with persons who use drugs than women χ2 (5) = 82.516, p = 0.000.
17 DIAGRAM 10. NUMBER OF MEMBERS IN HOUSING
35.0
30.0
25.0
20.0 % 15.0
10.0
5.0
0.0 0 1 2 3 4 5 6 7 20 Number of family members
Injection Drug Use Practice
Average period of drug use for the study respondents is 13.50 years (SD 5.758; CI 11.58-15.60; min 5 and max 25 years), but for men -17.38 (SD 8.089; CI 16.89-17.87; min 1 and max 50 years). Injection drug use of the respondents started at the age of 19.8 years on average (median -20 years, CI 19.63-19.98), with minimum age of 10 years and maximum-36 years (SEM=0.089). No difference in age when a drug user starts drug use is revealed between men and women. Total years of injection drug use amounted to 17.4 years (SD 8.08) for men and 13.6 years (SD 5.76) for women, this difference is statistically important p = 0.007.
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DAIGRAM 11. TREATMENT EXPERIENCE IN OST PROGRAM
currently enrolled in program 14% stopped treatement in last month 0%
stopped treatment several months ago … never 68% had been involved a year ago and more 11% refrain from answering …
Majority of respondents (n=743, 68%) specified that they had never been in Methadone/Subuxon replacement therapy (OST), however, men have had more treatment experience compared to women, this difference is statistically authentic χ2 (4) = 3.104, p = 0.007. For the last 30 days average rate of injection numbers amounted to 3.3 (SD=1.9; min=0, max=33), however, men compared to women made injections in a group consisting of more members (2.21 vs 3.37), which is statistically authentic χ2 (4) = 43.086, p = 0.000.
19 DIAGRAM 12. NUMBER OF INJECTIONS MADE DURING THE LAST 30 DAYS
16 and more injections 13%
Up to 5 11-15 injections injections 41% 18%
6-10 injections 28% DIAGRAM 13. DISTRIBUTION OF NUMBER OF THE LARGEST GROUP MEMBERS WHILE SINGLE INJECTION DURING THE LAST 30 DAYS
6 and more 7.2
3 - 5 61.1
2 22.2
1 7.8
0 1.7
The picture of drugs used during the last 30 days is characterized with diversity and clearly indicates at using more than one drug by one person. With regard to injecting drugs, significant difference among men and women is not revealed in case of opiates and stimulators, namely opiates are mostly used by men χ2 (2) = 9.860, p = 0.007, and home-made stimulators (Vint, Jeff) by women χ2 (1) = 11.979, p = 0.001. The picture for injecting drugs used during the last 30 days is provided at diagram 14. It should be mentioned cannabis, which is equally used both women (18, 52%) and men (552, 47.4%) from majority of the respondents. The difference in use of psychoactive substances (so-called “Bio”) is noticed, particularly, women (9, 26%) specified its use compared to men (146, 14%),
20 concerning MDMA, ecstasy those substances are used by only from men (6, 0.6%); those differences are statistically authentic p = 0.000. During the last 30 days whole picture for injection and non- injection drug use is provided at diagrams 14 and 15.
DIAGRAM 14. NON-INJECTION PSYCHOACTIVE SUBSTANCES USED DURING THE LAST 30 DAYS %
volatile solvents, smelling means Spices (bio-drugs, "MDMA" ) cannabis, hashish psychotropic substances (Xanax, Benzoates,… antihistamines (dimedrol, pipolphen,… alcohol bio-hashish
0 10 20 30 40 50 60
DIAGRAM 15. INJECTION PSYCHOACTIVE SUBSTANCES USED DURING THE LAST 30 DAYS (%)
antihistamines (dimedrol, pipolphen, suprastin and others) spices (bio-drug, "MDMA" ) tropikamid, ketamine, kalypso spa salts, cristal metamphetamine vint, jeff stret subutex heroin, sierets desomorphin 0.0 10.0 20.0 30.0 40.0 50.0 60.0
Difference in men and women participated in selection process is statistically authentic based on place for final injection χ2 (7) = 15.309, p = 0.032), women never specified injection in muscles or axillary areas (tables 1). Difference in number of overdoses according to gender during the last 30 days is not statistically authentic. 7% of the respondents (71 respondents, 1 woman) indicated at only one case of overdose during the last 30 days, only 3 men specified that they had had overdose twice, the reasons
21 of overdose are explained only by men mostly they consider improper calculation (17 cases, 11.3%), mixture with other substances (17 cases, 11.3%) and incorrect preparation (3 cases, 0.3%), but others refrain from answering the question. Irrespective of 7 cases, on the question related to recovery from overdose, only 36 answers were obtained and most of them specified Naloxone injection (29 cases).
TABLE 1. PLACE OF LAST INJECTION ACCORDING TO GENDER
Women Men Superficial veins of hands or legs 23.5% 48.2% Deep veins of hands or legs 47.1% 25.1% Inguinal vein 20.6% 18.3% Subclavian, clavicular area 5.9% 1.7% Veins of neck 2.9% 2.1% Axillary area 0.0% 3.3% Muscles 0.0% 1.2% Other 0.0% 0.1%
Risk Assessment Battery
Risk assessment battery is a standardized document, which assess sexual and injection practice according to risk composition assigning relevant ranking scores to a specific behavior. The final result of the instrument –risk behavior index (RAB index) from 0 to 1 and indicates at magnitude of HIV infection risks, the closer it to 1 the higher is sexual and injection risk behaviors and consequently, risk for blood-borne infections. In the selection process average value of RAB index is 0.25 (minimum=0.05, maximum=0.63; SD 0.09); correlation connection between level of education and RAB index (χ2 (105) = 102.931, p = 0.539) and between gender and RAB index (χ2 (21) = 30.929, p = 0.075) was unable to be proved, but difference is statistically authentic between cities (χ2 (189) = 768.685, p = 0.000) (daigaram14). While analyzing ANOVA average RAB index of minimum one city is differ from average values of all other cities F (2, 1075) = 44.9, p=0.000. It is noteworthy to mention that risk behavior index up to 0.5 is typical for the whole selection, only little amount of share of the respondents (0.8%) when risk behavior index is more than 0.5 (diagram 15).
DIAGRAM 16. DISTRIBUTION OF RISK BEHAVIOR INDEX ACCORDING TO CITIES
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140
120
100
80
60
40Frequency
20
0 0.05 0.08 0.1 0.13 0.15 0.18 0.2 0.23 0.25 0.28 0.3 0.33 0.35 0.38 0.4 0.43 0.45 0.48 0.5 0.53 0.55 0.63 RAB-index Tbilisi Zugdidi Poti Samtredia Kutaisi
DIAGRAM 17. HISTOGRAM OF RISK ASSESSMENT INDEX IN WHOLE SAMPLING
Taking into consideration that studying risky behavior index showed difference in the value of minimum one city from the values of other cities, while reviewing differences among average values by Post Hoc test it has been revealed that Rustavi RAB index is significantly different from other average values of rest cities (table1, diagram 16).
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TABLE 2. AVERAGE OF RISK ASSESSMENT INDEX ACCORDING TO THE CITIES
95% CI City N RAB mean SD Lower limit Upper limit Telavi 70 0.3096 0.05963 0.2954 0.3239 Tbilisi 353 0.2362 0.08698 0.2271 0.2453 Rustavi 101 0.3653 0.1035 0.3449 0.3858 Gori 82 0.1936 0.07058 0.1781 0.2091 Batumi 100 0.2235 0.07686 0.2083 0.2387 Ozurgeti 68 0.2662 0.08902 0.2446 0.2877 Kutaisi 70 0.2268 0.07794 0.2082 0.2454 Samtredia 68 0.2632 0.09507 0.2402 0.2862 Poti 75 0.2840 0.11637 0.2572 0.3108 Zugdidi 98 0.1612 0.04682 0.1518 0.1706
DIAGRAM 18. DISTRIBUTION OF AVERAGE VALUE OF RISK ASSESSMENT INDEX AMONG CITIES
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
The analysis of variables related to risky behavior for risk assessment battery brought to light that 18% of total selection specified that they shared needles, syringes and other injection instruments with different number of people for the last 6 months. The important thing is that difference between cities is statistically authentic (χ2 (27) = 336.026, p = 0.000) and the following cities are distinguished by share risk practice: Poti, Rustavi and Samtredia (diagram 19).
24 DIAGRAM 19. DISTRIBUTION OF SHARE OF NEEDLES, SYRINGES OR OTHER INJECTION INSTRUMENTS WITH OTHERS FOR THE LAST 6 MONTHS ACCORDING TO THE CITIES
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
in no cases with one person with two or three persons with four or more persons
On a question for the last 6 months how often you shared syringes with another person who was infected with HIV or affected with AIDS and you were informed about it or discovered later, absolute majority of the respondents’s (1080, 98%) answers were negative, however, share practice with diverse frequencies in 17 respondents were revealed in the cities such as: Tbilisi, Ozirgeti, Kutaisi and Poti (diagram 20). It should be mentioned that no one form those respondents were infected with HIV. The difference between the cities is statistically authentic χ2 (27) = 85.001, p = 0.000. For the respondents the main source of needles and syringes is Needle and Syringe Program (70%) and pharmacy (18.7%), however, for the last 6 months totally 7 respondents (3 from Tbilisi, 3- Poti and 1-Kutaisi) specified about use of syringe dropped in the streets (diagram 21), which is a too risky behavior. These differences between the cities are statistically authentic χ2 (9) = 17.037, p = 0.048.. Gathering in various places (flats, specific places, brewing) to use drugs ere specified by the large part of the respondents (969, 87.6%), only a few respondents (137, 12.4%) pointed out that they had never had such practice for the last 6 months and this practice is mostly seen in the cities such as: Tbilisi, Batumi, Kutaisi and Zugdidi. This difference is statistically authentic χ2 (27) = 300.683, p = 0.000.
25 DIAGRAM 20. FOR THE LAST 6 MONTHS HOW OFTEN HAVE YOU SHARED SYRINGE WITH A PERSON WHO WAS INFECTED WITH HIV OR AFFECTED BY AIDS AND YOU WERE INFORMED ABOUT IT OR DIVORCED LATER?
100% 98% 96% 94% 92% 90% 88% 86% 84% 82%
in no cases several tims or less several times each month once or more each week
DIAGRAM 21. WHERE DID YOU OBTAIN SYRINGES AND NEEDLES FOR THE LAST 6 MONTHS?
100% 0.3%
90% other 80% NSP 70% 69.7%
60% flats, where injections are done 50% pharmacy 40% 10.3% 30% picki up syringe dropped in streets 20% take off from person with 18.7% 10% 0.4% diabetes 0.5% 0%
26 On a question -how have you cleaned syringe for the last 6 months- the respondents from Poti, Samtredia, Rustavi and Tbilisi are distinguished by syringe cleaning practice (Diagram 22), which provides statistically essential difference (χ2(45) = 390.450, p = 0.000). It is noteworthy that in 80% of the cases the practice of use of new syringe is seen, but cleaning practice of syringe by water or water and soap is revealed in 10% of the whole sampling (112 respondents) due to Rustavi, Samtredia and Poti (Diagram 23), the difference is statistically authentic χ2(9) = 211.353, p = 0.000.
DIAGRAM 22. HOW HAVE YOU CLEANED SYRINGES FOR THE LAST 6 MONTHS
Zugdidi Poti Samtredia Kutaisi Ozurgeti Batumi Gori Rustavi Tbilisi Telavi 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% in no cases always used new syringe always cleaned before use always cleaned after use sometimes cleaned, sometimes not never cleaned my syringe
DIAGRAM 23. HOW HAVE YOU CLEANED SYRINGES FOR THE LAST 6 MONTHS
1% not cleaned at all 1%
by soap/water or water 10% 0% alcohol
0% chloride 9% boiled water
2% 77% not cleaned
always use new needle
cleaned in other ways
27 Water is used for syringes cleaning in Rustavi 46.5%), Samterdia (54%), Poti (50%) and relatively low values are revealed in Tbilisi (8%), Ozurgeti (17%) and Kutaisi (11.3%). In Batumi, Gori and Zugdidi the similar practice has not seen, this difference is statistically authentic χ2 (27) = 396.169, p = 0.000. For the last 6 months the share practice for instruments (boiling bowl, spoon and other) is widely spread, however, the difference among the cities are statistically important (χ2(27) = 447.673, p = 0.000) and mostly revealed in Telavi (100%), Tbilisi (64.8%), Rustavi (89%), Ozurgeti (84%), Samtredia (55%), Poti (53.8%), but in other cities there are relatively low rates: In Gori (18%), Batumi (18%), Kutaisi (25.4%). During the analysis for sexual practice, it is evident that the women (17.6%) in more cases have had sexual relations in exchange for drugs compared to men (1.2%). The same can be said for sexual relations done for money, mostly it is characterized for women (14.7% vs 1%), those both differences are statistically authentic (p = 0.000) 10% of the respondents (122) specified that for the last 6 months had paid money for sexual relations, the highest rate is revealed in Poti 31.3%, then comes Gori 17%, Batumi 13%, Rustavi 14% and Tbilisi 10%, in other cities relatively low rate is seen: Ozurgeti 4.3%, Kutaisi 2.8%, Samtredia 2.9% and Zugdidi 7%, this difference between the cities is statistically authentic (p = 0.000). On a question for the last 6 months how often have you had sexual relations with a person who was HIV infected and you were informed about it or discovered later, totally 11 positive answers were obtained, from where 9 have had such contacts several times and the other two –relatively regular contacts (several times each month and one or two each week). For the last 6 months the rate for protected sexual practice is low and is differs from among the cities, which is statistically authentic χ2(27) = 355.792, p = 0.000 (see diagram 24). DIAGRAM 24.FOR THE LAST 6 MONTHS DISTRIBUTION OF PROTECTED SEXUAL RELATIONS ACCORDING TO THE CITIES
100% not used at all 80%
60% used sometimes
40%
20% used in most cases
0%
28 All respondents are worried abut threat to be infected with HIV, irrespective of the fact whether being or not in sexual relations with HIV person (whether were informed about it or discovered it later) for the last 6 months, in this regard statistically important difference has not been proved, but between the cities the dramatic difference exists and the rewpondents in Telavi 44.3%) and Gori (62.2%) were never worried this threat. This difference appeared to be statistically authentic (p = 0.000).
DIAGRAM 25. TO WHAT EXTENT ARE YOU WORRIED WITH BEING INFECTED BY HIV
a little bit , 26.2%
moderately , 19.8%
not worry at all 16.0%
very , 13.6% significantly , 24.4%
In whole selection testing rate for HIV infection per respondent is 3 (min. and max. 10, SD 1.72), however, this rate is significantly differ from between the cities (table 3, diagram 26), which is statistically authentic (p = 0.000).
TABLE 3. HOW MANY TIMES HAVE YOU TAKEN BLOOD SAMPLE FOR DETECTION OF HIV?
Std. 95% confidence interval city N average minimum maximum Deviation Lower limit Upper limit Telavi 70 4.73 1.667 4.33 5.13 2 10 Tbilisi 361 2.67 1.360 2.53 2.81 1 10 Rustavi 101 1.48 .807 1.32 1.63 1 5 Gori 82 3.79 1.561 3.45 4.14 1 10 Batumi 101 4.42 2.011 4.02 4.81 1 10 Ozurgeti 70 1.91 .737 1.74 2.09 1 4 Kutaisi 71 2.28 1.436 1.94 2.62 0 10 Samtredia 70 2.19 1.231 1.89 2.48 1 5
29 Poti 80 1.81 .506 1.70 1.92 1 3 Zugdidi 100 3.53 2.062 3.12 3.94 1 10 Total 1106 2.85 1.720 2.75 2.95 0 10 DIAGRAM 26. AVERAGE NUMBER OF TESTS FOR HIV ACCORDING TO THE CITIES
The majority of the respondents (759, 68.6%) were tested for HIV for the last 6 months, the rest more than a year ago and it is important that all of them knew their status (98.8%).
Service Assessment
The list of services that drew the respondents’s attention were assessed via three questions by ranking sequence (in the first, second and third places), what they wish as additional service and which services are used more frequently by them also according to the sequence of their use (diagrams 27, 28).
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DIAGRAM 27.WHICH SERVICE ATTRACTED MORE ATTENTION FROM BENEFICIARIES FOR WHICH THEY DECIDED TO INVOLVE IN NSP (ACCORDING TO PRIORITY)
trainings, risk consultations confirative ribonucleic acid test for hepatitis C PDI Naloxone lawyer's consultations doctor's consultation HIV testing 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1st option 2nd option 3rd option
Only one fourth of the respondents (272, 24.6%), answered the question on additional service, however, the most desirable service appeared dental service (45%) and hepatic examiantions (20%).
DIAGRAM 28. DESIRABLE SERVICE
dentist, 44.5 other , 2.2
support with medications , 2.2 refrain from answering , 4.8
doctors in situ , 8.1 hepatitis C confirmation, treatment , 13.2 liver function tests and elastography, 20.2 lawyer , 4.8
HIV tests and needles/syringes ranked the first place according to frequency of service use, in which information materials were not mentioned (diagram 29)
31
DIAGRAM 29. DISTRIBUTION OF SERVICES BASED ON FREQUENCY OF THEIR USE
information materials vein care means PDI trainings, risk consultations condoms Naloxone syringes and needles lawyer's consultations psychologist's consultations doctor's consultation Hepatitic C testing HIV testing
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Ioption II option III option
Assessment of transfer of knowledge on HIV Infection
The level of information capacity related to transfer of HIV infection in women and men does not differ ; majority of the respondents (847, 76.6%) all questions on HIV (totally 5 questions) answers correctly, see detailed questions and answers on diagram 30
DIAGRAM 30. DISTRIBUTION OF ANSWERS ON HIV TRANSMISSION
32 may a person be infected via insects? 2.4 90 7.6
may a person be infected by sharing food/water with a 2.5 96.6 0.9 person already infected with HIV
do you think HIV-infected person looks as healthy 84.8 7.3 7.9 person?
can person reduce HIV infection risk if he/she uses 98.6 1.20.2 condoms in all cases?
HIV infection risk reduces if you have one dedicated 99.2 0.70.1 sexual partner
yes no unknown
Assessment of knowledge and Practice on Hepatitis C
The level of information capacity on transmission of hepatitis C in men and women does not differ form each other, majority of the respondents (559, 54.2%) answered all questions correctly (diagram 31). One question (whether hepatitis C is transferred by domestic things were answered properly mostly by women than men (χ2 (2) = 32.514, p = 0.00).
33 DIAGRAM 31. DISTRIBUTION OF ANSWERS ON TRANSMISSION OF HEPATITIS C
hepatitis C is transmitted by sexual contacts 61.2 27.8 11.0
hepatitis C is transmitted by food 0.4 99.0 0.6
hepatitis C is transmitted by holding objects in public spaces 0.5 98.4 1.1 hepatitis C is transmitted by sharing already used nedle- 97.2 2.60.2 syringe
hepatitis C is transmitted by sharing domestic things 3.3 93.5 3.2
hepatitis C is transmitted by sharing personal hygine things 92.2 5.32.5
hepatitis C is transmitted by coughing, sneezing-drops 1.6 97.1 1.3
hepatitis C is transmitted by shaking hands 0.3 99.5 0.3
yes no unknown
Majority of the respondents answered correctly on the questions on infection risks for hepatitis C, except 6 respondents who refrain from answering or did not know the answer (Diagram 32). Also representatives of both genders have the same information on infection risks, no difference is revealed. On the question whether a person can be infected by hepatitis C but without symptoms 92.3% of the respondents answered properly. The absolute majority of the respondents were informed where tests are to be performed (1104, 99.8%). The most respondents (92.8%, 1021) specified that they were tested in the last 2 years, the other 6.5% (72 respondents) pointed out that they were tested more than 2 years ago and a few respondents (0.5%, 6 respondents) refrain from answering the question or had not been testes (0.6%, 7 respondents). Consequently, those 13 respondents talked about the reasons for non-performance of tests, such as; “I do not consider necessary to perform testing, “I am afraid of positive response” “due to financial problems” and others.
DIAGRAM 32. DISTRIBUTION OF ANSWERS ON INFECTION RISKS FOR HEPATITIS C
34 previously affected with hepatitis and I can not be infected 9.9 90.1
Hepatitis C infection risk reduces by not applying non-sterile 15.6 84.4 used medical equipment
Hepatitis C infection risk reduces while sharing already used 3.6 96.4 needle-syringe
Hepatitis C infection risk reduces by use of condoms 38.5 61.5
hepatitis C infection risk via little vaccination 97.7 2.3
no yes
One third of the whole sampling (358 respondents) specified that they were treated within up to 2 years, 9 respondents wre treated more than 2 years ago (totally 33%, 367 respondents), 450 (41%) respondents, who are infected indicated that they were not treated and 20 respondents (2%) refrained from answering the question. (diagram 33).
DIAGRAM 33. FREQUENCIES OF CONDUCTING HEPATITIS C TREATMENT
treatement not required as infected but not he/she is not treated infected 41% 24%
treated refuse to answer 33% 2%
From those who completed treatment (367 respondents), among them little part is the cases for ceasing treatment earlier than due time (6 respondents 2%), the largest part specified completion of the treatment (see diagram 34);
35
DIAGRAM 34. STATUS OF HEPATITIS C TREATMENT (367 RESPONDENTS)
stopped before treatment was completed 2%
completed 76% currently on treatment 17%
refuse to answer 5%
The largest part of the beneficiaries (367 respondents) specified that they were recovered from hepatitis C 9268 respondents, 73%), 8 respondents (2%) did not the results, 91 respondents 925%) did not have the answer. It is noteworthy that after completion of treatment 235 out of 367 respondents (64%) were retested for hepatitis C, from where only 5 respondents (1.36%) appeared to positive, in other cases responses did not match, so no sense to study their frequencies. Within the treatment period 234 (62%) out of 376 proves that they used drugs, the part of the sampling who were infected, had never been treated and specified various reasons (diagram 35). On a question on desirable place or location where hepatitis C testing, confirmation and provision of treatment service may be carried out, majority of the respondents wished all the services to be implemented in their cities in harm reduction service centers (diagram 36). Results of HIV and hepatitis C testing of the respondents were entered to questionnaires (see table #4). Probability to be infected by HIV I is women exceeds three times compared to men (OR 3.424; CI 95% 0.421-27.840), and Probability to be infected by hepatitis exceed 1.5 time in women than men OR 1.536; CI 95% 0.685-3.444). 9 cases of co-infection were revealed (8 men, 1 woman) in Gori, Batumi, Kutaisi, Poti and Zugdidi. Difference between the cities with regard to the cities is statistically important.at p=0.000 level.
DIAGRAM 35. REASONS FOR REFUSAL TO CONDUCT HEPATITIS C TREATMENT (RESPONSES OF 470 RESPONDENTS WITH MULTIPLE SELECTION POSSIBILITY)
36
due to other reason 4.4 does not know the reason 2.0 did not answer 0.7 waiting for treatment (in queuee) 16.8 it was far to take meducine and visit doctor 5.6 does not want needle injections 0.5 treatement is acoompanied with many side-… 5.6 treatement is expensive 9.0 under doctor's advice treatment is not… 4.1 not accessible 11.6 not infected and does not need treatment 31.4
DIAGRAM 36. DESIRABLE LOCATION FOR HEPATITIS C TESTING, CONFIRMATION AND PROVISION OF TREATMENT SERVICE
without answer 1.0
other 1.2
with other service provider in my city 1.6 harm reduction (needle and syringe program) service… 65.3
OST center/department in my city .3
C hepatitis treatment facility in my city 30.7
TABLE 4. DISTRIBUTION OF RESULTS FOR HIV AND TESTING
Result Women Men HIV(+) 1 9 HIV(-) 32 986 HCV(+) 25 659 HCV(-) 8 324
37
Main findings
The study was conducted in 14 service centers among the beneficiaries who are benefited from harm reduction services for minimum 6 months and agreed to participate in the study. The most part of 1106 study respondents were men (96.6%), with equal median age of participants.
Unemployment rate is very high in the sampling (46.9%), however more men are employed compared to women. There is no difference in personal income received for the last 30 days according to gender, average income is 398 GEL. In the last month for majority of the respondents it was available 500 GEL for personal use. It should be mentioned that most share of those sources of that income are from employment (40%) and from friends (21%), relatives or borrowings. (The respondents spent on average 233 Gel for drugs in the last month.
Majority of the respondents live with their families, together with 3-members on average, however mostly men have own flats than women, who basically live with their parents, friends, partners or relatives. It is noteworthy to mention that more men specify to live with families consisting of more members as well as with persons who use drugs than women. Injection drug use in the sampling started at the age of 19.8 on average and the men have more drug use experience than women. Majority of the respondents have never been treated (68%), irrespective of the fact 53% of the respondents mentioned opioids use for the last month. The men have more experience in OST treatment than the women. Average number of injections (9 injections) is high for men in the last month compared to women (6 injections). For the last 30 days while single drug use, members of group were 3. Individual injection practice was revealed in men, but not in women and homo/bisexual persons, however this difference is not statistically authentic. 57.2% (412 respondents) of the whole sampling do injections in a group consisting of 3-5 members.
The picture typical to Georgia is obtained according to low frequency of injections - injection every other day, one drug user uses drug on each third day. Men mostly use opiates, homemade stimulators (vint, jeff) and new psychoactive substances are used mostly by men. Cannabis is used both of them. Injection places for men are muscles and axillary area; injections in deep veins are more characterized for women. For the last 30 days difference in number of overdosed according to gender is not statistically important, it is equally revealed in both men and women. With regard to RAB index according to gender is not important, but differences between cities in terms of mean value if index (risky behavior distribution) are revealed as well as risky injection and sexual practices, which are important is the cities: Rustavi, Poti, Ozurgeti and Samtredia compared to the other cities. Such risky behaviors are:
38
• Overdoses caused by mixture of drugs, improper preparation and incorrect calculation of doses (7% of whole sampling in last month); • Group injection practice for men, consisting of more than 3 members; • Insafe injection practice in deep veins, axillary areas and inguinal vein; • Share practice of water for washing syringes ; • use of syringes dropped in streets; • sexual relations in exchange from drug or money; • mostly unprotected sexual relations with several partners.
The respondents specify that at first their attention was brought by HIV and hepatitis testing services and condoms, on the second place needles and syringes, PDI interventions, it is important that trainings, risk consultations and information materials did not appear in first option list. Mostly they are 3rd option list. According to frequently uses services testing and needles/syringes are seen, however the level of use for condoms and Naloxone is very low (it would be expected that Naloxone and lawyer’s consultation to be basic service, which are limited and provided for beneficiaries as additional service). The most desirable additional service was considered dental and gynecological service
Information capacity, knowledge on transmission of HIV and hepatitis C is quite high, irrespective of gender, however little difference is revealed, more women are informed that hepatitis C is not transmitted by domestic objects than men. Representatives of both genders are equally informed about infection risks for hepatitis C and everyone knows where to go to be tested. Most of the respondents are tested. Little part -1% exists, who has never been tested. Majority of the respondents mention about treatment performed and the share of those respondents who stopped treatment is very low (2%). Arte for retesting is very high; it is desirable that hepatitis C testing, diagnostics and treatment service would be integrated in harm reduction services in the same city, where drug users are living. HIV infection and hepatitis C is expected to develop n women than men
Recommendations
• according to presented risky sexual behavior, special interest should be paid to information dissemination on expected risks for risky injection and sexual practice and ways of their prevention • more attention should be paid to risky injection behavior practice and based on specific city to develop relevant (city-specific) risk reduction consulting module to be applied by
39 an outreach worker while consultation with beneficiaries: special focus should directed to: o Threats due to share practice of used syringed and needles (especially sharing happens with HIV positive person, whether they are on treatment or not) and their prevention ways o Risks related to use of syringes dropped in streets and ways of their prevention; o Risks related to injections in large groups and ways of their prevention; o Risks expected by injections in deep veins, inguinal vein and in other unsafe places and ways of their prevention; o Prevention of overdose caused by mixture of drugs and improper calculation of dose; o Risks related to share practice of water for washing syringe and their prevention • according to revealed risky sexual practice, it is recommended to conduct actively risk reduction consultations on sexually transmitted diseases, the expected threats conditioned by unprotected sexual relations (in exchange for money or drug) among them probability to transmit hepatitis C in a sexual way. It is noteworthy to mention expected risks due to unprotected sexual relations (if partner is on treatment or not); • • More actively propose Naloxone to beneficiaries and condoms to increase rate of their use which assists prevention of expected potential overdose and sexually transmitted diseases; • In order to increase utilization of information material, it should be assessed and respectively updated information materials to grow application level; for this purpose it is required to assess to what extent materials satisfy the needs and the expectations what beneficiaries have and how they are oriented for beneficiaries and properly understood by them • Recommendation is to be provided for OST treatment: especially in women it is necessary to raise awareness of treatment and benefit obtained from it to stimulate involvement in OST therapy • It is recommended to integrate confirmation and treatment service for hepatitis C in harm reduction services as lots of beneficiaries have willingness to receive this service in harm reduction service centers that assists more involvement of beneficiaries in treatment and better adherence. .
40 Bibliography • WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users – 2012 revision. • Harm reduction International www.ihra.net • The European Monitoring Centre for Drugs and Drug Addiction, http://www.emcdda.europa.eu/activities/hrdu • Sirbiladze, T., Tavzarashvili, L., Chikovani, I., Shengelia, N., & Sulaberidze, L. (2015). Population Size Estimation of People who Inject Drugs in Georgia 2014. Tbilisi. Retrieved from http://curatiofoundation.org/wp-content/uploads/2016/05/PWIDs-PSE-Report-2015_ENG.pdf • Wilson, D. P., Zhang, L., Kerr, C., Kwon, A., Hoare, A., Otiashvili, D., … Williams-Sherlock, M. (2011). Evaluating the Cost-Effectiveness of Needle-Syringe Exchange Programs in Georgia. Retrieved from http://altgeorgia.ge/2012/myfiles/UNAIDS_reporrt_eng.pdf • Broadhead, R. S., Heckathorn, D. D., Altice, F. L., E El Van Hulst, Y., Carbone, M., Friedland, G. H., … Selwyn, P. A. (2002). Increasing drug users’ adherence to HIV treatment: results of a peer-driven intervention feasibility study. Social Science & Medicine, 55, 235–246. Retrieved from http://chipcontent.chip.uconn.edu/chipweb/pdfs/Broadhead et al., 2002.PDF • Setia, M. S. (2016). Methodology Series Module 3: Cross-sectional Studies. Indian Journal of Dermatology, 61(3), 261–264. http://doi.org/10.4103/0019-5154.182410 • http://ohrp.cit.nih.gov/search/irbsearch.aspx • Metzger DS, et al. The Risk Assessment Battery: Validity and Reliability; Paper presented at the 6th Annual Meeting of National Cooperative Vaccine Development Group for AIDS.Nov, 1993. • Otiashvili, D., Piralishvili, G., Sikharulidze, Z., Kamkamidze, G., Poole, S., & Woody, G. E. (2013). Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use, and reducing HIV risk behavior – Outcomes of a Randomized Trial. Drug and Alcohol Dependence, 133(2), 10.1016/j.drugalcdep.2013.06.024. http://doi.org/10.1016/j.drugalcdep.2013.06.024 • Dembe, A. E., Partridge, J. S., & Geist, L. C. (2011). Statistical software applications used in health services research: analysis of published studies in the U.S. BMC Health Services Research, 11, 252. http://doi.org/10.1186/1472-6963-11-252
Annexes
Annex #1 Report of Ethic Commission Annex #. Study Questionnaire Annex #3 informed consent
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