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. 2 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. 3 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 4 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