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PEOPLE WHO USE NPS/: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

TECHNICAL REPORT

UNITED NATIONS OFFICE ON AND CRIME Vienna

Project "Partnership for Effective HIV Prevention and Care for People Who Use Drugs in Ukraine"

People Who Use NPS/Stimulants: Basic Needs and Barriers in Access to HIV Related Medical and Social Services in Ukraine

Kyiv, 2020 4 This translation was made by UNODC Regional Programme Office for Eastern (UNODC RPOEE). UNODC RPOEE is not responsible for the content or accuracy of this translation. The original Ukrainian edition shall be the binding and authentic edition. People Who Use NPS/Stimulants: Basic Needs and Barriers in Access to HIV Related Medical and Social Services in Ukraine. © Regional Program Office for Eastern Europe of the United Nations Office on Drugs and Crime, 2020 Rights protected. The document may be copied, distributed and adapted for non-commercial purposes provided that reference is made to this document, as set out below. In any case, the use of this document does not imply that UNODC approves any particular organization, product or service. Unauthorized use of the names or logos of the UNODC is not allowed. Adaptation of this document requires permission from UNODC RPOEE. In the case of a translation of the document text, an explanatory note is provided together with the proposed quotation: "This translation was not created by the United Nations Office on Drugs and Crime (UNODC). UNODC is not responsible for the content or accuracy of this translation. The original version in Ukrainian is a legally binding authentic edition". Any mediation in disputes is carried out in accordance with the rules of the UNDOC. Recommended citation. People Who Use NPS/Stimulants: Basic Needs and Barriers in Access to HIV Related Medical and Social Services in Ukraine, Kyiv, 2020 Third party materials.The use of third-party materials in this document, such as tables, figures or photographs, places the user's responsibility for obtaining permission for such use from third parties and permission from the copyright owner. The risk of claims caused by the infringement of the right of a third party in connection with any component of the document rests solely with the user. General disclaimer.The designations and representations used in this publication do not imply the expression of a UNODC opinion on the legal status of any country (territory, city or district) or its authorities, or on the delimitation of its border. Dotted and dashed lines on the maps indicate the approximate lines of borders, on which there is no full agreement. Mention of specific organizations, companies or certain goods or programs does not mean that they are approved or recommended by UNODC in comparison with others, similar in nature, not mentioned. Errors and omissions are excluded, the names of patented products are separated by initial capital letters. UNODC has taken all reasonable precautions to verify the information contained in this publication. However, the published material is distributed without any guarantees, express or implied. The responsibility for the interpretation and use of the material rests with the reader. In no case are UNODC liable for damages resulting from its use. Design and layout by — Ukraine - de Lage Landen Consulting Group LLC. Printed in Ukraine.

5 Acknowledgements

This technical report was developed by the United Nations Office on Drugs and Crime (UNODC) Regional Programme office for Eastern Europe in collaboration with representatives from the community of people who use drugs, national and international experts in the field. Oleksandra Yatsura and Liliia Tarasiuk, coordinated the development of the study and methodology under the supervision of Sergii Rudyi, National Programme Officer, UNODC. The technical report was consolidated and written by Oleksandra Yatsura and Hennadii Roshchupkin. The study was conducted with the kind support by representatives of Key Populations (KP) and Civil Society Organizations (CSOs) - Andrii Chernyshov, Oleh Dymaretskyi, Yuliia Kohan, Anton Tomozov, Petro Poliantsev, Vitalii Tsariuk, and Dmytro Shamrai. Other UNODC staff who made significant contributions include Zhannat Kosmukhamedova, Head, UNODC Regional Programme Office for Eastern Europe; Gorica Popovic, UNODC; Ilia Iurchenko, UNODC. This technical report was cleared by Research and Trend Analysis Branch of United Nations Office on Drugs and Crime.

6 TABLE OF CONTENTS

Abbreviations ...... 9 Executive Summary ...... 10 Recommendations ...... 11 Introduction ...... 13 Methodological principles of the assessment ...... 15 Socio-demographic profile of participants of the assessment ...... 18

Chapter 1. Actual models of NPS/ use in Ukraine ...... 23 1.1. Types of substances and practice of their use ...... 23 1.1.1. The most popular NPS/stimulants among KPs ...... 23 1.1.2. Practices and experience of using NPS/stimulants among KP representatives ...... 31 1.2. consumption by users of psychoactive substances ...... 36 1.3. Environments where NPS/stimulants are used ...... 38 1.4. Cases of overdose among users of psychoactive substances ...... 42 1.5. Needs related to the use of NPS ...... 43 1.5.1. Access to NPS/stimulants ...... 43 1.5.2. Access to NPS/stimulants during quarantine (COVID-19) ...... 45 1.5.3. Other needs ...... 46

Chapter 2. Basic needs related to access to health services for representatives of the TGA ...... 49 2.1. Use of health services by representatives of the communities ...... 49 2.1.1. Visiting a medical facility, examination ...... 49 2.1.2. Testing ...... 52 2.1.3. Treatment of diseases ...... 57 2.1.4. Refusal of medical services ...... 60 2.2. Awareness of respondents about the risks to their health and relevant medical services ...... 61 2.2.1. Awareness of the risk of injecting use ...... 61 2.2.2. Participation in substitution therapy (OST) programs ...... 62 2.2.3. Pre-exposure prophylaxis ...... 63 2.2.4. Help in cases of overdose ...... 65 2.2.5. Treatment of drug addiction ...... 67 2.3. Sources of information on HIV/STIs/hepatitis, medical and social services ...... 70

Chapter 3. Basic needs related to availability of social services for representatives of the TGA ...... 75 3.1. Awareness of respondents about social services ...... 75 3.2. The needs for social services ...... 81

7 3.2.1. The need for psychological services ...... 81 3.2.2. The need for legal services ...... 83

Chapter 4. Problematic issues and obstacles in the access of KP representatives and their close contacts to a range of services ...... 87 4.1. Provision of assistance by medical personnel, quality of medical services ...... 89 4.1.1. Respondents' perception of readiness of health personnel to provide care ...... 89 4.1.2. Delivery of medical services ...... 91 4.1.3. Professional level of medical personnel ...... 93 4.1.4. Attitude of medical personnel, disclosure of status, manifestations of stigma ...... 94 4.1.5. Quality of medical services ...... 95 4.2. Relations with state and non-state institutions ...... 98 4.2.1. Relations with public organizations: awareness, attitude, provision of services ...... 98 4.2.2. Relations with the police ...... 102 4.3. Criminalization of the use of psychoactive substances ...... 103

Chapter 5. Ways to attract new clients from among the TGA to receive medical and social services ...... 107 5.1. Attitudes towards people who change their behavior to a healthier one ...... 107 5.2. Involvement of a sexual partner in protected sexual relations, testing and medical examination ...... 108 5.2.1. Drug sharing ...... 108 5.2.2. Sexual relations and use of alcohol/psychoactive substances ...... 110 5.2.3. Condom use ...... 114 5.2.4. Use of lubricants ...... 117 5.2.5. Examination ...... 118 5.2.6. Testing for HIV, hepatitis, STIs ...... 120 5.3. The impact of communication with parents (relatives) on the use of services ...... 123 5.3.1. Models of interaction with parents (relatives) ...... 123 5.3.2. The impact of relationships on discussion and resolving of health issues ...... 125 5.3.3. Involvement of relatives in testing and medical examination ...... 129 5.4. Involvement of friends in discussing and resolving health issues ...... 130 5.4.1. Discussion of the issues with friends ...... 130 5.4.2. Help from friends in issues relevant for health and prevention ...... 133 5.4.3. Involvement of friends in testing ...... 133

CONCLUSIONS ...... 137 REFERENCES ...... 140 ANNEX 1 ...... 142 ANNEX 2 ...... 148 ANNEX 3 ...... 154 ANNEX 4 ...... 160

8 Abbreviations

AIDS Acquired immunodeficiency syndrome ART Antiretroviral therapy Fast-Track Fast-Track Cities Initiative - an initiative to accelerate action in large cities to end the AIDS epidemic as part of the UNAIDS Strategy "Fast-Track: ending the AIDS epidemic by 2030" FGD Focus group discussion HIV Human immunodeficiency virus HCF Health care facilities K or O Abbreviations for "Kyiv" or "Odesa" - the cities where the FGD and surveys were organized KP Key populations with regard to HIV infection OST Opioid substitution therapy PHC State Institution "Public Health Center of the Ministry of Health of Ukraine" PHCC Primary health care center PLWH People living with HIV PrEP Pre-exposure HIV prophylaxis PS/NPS (New) Psychoactive substances PWUD People who use drugs PWID People who use injecting drugs PWND People who use non-injecting drugs NGO Non-governmental organization RT Rapid tests SW Sex workers STIs Sexually transmitted infections TB Tuberculosis TG Transgender people TGA Target group of the assessment VG Viral hepatitis UN United Nations MSM Men who have sex with men UNAIDS United Nations Joint Program on HIV/AIDS UNODC United Nations Office on Drugs and Crime

9 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Executive Summary

Today, while much has been achieved in the fight against the HIV epidemic, it remains a major global public health problem. The growing number of HIV infections that disproportionately affect representatives of Key Populations (KP) and their sexual partners is aggravated by inadequate availability of integrated HIV prevention services. Recognizing the significance of this problem, UNODC has been implementing consistent efforts towards creating a supportive environment for KPs that would contribute to the reduction of the number of new HIV infections among the targeted group. These efforts included developing an integrated approach to the provision of easily accessible HIV- related services, that would also cover people who use new psychoactive substances(NPS) and/or stimulants. For this aim, in 2020 UNODC conducted a pilot study in Ukraine in the two “Fast-Track Cities” (as defined in the framework of UNAIDS Strategy "Fast-Track: ending the AIDS epidemic by 2030") – Kyiv and Odesa, to assess the needs and identify the barriers for KPs that hampers their access to the HIV-related services. This study revealed a substantial gap in data on the accessibility of HIV testing and treatment services for the KP representatives who use NPS and/or stimulant drugs that justified the need to carry out more in-depth research. Designated to fill in this knowledge gap, the presented paper is a strategic-level analytical report prepared by UNODC, which the main goal is to develop a better understanding of the basic needs of people who use NPS and/or stimulant drugs and the specific challenges that hinder their access to medical and social services on HIV prevention. This paper is envisioned to fit within the scope of UNODC's global HIV programme designated to assist countries in implementing evidence-informed and human rights-based interventions to prevent HIV transmission and to provide treatment, care and support to people living with HIV and AIDS. From a practical perspective, the results of the assessment are expected to support the formation of an evidence-based dialogue with key partners at the national and regional levels and help to determine the focus of advocacy efforts. This will support the Ukrainian government in achieving the goals of the UNAIDS Strategy "90-90-90" and developing a better prevention strategy for the abuse of stimulant drugs and NPS among representatives of KP. The main target audience of this report is government officials and civil society engaged in the development of national laws and policies related to the HIV/AIDS response. However, for the sake of increasing visibility of the problem, the paper will target a wider audience including international organizations, the private sector and the wider public. The presented study employed a cross-disciplinary approach incorporating a desk review of the existing relevant literature as well as focus group discussions (FDG) and an anonymous online survey. The conducted assessment is based on a number of relevant guidelines and manuals, such as technical guide on "HIV prevention, treatment, care and support for people who use stimulant drugs”1 to develop an improved understanding of HIV-related health issues and medical and social services. In addition to that, whenever possible the authors of this paper engaged public and private partners, leveraging a broad set of expertise to make the report more informed and balanced contributing to greater feasibility of its objectives and goals. From a methodological perspective, the presented report employed qualitative content analysis of primary data gathered from the focus group discussions (FDG) and an anonymous online survey. To ensure a gender perspective in the conducted research, the report ensured to incorporate the accumulated experiences of both male and female representatives of KPs in the focus group discussions. In total, the study engaged 258 representatives of the KPs who use NPS/stimulant drugs. The results revealed that the majority of respondents are aware of the possibilities provided by health facilities, but help/services provided by NGOs are much less understood or visible. In addition, it was pointed out that the existing educational, informational and preventive activities need to be more efficient, audience-oriented and brought closer to the immediate environment of KPs. Unethical behaviour of staff in public health facilities and high tariffs for services also hinder the access of KPs to a range of HIV services, as do problems with law enforcement (LE) and criminalization of PS - which represent one of the core problems for the majority of participants in the assessment.

1 https://www.unodc.org/documents/hiv-aids/publications/People_who_use_drugs/19-04568_HIV_Prevention_Guide_ebook.pdf

10 Recommendations

Consistent with the findings of this report, UNODC developed the following recommendations aimed at improving access to HIV-related medical and social services and removing existing barriers faced by the representatives of the key populations. These recommendations can be grouped in four major categories:

1. Awareness raising There is a need to strengthen efforts to inform the immediate environment of the key populations – those people whom they trust and to whom they can turn for help. The topics may include health risks, opportunities for testing, examination, and other necessary medical and social services. To this end, the following measures are advisable: • for social workers of social services and NGOs, outreach workers, psychologists (with respect to the client's rights for privacy) to intensify activities of the following nature: informational and educational work among the social environment of the key populations, social support for their families, motivation for HIV testing and receiving the necessary medical and social services; • for primary care workers, family doctors to ensure provision of medical services to representatives of the key populations on the basis of a "friendly approach", to encourage them and their relatives to protect their own health and improve such practices; • for HIV service NGOs, international and donor organizations to facilitate the introduction of joint social networks, mobile applications, development and distribution of handouts, outdoor advertising in the most popular places visited by representatives of the key populations, as well as their parents, friends and partners.

2. Capacity building • Introduce training and refresher courses for health professionals working in the field of HIV. This training course should, first, combine all existing resources (including modules and training programs), which were used both at the national level and with support of donor programs and projects; secondly, make it a permanent course and enrol primary and secondary health care specialists working in the field of HIV, from all regions of Ukraine. When developing curricula, the following topics to be considered: o formation of safer behaviour among the representatives of the key populations (as well as safety for their close contacts) and ways to preserve their health; o prevention of stigma and discrimination and unethical treatment of representatives of the key populations in the course of provision of medical services; o cooperation with entities providing social services to clients and law enforcement agencies; o access to evidence-based HIV, HVB, HCV prevention, treatment and care • Building the capacity of the community-based organizations; • Training peers

3. Increased access to services • For non-governmental HIV service organizations, social service providers to intensify their activities with the aim to attract new clients from among the key populations, to receive HIV-related services and undergo HIV testing. The activities may include: o introduction of new approaches and various forms of work with the key populations: counselling and

11 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

educational work with existing clients of HIV service NGOs, leaders of the key population communities, delivering individual and group consultations, outreach work, launching mobile clinics near the locations preferred by the key population - clubs, , festivals, etc .; o informing about the possibilities of receiving HIV-related services, including through targeted information sharing aligned with the needs of specific key populations; outdoor advertising (billboards, videos, handouts, mobile applications, etc.); o dissemination of information about the possibilities of obtaining HIV services and their providers in the cities where mass events are organised (events, festivals, , bars, discos, etc.) and using information tools which are most popular among the key populations (, mobile applications, instant redirection to web-pages of providers or informants of HIV services, etc.).

4. Monitory and evaluation • Elaborate performance indicators for assessment of effectiveness of work and carry out ongoing monitoring/ evaluation of the effectiveness of measures taken in order to respond in a timely manner and improve activities (such evaluation of efficiency can also be carried out through social networks, telephone surveys or mobile applications). • Monitor and evaluate the impact of programs and project which target the immediate environment of KP (parents/relatives, official representatives, friends, sexual partners, etc.) on the actual changes in substance use and risky behaviour among KP. Based on the results, develop recommendations for the implementation of HIV prevention measures among KP representatives which would include more effective participation of their immediate environment. • Develop and adopt common approaches to analyse the effectiveness of training through the assessment of effectiveness of applying obtained theoretical knowledge in practice (such analysis may include assessing the satisfaction of the client and/or accompanying person, services received, referral to specialized professionals, client management and client’s adherence to HIV/STI treatment process, etc.). Introduce such analysis and take urgent measures to improve specific training based on the results of the assessment • Develop and integrate through Internet networks, mobile applications the tools for evaluating the effectiveness of information activities, campaigns, interventions aiming to engage new clients from among the representatives of the key populations in HIV-related services.

12 Introduction

According to the UNAIDS estimation, 54%2 of all new HIV infections among adult population in the world affect representatives of Key Populations (KP) and their sexual partners , while less than 50% of KPs are covered by integrated HIV prevention services.3 Large-scale programs and efforts aiming to create appropriate social and legal environment with the purpose to reduce the number of new HIV infections among KPs are becoming increasingly important. In Ukraine, the HIV prevention programs, which also include prevention of VH, STIs, testing for HIV and TB among KPs (PWID, SW, MSM and TG), are one of the main elements of the HIV prevention strategy. 4 According to the Public Health Center (PHC), the most significant positive changes in the long-term dynamics have been achieved in HIV prevention programs among PWID.5 However, it is important to ensure the continuity of medical care for HIV-positive PWID from the stage of HIV testing to the stage of referral to public health facilities (PHF) for the ART treatment. Thus, among 2,440 people who were tested for HIV in 2018 and received a positive result, almost a half (1,645 people) were taken under medical supervision; at the same time, due to interventions that optimise detection of HIV cases, additional 2,248 PWIDs who knew about their HIV-positive status but did not refer to the PHF have been involved in medical supervision and ART. 6

Among KPs, men who have sex with men (MSM) are specifically challenged with the problem of access to a range of services or non-referral for HIV-related services. In particular, such cases frequently occur at the stage of referral of a person with HIV-positive test result from the NGO testing point to the PHF: among 324 MSM tested for HIV and who received a positive test result in 2018, as much as 245 MSM (76%) were taken under medical supervision and started ART. 7 The data provided by the PHF show that the coverage of MSM with prevention programs in Ukraine is gradually increasing, but due to high level of stigma and discrimination in the society, the majority of representatives of these pupulations do not refer for getting HIV-related services (while the results of the survey among these KPs in Kyiv show that 100% of them know where to go for the test8). Therefore, the data from various sources demonstrates that Ukraine has not yet managed to take under control the HIV epidemic in the MSM group: the HIV prevalence among younger MSM is increasing, and the coverage of HIV-positive MSM by medical supervision and ART remains low.9 In 2019, HIV prevalence among SW who are injecting drug users was 36%, compared with 3% of SW who are not PWID. The practice of drug use among SW is quite common, which can negatively affect the epidemic situation and requires effective action.10 In 2018, the first significant results were achieved in the coverage of TG by prevention programs: in particular, 5 TG were tested positive, while 4 of them referred to a PHF and started ART.11 The success of any national response to HIV depends on the effectiveness of intersectoral cooperation between all relevant stakeholders. PWID have been in the spotlight since the introduction of HIV prevention, treatment and care. Recent tendencies in drug use indicate an important role of psychoactive substances/stimulant drugs use in the HIV epidemic.

2 UNAIDS Data 2020 3 Newsletter №50. – Public Health Center of the Ministry of Health of Ukraine. - Kyiv, 2019. - P. 9. - Website. URL:https://phc.org.ua/sites/default/ files/users/user90/HIV_in_UA_50_2019.pdf (last accessed 15.05.2020) 4 Ibid. - P. 40. 5 Ibid. - P. 40. 6 Ibid. - P. 42. 7 Ibid. - P. 47. 8 Analytical report on the results of the 2017 study "Chemsex and drug use among MSM in Kyiv: new challenges". - Kyiv, 2018. - P. 52. 9 Newsletter №50. – Public Health Center of the Ministry of Health of Ukraine. - Kyiv, 2019. - P. 49 - Website. URL::https://phc.org.ua/sites/default/ files/users/user90/HIV_in_UA_50_2019.pdf (last accessed 15.05.2020) 10 Ibid. - P. 51. 11 Ibid. - P. 51.

13 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Stimulant drugs and new psychoactive substances (NPS) are the most wide spread drugs that are currently used in non-injectable form and may provoke increased sexual activity, and, in turn, increase a risk of contracting HIV, VH, STIs. Therefore, NPS/stimulant users fuel the epidemics of HIV/STI/HCV. Providing funding for programs in public health (prevention, , treatment) and free access to vital treatment for representatives of the KPs who use PS is one of the priority areas for effective of the state12, thereby making the analysis of availability of HIV-related health care services for the KPs increasingly important today. The United Nations Office on Drugs and Crime (UNODC) defines NPS as substances that are not controlled by the 1961 Single Convention on Narcotic Drugs or the 1971 Convention on Psychotropic Substances, but whose non- medical use may pose a public-health threat. According to UNODC report in 2017 on the global situation on drugs covering a period between 2009 and 2016, there were reports on 739 NPS, of which 36 per cent were stimulant drugs.13 In 2019, four substances (all fentanyl analogues) were scheduled under the Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol and five substances under the Convention on Psychotropic Substances of 1971. Such decision by the Commission on Narcotic Drugs led to raising of the total number of psychoactive substances under international control to 282 at the end of 2019. Moreover, according to the latest World Drug report “the number of NPS identified by authorities worldwide and reported to UNODC is already more than three times that figure, having reached a total of 950 in December 2019, up from 892 in December 2018 and 166 in 2009”14. According to the UNODC data “most of the synthetic NPS identified in the period 2009–2019 had stimulant effects (mostly cathinones and phenethylamines), followed by synthetic and (mostly tryptamines)”.15 Against this background, UNODC has recently focused on creating a supportive environment, ensuring the availability of HIV-related services to KPs (PLWH, SW, MSM and TG) and developing an integrated approach to the provision of these services, aiming to also cover the users of NPS/stimulant drugs. In particular, the manual "HIV prevention, treatment, care and support for people who use drugs. Technical Guide»16 and a number of other guidelines17 developed with the assistance of UNODC, will help to implement effective practices which meet the needs of users of stimulant drugs. These practices include provision of HIV-related services to this new, yet growing group - users of NPS/stimulant drugs, which will ultimately help reduce the gaps in achieving the goals of the UNAIDS Strategy "90-90-90". In order to explore accessibility of HIV services for the KPs who use NPS/stimulant drugs, and to identify barriers to these services for such groups and their partners, in 2020 UNODC is conducting a pilot study in Ukraine to assess the needs and identify the barriers to accessibility of HIV testing services for the KPs in Kyiv and Odesa (these cities are defined as "Fast-Track Cities"18 in the framework of UNAIDS Strategy "Fast-Track: ending the AIDS epidemic by 2030"). This assessment will help reveal additional factors and problems that slow down or impede the achievement of goals of the UNAIDS Strategy "90-90-90" in Ukraine.

12 Addiction to psychoactive substances, Public Health Center. Web resource. URL:https://www.phc.org.ua/kontrol-zakhvoryuvan/zalezhnist-vid- psikhoaktivnikh-rechovin (last accessed 15.05.2020) 13 HIV prevention, treatment, care and support for people who use stimulant drugs. Technical guide. - UNODC, WHO, UNAIDS. - p. 7. -Web resource. URL:https://www.unodc.org/documents/hiv-aids/publications/People_who_use_drugs/19-04568_HIV_Prevention_Guide_ ebook.pdf (last accessed 15.05.2020) 14 World Drug Report 2020 (United Nations publication, Sales No. E.20.XI.6), p.65, URL: https://wdr.unodc.org/wdr2020/field/WDR20_ BOOKLET_4.pdf 15 Ibid. 16 HIV prevention. UNODC. URL:https://www.unodc.org/documents/hiv-aids/publications/People_who_use_drugs/19-04568_HIV_ Prevention_Guide_ebook.pdf ( last accessed 15.05.2020) 17 URL: https://www.unodc.org/documents/hiv-aids/2017/1_Stim_HIV_Syst_Lit_rev_Part_1_methodology_and_summary.pdf (last accessed 15.05.2020); URL:https://www.unodc.org/documents/hiv-aids/2017/2_Stim_HIV_Syst_Lit_Rev_Part_2_ATS.pdf (last accessed 15.05.2020); URL:https://www.unodc.org/documents/hiv-aids/2017/3_Stim_HIV_Syst_Lit_Rev_Part_3_Cocaine_and_Crack-.pdf (last accessed 15.05.2020); URL:https://www.unodc.org/documents/hiv-aids/2017/4_Stim_HIV_Syst_Lit_Rev_Part_4_-_New_Psychoactive_Substances.pdf (last accessed 15.05.2020); URL:https://www.unodc.org/documents/hiv-aids/2017/5_Stim_HIV_Syst_Lit_rev_Part_5_Prevention_and_treatment.pdf (last accessed 15.05.2020) 18 Fast-Track Cities Initiative - an initiative to accelerate action in major cities to end the AIDS epidemic

14 Methodological principles of the assessment

The ultimate goal of this assessment is to identify the basic needs of people who use NPS and/or other stimulant drugs and to reveal barriers that hinder availability of medical and social services on HIV prevention, testing and treatment for the key populations. The results of the assessment will contribute to the formation of the evidence base and will facilitate a dialogue with key partners at the national and regional levels; they will help determine the focus of advocacy efforts to help Ukraine achieve the goals of the UNAIDS Strategy "90-90-90" and advance prevention of abuse of stimulant drugs and NPS among representatives of risk groups. Objectives of the assessment: - to identify and analyze actual models of NPS/stimulant drug use in Ukraine; - to clarify the basic needs for the availability of health services for representatives of communities which are target groups of this assessment (TGA); - to establish the basic needs for the availability of social services for representatives of communities which are TGA; - to analyze issues/barriers that prevent access to a whole range of services for the KP representatives and their close social contacts; - to suggest ways to engage new clients from among the TGA to receive medical and social services. The methodology is based on integrated approach where the following research methods were applied: • desk review - was conducted to identify and analyze actual models of NPS/stimulant drug use in Ukraine; • qualitative methods - focus group discussions (FGD) with representatives and leaders of communities considered as KP; • quantitative methods - anonymous online survey19 using a questionnaire for KP representatives. While developing the research tools, the research team used the following sources: - European Social Survey20; - "Estimating Prevalence: Indirect Methods for Estimating the Size of the Drug Problem"21; - "European Drug Report: Trends and Developments"22; - "Analytical report on the results of a study within the project "Underage, overlooked: improving access to integrated HIV services for adolescents most at risk in Ukraine"23 etc. Target groups of the assessment (TGA): people who use NPS and/or stimulants, including sex workers (SW), men who have sex with men (MSM, in particular MSM who practice chemsex), clients of female SW and transgender people. Geography of research included two cities of Ukraine - Kyiv and Odesa, which were defined in line with the UNAIDS Strategy as ‘Fast-Track Cities’. Recruitment of respondents was performed as follows: - for MSM - the selection was made with the help of the community center in Kyiv (clients of the NGO "Alliance.

19 In connection with the introduction during the study of restrictive measures related to combating the spread of the coronavirus epidemic (COVID-19) in Ukraine, it is planned to semi-structured interview «face to face" has been replaced by an online survey. 20 Web resource. URL: https://www.europeansocialsurvey.org 21 Estimating Prevalence: Indirect Methods for Estimating the Size of the Drug Problem. - UNODC, 2003. - Web resource. URL: https://www.unodc. org/documents/GAP/GAP%20Toolkit%20Module%202%20Final%20RUSSIAN%2002-60054_E_BOOK.pdf 22 European Drug Report: Trends and Development. - EMCDDA, 2016. - Web resource. URL:www.emcdda.europa.eu/system/files/ publications/2637/European%20Drug%20Report_Russian_web.pdf 23 Analytical report on the results of the research within the project "Underage, overlooked: improving access to integrated HIV services for adolescents most at risk in Ukraine "/Balakireva OM, Shevchenko SL etc. - Kyiv: ICF "Public Health Alliance", ICF East-West AIDS Foundation (AFEW-Ukraine), 2019. - 60 p. - Web resource. URL:http://afew.org.ua/research5/

15 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Global"), as well as through social networks (including "Telegram") and personal contacts of clients of the community center using a method called "snowball"; - for PWND, SW, TG - participants were enrolled with the support of NGOs "Volna" and "Mist" and community leaders, as well as through personal contacts of clients of these public organizations using a method "snowball"; - for clients of female SW - the recruitment was facilitated by the NGO "Ukrainian Center for Social Forecasting". A total of 258 respondents were involved in the survey, while 49 participated in the FGD and 209 took part in the baseline survey (for more details, see the section "Socio-demographic profile of participants of the assessment"). Criteria for selection of respondents: - each participant represents one of the categories of TGA; - participants are above the age of 18 years old and stay most of their time/live in Kyiv or Odesa; - the period of non-injection use of NPS/stimulant drugs is not less than 90 days (3 months); - participants have provided permission to participate in the study; - breakdown by gender and age criteria is not strictly stipulated (because the majority of NPS/stimulant drug users are men). The FGD participants did not participate in the baseline survey. Arrangements for the online survey Due to the unfavorable epidemiological situation in Ukraine related to the spread of coronavirus (COVID-19), initially planned semi-structured face-to-face interviews were replaced by online survey, which was organized as explained below. Two links to Docs.google.com server were created: - for interviewers to fill in the questionnaire form – the interviewers followed this link to record all the answers of the respondents;24 - for respondents – a link to tables connected to questionnaire form, for a respondent to review and choose the necessary answer to a question and respond to the interviewer.25 The online interview took place at a time which was agreed with the respondent. Immediately before the interview, the respondent received a link to the questionnaire form. Principles of research Collection, storage and analysis of empirical data for the research were performed in due compliance with ethical standards and respect of the rights of respondents (voluntarity, anonymity and confidentiality). To this end, all UNODC consultants in Ukraine who involved in this assessment, including all FGD moderators and interviewers, have been informed of the confidentiality requirements which relate to restriction to disclose or share in any form with third parties any information about the respondents which became available to them in the course of performing their duties within this assessment. Voluntary participation. Prior to the FGD or interview, each participant was informed about the purpose and objectives of the assessment and its specifics, as well as about the guarantees of anonymity and confidentiality for respondents, their right to voluntarily participate in the survey, or to quit it at any time. All participants of the assessment (those who engaged in the FGD and in the baseline survey) provided informed consent to participate in the assessment. Confidentiality.Importance of confidentiality was highlighted in the text of the informed consent, which respondents filled out and signed before the FGD or interview. To further maintain confidentiality within the FGD, participants were given the opportunity to use a pseudonym or a "nickname".

24 Questionnaire for the interviewer. - Access mode: https://docs.google.com/forms/d/e/1FAIpQLSemxoxRwPyxVzYjxcVEmm 1mJgpdFGusXGx0jeFAnTV52UkiwA/viewform 25 Questionnaire for the respondent. - Access mode: https://docs.google.com/forms/d/e/1FAIpQLSfGB3vN_ JyaoEB1NhoItT3K3OFiKUOOP- xKbf1F6VxWglKxIA/viewform

16 All information obtained during this assessment was stored on a password-protected computer that was accessible only to the assessment team. No identifying information about the team or participants was used in the reports. Data processing and analysis • FGD: - transcripts of audio recordings of discussions were prepared; - qualitative methods were used to analyze the obtained data; on the basis of received results the initial analysis was performed and a summary on the basic needs of the KP representatives and barriers to access quality medical and social services was drafted; - on the basis of the analysis of the information received in FGDs, the tools to be used for the baseline survey among the respondents were finalized. • Online survey: - for data collection the online resource was used (link: Google.forms.gle) which redirected to the questionnaire form; - analysis of data was performed using quantitative methods and the program SPSS.PC which allowed disaggregation by TGA, gender and age. The tools for the online survey were refined on the basis of data obtained in the FGD; these tools were then tested in 5 interviews with representatives of the TGA. Coordination of the field stage of the survey was arranged. The data obtained as a result of the field study was analyzed. Limitations in the context of this assessment: - Unrepresentativeness of the sample: due to the lack of data on the number of TGA representatives, at the initial stage there were problems with determining the sampling frame and, accordingly, the sample. However, in view of the purpose and objectives of the assessment it was possible to rely on unrepresentative samples for each of the KPs; - Lack of absolute objectivity and reliability of conclusions: respondents were free to choose what to say and expressed their subjective opinion on a number of issues. However, during the collection of empirical data, respondents were guaranteed anonymity and confidentiality, comfortable conditions for participation in the assessment and interaction with trained FGD moderators and interviewers who helped to explain complex questions; - Introduction of quarantine on the territory of Ukraine. Due to the announcement of restrictive measures aiming to combat the spread of the coronavirus epidemic (COVID-19) in the country, immediately before the start of the baseline survey, the assessment team had to replace the initially selected survey method (face-to-face interviews) with online survey; - Observance of timelines: in view of a number of factors (introduction of quarantine restrictions, change of assessment methods, limited openness of target audience, postponement of the field study, reluctance of some KP representatives to make contact, refusals to engage in the assessment), the timeline was slightly extended by the assessment team.

17 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Socio-demographic profile of participants of the assessment

Characteristics of FGD participants

At the first stage of the assessment, 6 FGDs were convened with representatives of the target group. A total of 49 respondents participated in the FGD, including 26 in Kyiv and 23 in Odesa. General characteristics of respondents and their distribution by groups are given in Table 1 (see below). Table 1. Characteristics of FGD participants

City Total Kyiv Odesa N % N % N % Respondent's PWND 18 69.2% 14 60.9% 32 65.3% category MSM 8 30.8% 9 39.1% 17 34.7% Subtotal 26 100.0% 23 100.0% 49 100.0% Male 15 57.7% 16 69.6% 31 63.3% Female 8 30.8% 7 30.4% 15 30.6% Gender Transgender person 2 7.7% 2 4.1% Non-binary personality 1 3.8% 1 2.0% Subtotal 26 100.0% 23 100.0% 49 100.0% 18-24 years 9 34.6% 6 26.1% 15 30.6% 25-29 years 6 23.1% 6 26.1% 12 24.5% Age 30-34 years 3 11.5% 1 4.3% 4 8.2% 35-39 years 7 26.9% 5 21.7% 12 24.5% 40-59 years 1 3.8% 5 21.7% 6 12.5% Subtotal 26 100.0% 23 100.0% 49 100.0% Employed 14 53.8% 11 47.8% 25 51.0% Student 2 7.7% 2 8.7% 4 8.2% Employment Employed and studying 3 11.5% 3 6.1% Jobless 7 26.9% 10 43.5% 17 34.7% Subtotal 26 100.0% 23 100.0% 49 100.0%

Marital Married 24 92.3% 20 87.0% 44 89.8% status Not married 2 7.7% 3 13.0% 5 10.2% Subtotal 26 100.0% 23 100.0% 49 100.0%

Thus, out of the whole cohort of FGD participants, 32 persons (65.3%) identified themselves as PWND (18 of them in Kyiv and 14 in Odesa) and 17 (34.7%) - MSM (8 in Kyiv and 9 in Odesa). The breakdown by gender in both cities is almost even. At the same time, in Kyiv, in addition to women and men, transgender people (n = 2; 7.7%) and 1 non-binary person (3.8%, respectively) were involved in the survey. In both cities, the following age categories were prevailing: "18-24 years" (9 in Kyiv and 6 in Odesa), which is almost a third (30.6%) from the total number of FGD participants; "25-29 years" (6 people in Kyiv and Odesa, each) and "35- 39 years" (7 in Kyiv and 5 in Odesa). In Kyiv there was a more or less even breakdown by age categories, except for the category "40-59 years", which was represented by 1 respondent (3.8%). In Odesa, the least represented was a category "30-34 years", which was also represented by 1 person. However, the total number of FGD participants in Odesa was less than in Kyiv (23 versus 26 people).

18 In general, the share of those who are married prevailed among the FGD participants - 44 respondents versus 5 who are not married. As for the employment of respondents, half of them (51.0%) work, in particular 47.8% of FGD participants in Odesa and 53.8% in Kyiv. The second largest category is "unemployed", which corresponds to 34.7% of the total number of FGD participants in both cities, including 43.5% of respondents in Odesa and 26.9% in Kyiv. There are no respondents in Odesa who combine work and study. The FGD participants did not engage in the second phase of the assessment.

Characteristics of the survey participants

In the second stage of the assessment, 209 semi-structured online interviews were conducted with representatives of the target audience in Kyiv (105 respondents) and Odesa (104 respondents). General characteristics of the survey respondents are presented in Table 2. Table 2. Characteristics of survey participants

Cities Total Kyiv Odesa N % N % N % Sex workers 18 14.8% 16 14.7% 34 14.7% MSM 29 23.8% 33 30.3% 62 26.8% Respondent's Transgender person 1 0.8% 1 0.9% 2 0.9% category I am PWUD, but I do not belong to any 69 56.6% 58 53.2% 127 55.0% of the KP Client of female SW 5 4.0% 1 0.9% 6 2.6% Subtotal 122 * 100.0% 109 * 100.0% 231 * 100.0% * respondents had the opportunity to choose several options of answer Male 76 72.4% 67 64.4% 143 68.4% Gender Female 28 26.7% 36 34.6% 64 30.6% Transgender person 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0% 18-24 years 30 28.6% 21 20.2% 51 24.4% 25-29 years 29 27.6% 21 20.2% 50 23.9% Age 30-34 years 18 17.1% 20 19.2% 38 18.2% 35-39 years 18 17.1% 18 17.3% 36 17.2% 40-59 years 10 9.5% 24 23.1% 34 16.3% Subtotal 105 100.0% 104 100.0% 209 100.0% Incomplete course of secondary school 4 3.8% 7 6.7% 11 5.3% Secondary school 20 19.0% 23 22.1% 43 20.6% Education Secondary specialized school 23 21.9% 26 25.0% 49 23.4% Unfinished higher 20 19.0% 18 17.3% 38 18.2% Higher 38 36.2% 30 28.8% 68 32.5% Subtotal 105 100.0% 104 100.0% 209 100.0% College/lyceum student 0 0.0% 1 0.9% 1 0.4% University student 7 6.3% 13 11.5% 20 8.9% Employed 45 40.5% 50 44.2% 95 42.4% Self-employed person 26 23.4% 14 12.4% 40 17.9% Housework/housewife 2 1.8% 11 9.7% 13 5.8% Activity Not able to work 6 5.4% 6 5.3% 12 5.4% (person with disability) Jobless 24 21.6% 17 15.0% 41 18.3% On maternity leave/home-based 1 0.9% 1 0.9% 2 0.9% quarantine Subtotal 111 100.0% 113 100.0% 224 100.0%

19 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Never been married 54 51.4% 40 38.5% 94 45.0% Civil marriage (the wedlock is not 20 19.0% 25 24.0% 45 21.5% registered) Marital Married, living with my wife/husband 11 10.5% 9 8.7% 20 9.6% Married, living with another sexual status 4 3.8% 1 1.0% 5 2.4% partner Divorced 13 12.4% 19 18.3% 32 15.3% Widowed 3 2.9% 10 9.6% 13 6.2% Subtotal 105 100.0% 104 100.0% 209 100.0%

Has a child/children 20 19.0% 39 37.5% 59 28.2% Children Does not have a child/children 85 81.0% 65 62.5% 150 71.8% Subtotal 105 100.0% 104 100.0% 209 100.0%

With a wife/husband (formal marriage) 11 10.5% 8 7.7% 19 9.1% With a partner (no formal marriage) and 28 26.7% 31 29.8% 59 28.2% child/children With parents 17 16.2% 20 19.2% 37 17.7% Who does the With a child/children 3 2.9% 6 5.8% 9 4.3% respondent live Living alone 21 20.0% 19 18.3% 40 19.1% with With friends/classmates 18 17.1% 13 12.5% 31 14.8% With relatives 6 5.7% 6 5.8% 12 5.7% (grandparents, uncle, aunt) Living in rented accommodation with 1 1.0% 1 1.0% 2 1.0% neighbours/owners Subtotal 105 100.0% 104 100.0% 209 100.0%

Analysis of the survey data shows that in general in the second stage of the assessment the following categories of the KPs got involved: 127 respondents (55.0%) who are PWUD yet not associating themselves with any of the KPs (including 69 in Kyiv, 58 in Odesa); SW - 34 persons (18 in Kyiv, 16 in Odesa), which is 14.7% of the total number of respondents; MSM - 62 (29 in Kyiv, 33 in Odesa), which is 26.8%; 2 transgender people (1 from Kyiv and 1 from Odesa) and 6 clients of female sex workers: 5 in Kyiv and 1 in Odesa). Among respondents, the share of men was greater (n = 143; 68.4%), with 76 men from Kyiv and 67 men from Odesa. The number of female respondents was twice less (n = 64; 30.6%), with 28 women from Kyiv and 36 women from Odesa. Only two transgender persons took part in the survey - one from each of the cities where the survey was held. A breakdown by age among respondents in Odesa was relatively even across all age categories. From among a whole cohort of respondents (n = 104) in Odesa, the largest share of respondents was in the category "40-59 years", represented by 24 respondents (23.1% of all respondents in Odesa); 21 respondents were recorded in the categories "18-24 years" and "25-29 years", each; 20 - in the category "30-34 years"; 18 - in the category "35-39 years". Breakdown by age in Kyiv differs from that in Odesa: it is less even. Among the respondents in the capital city (n = 105) the oldest age category "40-59 years" was the least represented – with only 10 respondents (9.5% of the total number of respondents in Kyiv). The largest group was "18-24 years", with 30 respondents; 29 respondents were in the age category "25-29 years", 18 respondents - groups "30-34 years" and "35-39", respectively. The breakdown of respondents by the level of education they obtained shows that most of them (n = 68; 32.5%) have completed higher education - 38 respondents from Kyiv and 30 from Odesa. However, this is only a third of the total number of respondents. Equally significant is a portion of those who have incomplete higher education (n = 38; 18.2%), secondary specialized school degree (n = 49; 23.4%) and secondary education (n = 43; 20.6%). It may be noted that the number of respondents who obtained one of the listed levels of education is approximately the same in both cities. The minority of respondents have incomplete secondary education (4 in Kyiv and 7 in Odesa). The analysis of information about employment status of the survey participants shows that in both cities the largest share of respondents (n = 95, equal to 42.4%, including 45 from Kyiv and 50 from Odesa) are employed. The second in

20 the ranking are two categories: "Self-employed persons" (n = 40, equal to 17.9% of the respondents, including 26 in Kyiv and 14 in Odesa) and "Jobless" (n = 41 or 18.3% of the respondents, including 24 in Kyiv and 17 in Odesa). As for the criteria ‘marital status’, respondents were represented evenly in both cities. The data demonstrates that the largest share of respondents are people who have never been married - 94 respondents (45.0%), including 54 in Kyiv and 40 in Odesa. 45 respondents (or 21.5%) live in a civil marriage, with 20 of them living in Kyiv and 25 in Odesa. The share of those who are officially married is represented by 20 respondents (9.6%), including 11 respondents in Kyiv and 9 in Odesa. In addition, 5 respondents (2.4%) are officially married but live with another sexual partner, including 4 in Kyiv and 1 in Odesa. There were 32 divorced respondents (15.3%), including 13 in Kyiv and 19 in Odesa. There are 13 widowers (6.2%), including 3 in Kyiv and 10 in Odesa. The majority of respondents (n = 150; 71.8%) from both cities do not have children, in particular 85 respondents in Kyiv and 65 in Odesa. However, 59 respondents (28.2%) stated that they have children - 20 in Kyiv and 39 in Odesa. Overall, the distribution of responses between categories of respondents as to who they live with was approximately the same in both cities. The majority of respondents (n = 59; 28.2%) indicated that they live with a partner who is not officially registered as a spouse (partner and with a child/children), including 28 in Kyiv and 31 in Odesa. There is a total of 40 respondents (19.1%), including 21 in Kyiv and 19 in Odesa who live alone; those who live with their parents - 37 (17.7%), including 17 in Kyiv and 20 in Odesa; with friends/classmates - 31 (14.8%), including 18 in Kyiv and 13 in Odesa; with a wife/husband (officially married) - 19 (9.1%), including 11 in Kyiv and 8 in Odesa; with relatives (grandparents, uncle, aunt, etc.) - 12 (5.7%), including 6 in Kyiv and 6 in Odesa; with a child/children - 9 (4.3%), including 3 in Kyiv and 6 in Odesa; in rented accommodation with neighbours/owners - 2 (1.0%), including 1 in Kyiv and 1 in Odesa. As for the breakdown of respondents by age and by categories of TGA, the shares were as follows: in the age category "18-24 years" most representatives were MSM and users of PS who do not associate themselves with any of the KPs - 35.3% and 33.3%, respectively, SW and MSM - 23.5%; in the age category "25-29 years" the users of PS who do not associate themselves with the KPs were most represented - 52.0%, MSM - 30.0%, there are 2 transgender people (4.0%), SW and a group "SW and MSM" were underrepresented - 8.0% and 6.0%, respectively; in the age category "30-34 years" the largest share of respondents were those who do not associate themselves with any of the KPs - 65.8%, while MSM and SW made up 21.1% and 10.5% respectively, clients of female SW - 2.6%; in the age category "35-39 years" the majority were users of PS not attributing themselves to any KP - 77.8%, and there were even fewer MSM and SW than in the previous age category - 8.3% and 11.1%, respectively; clients of female SW - 2.8%; in the oldest age category the largest share of respondents were PWUD not attributing themselves to the KPs - 73.5%, MSM - 5.9%, SW - 5.9%, SW and MSM - 2.9%, clients of female SW - 11.8% (which is the highest percentage among all age groups). A more detailed distribution is presented in Table 3. Table 3. Distribution of survey participants by categories and age

Age 18-24 years 25-29 years 30-34 years 35-39 years 40-59 years Total N % N % N % N % N % N % Sex worker 4 7.8% 4 8.0% 4 10.5% 4 11.1% 2 5.9% 18 8.6% MSM 18 35.3% 15 30.0% 8 21.1% 3 8.3% 2 5.9% 46 22.0% Transgender 0 0.0% 2 4.0% 0 0.0% 0 0.0% 0 0.0% 2 1.0% person Category PWUD who do of the not associate 17 33.3% 26 52.0% 25 65.8% 28 77.8% 25 73.5% 121 57.9% respondent themselves with the KPs SW and MSM 12 23.5% 3 6.0% 0 0.0% 0 0.0% 1 2.9% 16 7.7% Clients of female 0 0.0% 0 0.0% 1 2.6% 1 2.8% 4 11.8% 6 2.9% SW Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Both participants of the FGD and of the baseline survey have reported very different periods over which they use NPS/stimulant drugs, and there is no relation to their age, place of living, nor to any other demographic characteristics looked into in this study.

21

Chapter 1

Actual models of NPS/ stimulant use in Ukraine

1.1. Types of narcotic substances and practice of their use

1.1.1. The most popular NPS/stimulants among KPs

The survey revealed that the most popular psychoactive substances (PS)/stimulants among the respondents are (marijuana, weed, "drap", "plan", "dur’j", "anasha", "shyshky") (n = 143) and in powder form ("fen", "speed", "ampha", etc.) (n = 144). More than half of the respondents indicated that they use these substances every day or at least 1-3 times a month, in particular: Cannabis is consumed every day by 22 respondents (10.5%), 3-4 times a week – by 35 respondents (16.7%), 1-2 times a week – by 48 respondents (23.0%), 1-3 times a month – by 38 respondents (18.2%) and 64 respondents (30.6%) indicated that they had not used any PS/stimulants in the last 90 days; Amphetamine is used every day by 8 respondents (3.8%), 3-4 times a week - 16 respondents (7.7%), 1-2 times a week - 55 respondents (26.3%), 1-3 times a month - 65 respondents (31.1%), almost a third (n = 64; 30.6%) have not used it in the last 90 days. These are some of the cheapest and easily available substances on the Ukrainian market, which are available to literally all categories of the population.26 In addition, these substances have a fairly convenient form for rapid consumption - a mixture for smoking and powder which can be used as solution or in a dry form. These substances are most popular among MSM and respondents who are PWUD not associating themselves with any KP. Cannabis is more popular in Kyiv - 16 respondents (15.2%) indicated that they use it every day, in Odesa - 6 respondents (5.8%). Overall, 10.5% of respondents take cannabis every day; 16.7% (n = 35) of all respondents indicated that they use Cannabis 3-4 times a week (n = 21; 20.0% - in Kyiv; n = 14; 13.5% - in Odesa); 23.0% (n = 48) of all respondents indicated that they use Cannabis 1-2 times a week (n = 23; 21.9% - in Kyiv; n = 25; 24.0% - in Odesa); 18.2% (n = 38) of respondents reported consumption of Cannabis 1-3 times a month (n = 19; 18.1% - in Kyiv; n = 19; 18.3% - in Odesa); only 30.6% (n = 64) of all respondents informed that they used Cannabis for the past 90 days. Amphetamine powder is also more popular in Kyiv. However, this type of substance is most often used only 1-3 times a month by 31.1% (n = 65) of respondents, of which 37 (35.2%) in Kyiv and 28 (26.9%) in Odesa; 26.3% (n = 55) of respondents reported that they take Amphetamine powder 1-2 times a week (n = 29; 27.6% - in Kyiv; n = 26; 25.0% - in Odesa); only 7.7% (n = 16) of all respondents indicated that they use Amphetamine powder 3-4 times a week (n = 10; 9.5% - in Kyiv; n = 6; 5.8% - in Odesa). An insignificant percentage of respondents use Amphetamine every day (compared to Cannabis use) - 3.8% (n = 8), of which: 5 (4.8%) - in Kyiv and 3 (2.9%) in Odesa. For a more detailed distribution, see Table 1.1.1.1.

26 The average cost of Cannabis is UAH 200-500 per dose (US$1.00=UAH 27.00)- depending on the type and quality of the substance, and UAH 300-500 per gram is a cost of amphetamine powder (source of information - Internet).

23 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Table 1.1.1.1. Breakdown of respondents' answers about consumption of PS, by city of residence Cities Total Respondents' answers Kyiv Odesa N % N % N % Every day 16 15.2% 6 5.8% 22 10.5% 3-4 times a week 21 20.0% 14 13.5% 35 16.7% How often do you take these PS: 1-2 times a week 23 21.9% 25 24.0% 48 23.0% Cannabis (marijuana, weed, "drap", 1-3 times a month 19 18.1% 19 18.3% 38 18.2% "plan", "dur’", "anasha", "shyshky") Did not use over the last 90 days 24 22.9% 40 38.5% 64 30.6% Difficult to answer 2 1.9% 0 0.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 5 4.8% 3 2.9% 8 3.8% 3-4 times a week 10 9.5% 6 5.8% 16 7.7% How often do you take these PS: 1-2 times a week 29 27.6% 26 25.0% 55 26.3% Amphetamine powder 1-3 times a month 37 35.2% 28 26.9% 65 31.1% ("fen", "speed", "ampha", etc.) Did not use over the last 90 days 24 22.9% 40 38.5% 64 30.6% Difficult to answer 0 0.0% 1 1.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.0% 1 0.5% How often do you take these PS: 1-2 times a week 5 4.8% 12 11.5% 17 8.1% Methylenedioxymethamphetamine 1-3 times a month 44 41.9% 28 26.9% 72 34.4% (ecstasy, MDMA) Did not use over the last 90 days 50 47.6% 62 59.6% 112 53.6% Difficult to answer 6 5.7% 1 1.0% 7 3.3% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you take these PS: 1-2 times a week 1 1.0% 10 9.6% 11 5.3% Hallucinogens 1-3 times a month 17 16.2% 24 23.1% 41 19.6% (LSD, mushrooms, "trip", salvia) Did not use over the last 90 days 80 76.2% 70 67.3% 150 71.8% Difficult to answer 7 6.7% 0 0.0% 7 3.3% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you take these PS: 1-2 times a week 1 1.0% 6 5.8% 7 3.3% powder 1-3 times a month 26 24.8% 20 19.2% 46 22.0% (crystals) – "met", "lid", ice Did not use over the last 90 days 76 72.4% 77 74.0% 153 73.2% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 0 0.0% 1 1.0% 1 0.5% 3-4 times a week 1 1.0% 1 1.0% 2 1.0% How often do you take these PS: 1-2 times a week 4 3.8% 8 7.7% 12 5.7% Amphetamine in crystals 1-3 times a month 20 19.0% 7 6.7% 27 12.9% (Ephedrine, etc.) Did not use over the last 90 days 76 72.4% 85 81.7% 161 77.0% Difficult to answer 4 3.8% 2 1.9% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 0 0.0% 4 3.8% 4 1.9% 3-4 times a week 0 0.0% 9 8.7% 9 4.3% How often do take these PS: 1-2 times a week 0 0.0% 9 8.7% 9 4.3% Salt ("sil’") 1-3 times a month 8 7.6% 13 12.5% 21 10.0% Did not use over the last 90 days 94 89.5% 68 65.4% 162 77.5% Difficult to answer 3 2.9% 1 1.0% 4 1.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

24 CHAPTER 1

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you take these PS: 1-2 times a week 0 0.0% 7 6.7% 7 3.3% 1-3 times a month 13 12.4% 11 10.6% 24 11.5% ("speed", "meph", meow-meow) Did not use over the last 90 days 90 85.7% 85 81.7% 175 83.7% Difficult to answer 2 1.9% 1 1.0% 3 1.4% Subtotal 105 100.0% 104 100.0% 209 100.0% Every day 1 1.0% 2 1.9% 3 1.4% 3-4 times a week 5 4.8% 2 1.9% 7 3.3% How often do you take these PS: 1-2 times a week 4 3.8% 6 5.8% 10 4.8% Smoking mixtures, "spices" 1-3 times a month 4 3.8% 7 6.7% 11 5.3% Did not use over the last 90 days 90 85.7% 87 83.7% 177 84.7% Difficult to answer 1 1.0% 0 0.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

No less popular are substances from a group of hallucinogens, pharmaceutical drugs, opiates and other stimulants. Among these substances: Methylenedioxymethamphetamine (ecstasy, MDMA) - used by 90 respondents (43.1%); Hallucinogens (LSD, mushrooms, "trips", salvia) - 52 respondents (24.9%); Methamphetamine powder (crystals - "meth", "lid", ice) - 54 (25.8%); Amphetamine in crystals (Ephedrine and etc.) - 42 respondents (20.1%), Salt ("sil’") - 43 (20.6%), Mephedrone ("speed", "meph", meow-meow) and Smoking mixtures ("spices") are equally popular among all respondents – as confirmed by 31 respondents (14.8%). However, the frequency of use of these substances gradually shifts to 1-2 times a week and 1-3 times a month. These substances are more difficult to obtain and have a higher price. All other substances listed in the questionnaire are not popular and are used with medium or low frequency (1-2 times a week and 1-3 times a month). Among them are , substances, Antihistamines and others. However, it turned out that Glue is a substance that the respondents do not use at all. This may be due to the specifics of the preparation of the substance before use. Also, quality of the substance itself may be another factor (low quality of substance, many side effects, etc.). This fact could be interesting for further research. A more detailed distribution of respondents' responses regarding frequency of their consumption of NPS (by cities of residence) is given in Annex 1. Let us consider the responses regarding the consumption of PS with a breakdown by gender, age and the KP to which the respondent attributes him/herself. According to the data obtained, men use Cannabis much more often than women: with 13.3% of men who use Cannabis "every day" compared to 4.7% of women. The distribution of preferences for other substances (Amphetamine in powder form, Methylenedioxymethamphetamine (ecstasy, MDMA), Hallucinogens (LSD, mushrooms, "trip", salvia) and Methamphetamine powder (crystals)) is relatively equal for both genders (see Table 1.1.1.2.). Table 1.1.1.2. Breakdown of respondents' answers regarding consumption of PS, by gender

Gender Transgender Respondents' answers Male Female person Total N % N % N % N % Every day 19 13.3% 3 4.7% 0 0.0% 22 10.5% 3-4 times a week 28 19.6% 6 9.4% 1 50.0% 35 16.7% How often do you take PS: 1-2 times a week 39 27.3% 9 14.1% 0 0.0% 48 23.0% Cannabis (marijuana, weed, "drap", 1-3 times a month 26 18.2% 12 18.8% 0 0.0% 38 18.2% "plan", "dur’", "anasha", "shyshky") Did not use over 31 21.7% 32 50.0% 1 50.0% 64 30.6% the last 90 days Difficult to answer 0 0.0% 2 3.1% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

25 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 6 4.2% 2 3.1% 0 0.0% 8 3.8% 3-4 times a week 11 7.7% 5 7.8% 0 0.0% 16 7.7% How often do you take PS: 1-2 times a week 35 24.5% 19 29.7% 1 50.0% 55 26.3% Amphetamine powder 1-3 times a month 47 32.9% 18 28.1% 0 0.0% 65 31.1% ("fen", "speed", "ampha", etc.) Did not use over 43 30.1% 20 31.3% 1 50.0% 64 30.6% the last 90 days Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% How often do you take PS: 1-2 times a week 12 8.4% 5 7.8% 0 0.0% 17 8.1% Methylenedioxymethamphetamine 1-3 times a month 56 39.2% 15 23.4% 1 50.0% 72 34.4% (ecstasy, MDMA) Did not use over 71 49.7% 40 62.5% 1 50.0% 112 53.6% the last 90 days Difficult to answer 4 2.8% 3 4.7% 0 0.0% 7 3.3% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you take PS: Hallucinogens 1-2 times a week 11 7.7% 0 0.0% 0 0.0% 11 5.3% (LSD, mushrooms, "trip", salvia) 1-3 times a month 34 23.8% 6 9.4% 1 50.0% 41 19.6% Did not use over 93 65.0% 56 87.5% 1 50.0% 150 71.8% the last 90 days Difficult to answer 5 3.5% 2 3.1% 0 0.0% 7 3.3% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% How often do you take PS: 1-2 times a week 5 3.5% 2 3.1% 0 0.0% 7 3.3% Methamphetamine powder 1-3 times a month 30 21.0% 14 21.9% 2 100.0% 46 22.0% (crystals) – "met", "lid", ice Did not use over 107 74.8% 46 71.9% 0 0.0% 153 73.2% the last 90 days Difficult to answer 1 0.7% 1 1.6% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

More detailed distribution of respondents' responses on the frequency of NPS consumption (by gender) is presented in Annex 2. The majority of respondents in the age group "30-34 years" use Cannabis "every day", while all other age groups are more likely to use it "3-4 times a week" and "1-2 times a week". The lowest and least frequent use of Cannabis is by representatives of the older age group "40-59 years" - 20.6% of respondents indicated that they use Cannabis 1-3 times a month. The use of Amphetamine and Methylenedioxymethamphetamine is evenly distributed among all age groups with a frequency of use "1-3 times a month" - 31.3% and 34.4%, respectively. Amphetamine is more often used by representatives of younger age categories - the following respondents reported taking Amphetamine "1-2 times a week": "18-24 years" (31.4%), "25-29 years" (24.0%) and "30-34" (28.9%). Methylenedioxymethamphetamine (ecstasy, MDMA), Hallucinogens (LSD, mushrooms, "trip", salvia) and methamphetamine powder (crystals) - these substances are more popular in younger age groups - "18-24 years", "25-29 years", "30-34 years" who indicated a frequency of use: "1-3 times a month". Older age groups "35-39 years" and "40-59 years" are more prone to less frequent drug use. A detailed breakdown is presented in Table 1.1.1.3.

26 CHAPTER 1

Table 1.1.1.3. Breakdown of respondents' answers on use of PS, by age

Age Total Respondents' answers 18-24 25-29 30-34 35-39 40-59 N % N % N % N % N % N % Every day 5 9.8% 3 6.0% 8 21.1% 5 13.9% 1 2.9% 22 10.5% How often do you take PS: 3-4 times a week 9 17.6% 12 24.0% 5 13.2% 8 22.2% 1 2.9% 35 16.7% Cannabis (marijuana, 1-2 times a week 16 31.4% 14 28.0% 7 18.4% 5 13.9% 6 17.6% 48 23.0% weed, "drap", "plan", 1-3 times a month 14 27.5% 7 14.0% 7 18.4% 3 8.3% 7 20.6% 38 18.2% Did not use over the "dur’", "anasha", 7 13.7% 13 26.0% 11 28.9% 14 38.9% 19 55.9% 64 30.6% "shyshky") last 90 days Difficult to answer 0 0.0% 1 2.0% 0 0.0% 1 2.8% 0 0.0% 2 1.0% Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100% Every day 2 3.9% 1 2.0% 0 0.0% 4 11.1% 1 2.9% 8 3.8% How often do you take PS: 3-4 times a week 2 3.9% 5 10.0% 4 10.5% 2 5.6% 3 8.8% 16 7.7% 1-2 times a week 16 31.4% 12 24.0% 11 28.9% 7 19.4% 9 26.5% 55 26.3% Amphetamine powder 1-3 times a month 15 29.4% 19 38.0% 13 34.2% 9 25.0% 9 26.5% 65 31.1% ("fen", "speed", "ampha", Did not use over the 16 31.4% 13 26.0% 9 23.7% 14 38.9% 12 35.3% 64 30.6% etc.) last 90 days Difficult to answer 0 0.0% 0 0.0% 1 2.6% 0 0.0% 0 0.0% 1 0.5% Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100% Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you take PS: 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1 2.9% 1 0.5% 1-2 times a week 6 11.8% 4 8.0% 3 7.9% 1 2.8% 3 8.8% 17 8.1% Methylenedioxymetham- 1-3 times a month 22 43.1% 23 46.0% 11 28.9% 7 19.4% 9 26.5% 72 34.4% fetamine Did not use over the 20 39.2% 22 44.0% 23 60.5% 27 75.0% 20 58.8% 112 53.6% (ecstasy, MDMA) last 90 days Difficult to answer 3 5.9% 1 2.0% 1 2.6% 1 2.8% 1 2.9% 7 3.3% Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100% Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you take PS: 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1-2 times a week 4 7.8% 4 8.0% 2 5.3% 1 2.8% 0 0.0% 11 5.3% Hallucinogens 1-3 times a month 14 27.5% 18 36.0% 7 18.4% 1 2.8% 1 2.9% 41 19.6% (LSD, mushrooms, "trip", Did not use over the 33 64.7% 25 50.0% 27 71.1% 32 88.9% 33 97.1% 150 71.8% salvia) last 90 days Difficult to answer 0 0.0% 3 6.0% 2 5.3% 2 5.6% 0 0.0% 7 3.3% Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100% Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you take PS: 3-4 times a week 0 0.0% 0 0.0% 1 2.6% 0 0.0% 0 0.0% 1 0.5% 1-2 times a week 2 3.9% 2 4.0% 1 2.6% 1 2.8% 1 2.9% 7 3.3% Methamphetamine 1-3 times a month 12 23.5% 13 26.0% 7 18.4% 10 27.8% 4 11.8% 46 22.0% powder (crystals) – "met", Did not use over the 37 72.5% 34 68.0% 29 76.3% 25 69.4% 28 82.4% 153 73.2% "lid", ice last 90 days Difficult to answer 0 0.0% 1 2.0% 0 0.0% 0 0.0% 1 2.9% 2 1.0% Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100%

A more detailed distribution of respondents' answers regarding frequency of NPS use (by age) is presented in Annex 3. Weed or Cannabis is an unpopular substance among SW - only 22.2% indicated that they used it from "1-2 times per week" to "1-3 times a month"; 66.7% of respondents reported that they had not used Cannabis at all in the last 90 days. Similarly, Cannabis is not very popular among clients of female SW - 16.7% use it "1-2 times a week", 33.3% - "1-3 times a month"; 50.0% of clients of female SW have not used Cannabis at all over the last 90 days.

27 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

At the same time Cannabis is a very popular and regularly used substance among PWUD who do not attribute themselves to any KP - 70.2% of respondents indicated that they used Cannabis with a frequency "every day" to "1-3 times a month”. Cannabis is equally popular among MSM and the group "SW and MSM" - 80.4% and 81.2%, respectively, who indicated that they used Cannabis "every day" or "1-3 times a month". Such a difference in consumption between various categories may be explained by the specifics of the categories "SW" and "clients of female SW". Amphetamine powder is quite popular among all categories of respondents. 100% of clients of female SW use Amphetamine powder as often as "1-2 times a week" to "1-3 times a month". SW, MSM and the group "SW and MSM" actively and regularly take Amphetamine - 83.3%, 71.7% and 69.7%, respectively. Among respondents who do not attribute themselves to any KP, Amphetamine is slightly less popular - 65.3% indicated that they use this substance "every day" to "1-3 times a month". MDMA is not widespread among SW (77.8% of respondents out of this TGA indicated that they have not used MDMA in the last 90 days), but respondents from the categories of MSM, "SW and MSM" and clients of female SW actively use this substance - 65.2%, 75.0% and 66.7% respectively. Hallucinogens are popular only among MSM - 65.8% of respondents indicated that they use this substance "1-2 times a week" or "3-4 times a month". Table 1.1.1.4. Breakdown of respondents' answers regarding consumption of PS, by category

Respondent's category

I am PWUD but I do not Total Transgender SW and Clients of Respondents' answers Sex worker MSM attribute person MSM female SW myself to any KP N % N % N % N % N % N % N % Every day 0 0.0% 3 6.5% 0 0.0% 18 14.9% 1 6.3% 0 0.0% 22 10.5%

How often do you 3-4 times a week 0 0.0% 10 21.7% 1 50.0% 20 16.5% 4 25.0% 0 0.0% 35 16.7% take PS: 1-2 times a week 2 11.1% 11 23.9% 0 0.0% 30 24.8% 4 25.0% 1 16.7% 48 23.0% Cannabis 1-3 times a month 2 11.1% 13 28.3% 0 0.0% 17 14.0% 4 25.0% 2 33.3% 38 18.2% (marijuana, weed, "drap", "plan", Did not use over 12 66.7% 9 19.6% 1 50.0% 36 29.8% 3 18.8% 3 50.0% 64 30.6% "dur’", "anasha", the last 90 days "shyshky") Difficult to 2 11.1% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2 1.0% answer Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

Every day 0 0.0% 2 4.3% 0 0.0% 5 4.1% 1 6.3% 0 0.0% 8 3.8% 3-4 times a week 2 11.1% 4 8.7% 0 0.0% 10 8.3% 0 0.0% 0 0.0% 16 7.7% How often do you take PS: 1-2 times a week 6 33.3% 16 34.8% 1 50.0% 27 22.3% 2 12.5% 3 50.0% 55 26.3% Amphetamine 1-3 times a month 7 38.9% 11 23.9% 0 0.0% 36 29.8% 8 50.0% 3 50.0% 65 31.1% powder ("fen", Did not use over "speed", "ampha", 3 16.7% 13 28.3% 1 50.0% 42 34.7% 5 31.3% 0 0.0% 64 30.6% the last 90 days etc.) Difficult to 0 0.0% 0 0.0% 0 0.0% 1 0.8% 0 0.0% 0 0.0% 1 0.5% answer Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

28 CHAPTER 1

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 1 0.8% 0 0.0% 0 0.0% 1 0.5% How often do you take PS: 1-2 times a week 2 11.1% 4 8.7% 0 0.0% 7 5.8% 3 18.8% 1 16.7% 17 8.1% Methylenedioxime- 1-3 times a month 2 11.1% 25 54.3% 1 50.0% 32 26.4% 9 56.3% 3 50.0% 72 34.4% tamphetamine Did not use over 14 77.8% 16 34.8% 1 50.0% 75 62.0% 4 25.0% 2 33.3% 112 53.6% (ecstasy, MDMA) the last 90 days Difficult to 0 0.0% 1 2.2% 0 0.0% 6 5.0% 0 0.0% 0 0.0% 7 3.3% answer Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you take PS: 1-2 times a week 0 0.0% 10 21.7% 0 0.0% 0 0.0% 1 6.3% 0 0.0% 11 5.3% Hallucinogens 1-3 times a month 0 0.0% 20 43.5% 1 50.0% 19 15.7% 1 6.3% 0 0.0% 41 19.6% (LSD, mushrooms, Did not use over 16 88.9% 15 32.6% 1 50.0% 98 81.0% 14 87.5% 6 100% 150 71.8% "trip", salvia) the last 90 days Difficult to 2 11.1% 1 2.2% 0 0.0% 4 3.3% 0 0.0% 0 0.0% 7 3.3% answer Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 1 0.8% 0 0.0% 0 0.0% 1 0.5% How often do you take PS: 1-2 times a week 1 5.6% 1 2.2% 0 0.0% 3 2.5% 2 12.5% 0 0.0% 7 3.3% Methamphetamine 1-3 times a month 4 22.2% 11 23.9% 2 100% 22 18.2% 6 37.5% 1 16.7% 46 22.0% powder (crystals) – Did not use over 13 72.2% 34 73.9% 0 0.0% 94 77.7% 7 43.8% 5 83.3% 153 73.2% "met", "lid", ice the last 90 days Difficult to 0 0.0% 0 0.0% 0 0.0% 1 0.8% 1 6.3% 0 0.0% 2 1.0% answer Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

For a more complete distribution of respondents' answers regarding frequency of NPS consumption (by category), please refer to Annex 4. Participants of the FGD named drugs that they and their friends use (the respondents did not specify a number of users among friends; among friends those who use drugs were "all", "many", "some" or "few", and those "who have quit using drugs"), as well as briefed on peculiarities of the use of some substances: • There are different narcotic substances which are in use: - (K) "Absolutely different"; - (K) "Starting from weed, of course... And gradually... Tramadol began. Then "junk"... Somewhere slipped through. But mostly all young people of our age took tramadol. "Junk", tramadol”; - (K) "Gvynt"..."; - (O) “I used to use a lot of different things. Amphetamine, MDMA, LSD. I did not inject. Codeine, "junk". From the age of 16 I started use weed, then gradually went further and further"; - (O) "All drugs in the world, injectable too. For example, methadone, , amphetamine"; - (O) "I doubt there are people who have sniffed pure cocaine, and of course there are"; - (O) "I often smoke weed, almost every day"; - (O) “Ether, but it's not a standard practice. You can buy legally. Wild for 10-15 seconds"; - (K) "Mainly weed, tabs, "fen";

29 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

- (K) "Weed, amphetamine, "endem", amphetamine mixed with cocaine"; - (K) “These are my friends at work. Girlfriend: ecstasy, "endem". Legal: alcohol and cigarettes. Metfetamine, amphetamine, amphetamine with cocaine, cocaine, stimulants"; - (K) “There is one friend. The second is not a user any longer. Amphetamines - the whole group"; - (K) “Basically everything. MDA, "fen", weed"; - (K) “Several friends are taking weed. Ecstasy"; - (K) “I am in the minority among my acquaintances, because I practically do not use it. I have very little experience. I used weed, ecstasy, "dji". I definitely do not want to try everything else. Two of my acquaintances - they tried the whole palette: ecstasy, amphetamines, "dji", weed"; - (O) “There are a few acquaintances who like to smoke a little, and it's not . Once my friend and I were treated to "space"; - (K) “There are a couple of people I do this with every few months. Once it was "fen". Other times – "dji" or "butyrate"; - (K) “I have little experience. Four times in my life I tried "butyrate", ecstasy. Weed. I once tried to sniff methadone"; - (O) "Every second guy in a company takes something"; - (O) "Drugs of the amphetamine group, ecstasy, smoked weed. "Blotters" and mushrooms, unfortunately, I have not tried"; - (O) “Regularly. Amphetamine, ecstasy, "NGNMay" and other wild stuff"; - (O) “Sometimes - "shyshky Baha". Sometimes I used LSD to rethink my consciousness"; - (O) "Fen", weed, ecstasy, "mef", mushrooms, LSD. I ate tabs every two or three weeks. "Fenchik" once or twice a month. LSD - three or four times. "Shyshky" - once or twice a week. Mushrooms once. My plan is to get something else tasty”; - (O) “There is a friend who tried "spice" with me. This was the first and last time"; - (O) "Everything: from LSD, "blotters", "fen", "salts". Everything is so stupid! And I tried everything, thanks to friends"; - (O) “There are no such people who have quit. There are those who use now"; - (O) "Amphetamine, "salt", ecstasy"; - (O) “It was a long time ago. Not tempting me now. There are no such cases now"; - (O) “Situational. But, if, for example, I said that I will not sniff "fen", I may only say that once a year I can afford it - half a line, symbolically. Some mushrooms, "blotters" once every six months, but in general without anything"; - (O) “Yes, it happens. Weed, once a week, amphetamine - once every few months"; • restrictions imposed on the circulation of Tramadol caused the transition to other substances, including their injectable use: - (K) "When Tramadol was removed, people started injecting"; • there are differences in the choice of substances and methods of their use for different categories of consumers (richer-poorer, experienced-beginners): 1) more "advanced" substances are LSD, "blotters": - (K) “LSD, "blotters". For those who are more advanced"; 2) residents of the right bank of the river in Kyiv use more expensive substances, the method of use - sniffing, while residents of the left bank use cheaper substances: - (K) “People from the village come here [to Kyiv] to work. They rent apartments and they rent more on our left bank. It's cheaper here… - Are there more clubs on the left bank? - No, we have more on the right bank. The right bank is a richer. - Probably, the right bank sniffs more, more expensive"; 3) "Gvynt" is considered to be of lower quality (prestigious) than Heroin: - (K) “Personally, I tried "gvynt" when I was… probably... I was already in a deep downturn. Otherwise, why do I need that "gvynt"? I used to go and buy myself heroin. - On the right bank. I used to buy cocaine".

30 CHAPTER 1

1.1.2. Practices and experience of using NPS/stimulants among KP representatives

Methods of using NPS/stimulants

According to the survey results, the most popular way to use NPS/stimulants is "swallowing" - this was stated by 35.8% (n = 148) of all respondents (n = 75; 34.6% in Kyiv and n = 73; 37.2% in Odesa). The second most common method is "smoking" - as noted by 32.7% (n = 135) of all respondents (n = 73; 33.6% in Kyiv; n = 62, 31.6% in Odesa). Also, 114 respondents, which is 27.9% of all respondents, indicated that they "sniff" PS (n = 58; 26.7% in Kyiv; n = 56; 28.6% in Odesa). In addition, among the respondents there are those who also practice injecting drug use together with NPS/stimulants - 3.9% (n = 16) (n = 11; 5.1% in Kyiv; n = 5; 2.6% in Odesa). This may be linked to the practice of using various drugs by some respondents. That is, the older the respondent and the larger his or her experience of drug use, the more likely he or she uses both injectable and non-injecting drugs. The distribution of responses by city of residence is even (see Table 1.1.2.1.) and the above listed methods of use are equally popular in both cities. Table 1.1.2.1.

Breakdown of respondents' answers about the use of PS/stimulants, by the city of residence

Cities All responses Respondents' answers Kyiv Odesa

N % N % N %

Swallowing 75 34.6% 73 37.2% 148 35.8%

Smoking 73 33.6% 62 31.6% 135 32.7% How the PS/ stimulants are used Sniffing 58 26.7% 56 28.6% 114 27.6%

Injecting 11 5.1% 5 2.6% 16 3.9%

Subtotal 217 * 100.0% 196 * 100.0% 413 * 100.0%

* respondents had the opportunity to choose several answers

Respondents had the opportunity to choose several answers to this question - most often they chose two options at the same time: "swallowing" and "smoking" - as reflected in answers of 43.5% of respondents (n = 91). This corresponds to the data given above (section 1.1.1.) on popularity of a particular method of use.

Regarding dependencies between the method of use of NPS/stimulants and the experience of use and age, it can be noted that in the age group "18-24 years" respondents with experience of use "from 1 to 5 years" have preference to both injectable and non-injectable drugs – as was reported by 2.8% of all respondents. Moreover, in this age group one of respondents, despite young age, had a solid experience of drug use - more than 11 years (such cases should be considered individually). The rest of the respondents in this age group primarily practice "smoking" and "sniffing" - 35.8% and 32.1%, respectively.

"Swallowing" (32.1%) is more popular among "beginners" (respondents whose experience of use is less than 1 year).

In the age group "25-29 years" there are also respondents who use both injectable and non-injecting drugs, but their share is significantly lower - only 1.0%. Most spread practices for them are "swallowing" and "smoking" - 35.3% and 34.3% respectively.

31 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Table 1.1.2.2.27 Breakdown of answers regarding the method and experience of use of PS (by age) Experience of using PS/stimulants Method of less than 1 from 1 to 5 from 6 to 10 from 11 to 20 from 21 to 30 more than Age All responses using NPS year years years years years 31 years N % N % N % N % N % N % N % Swallowing 9 32.1% 20 29.4% 1 12.5% 1 50.0% 31 29.2% Smoking 12 42.9% 21 30.9% 4 50.0% 1 50.0% 38 35.8% Sniffing 7 25.0% 24 35.3% 3 37.5% 0 0.0% 34 32.1%

18-24 years Injecting 0 0.0% 3 4.4% 0 0.0% 0 0.0% 3 2.8% Subtotal 28 100.0% 68 100.0% 8 100.0% 2 100.0% 106 100.0% Swallowing 1 20.0% 25 36.8% 10 34.5% 36 35.3% Smoking 1 20.0% 22 32.4% 12 41.4% 35 34.3% Sniffing 3 60.0% 20 29.4% 7 24.1% 30 29.4%

25-29 years Injecting 0 0.0% 1 1.5% 0 0.0% 1 1.0% Subtotal 5 100.0% 68 100.0% 29 100.0% 102 100.0% Swallowing 1 50.0% 10 33.3% 11 36.7% 3 30.0% 0 0.0% 25 33.8% Smoking 1 50.0% 10 33.3% 10 33% 3 30.0% 1 50.0% 25 33.8% Sniffing 0 0.0% 8 26.7% 8 26.7% 4 40.0% 1 50.0% 21 28.4%

30-34 years Injecting 0 0.0% 2 6.7% 1 3.3% 0 0.0% 0 0.0% 3 4.1% Subtotal 2 100.0% 30 100.0% 30 100.0% 10 100.0% 2 100.0% 74 100.0% Swallowing 10 52.6% 7 41.2% 4 30.8% 7 36.8% 28 41.2% Smoking 6 31.6% 5 29.4% 5 38.5% 5 26.3% 21 30.9% Sniffing 3 15.8% 4 23.5% 3 23.1% 5 26.3% 15 22.1%

35-39 years Injecting 0 0.0% 1 5.9% 1 7.7% 2 10.5% 4 5.9% Subtotal 19 100.0% 17 100.0% 13 100.0% 19 100.0% 68 100.0% Swallowing 1 16.7% 11 52.4% 10 41.7% 5 55.6% 1 33.3% 28 44.4% Smoking 2 33.3% 3 14.3% 8 33.3% 1 11.1% 2 66.7% 16 25.4% Sniffing 3 50.0% 6 28.6% 5 20.8% 0 0.0% 0 0.0% 14 22.2%

40-59 years Injecting 0 0.0% 1 4.8% 1 4.2% 3 33.3% 0 0.0% 5 7.9% Subtotal 6 100.0% 21 100.0% 24 100.0% 9 100.0% 3 100.0% 63 100.0%

The PWID were also represented in the age category "30-34 years" - their share was 4.1% of all respondents, which is more than in the younger age group. Most popular for this group are "swallowing" and "smoking" - 33.8% and 33.8%, respectively. In the age category "35-39 years" 5.9% of all respondents confirmed that they predominantly "inject". Other popular practices among them are "swallowing" and "smoking" - 41.2% and 30.9%, respectively. The oldest age group "40-59 years" includes 7.9% of those who practice injecting drug use. "Swallowing" is popular for this group - 44.4%. Thus, the assumption that injecting drugs are used in combination with NPS/stimulants was partially confirmed - the proportion of injecting drug users increases with the increase of respondent's age and overall experience of drug use. However, these are not the only factors: no less important are other socio-demographic characteristics - education, contacts, level of income (it is worth to explore particular cases, such as long experience of use (10-11 years or above), use of injectable and non- injectable substances at a fairly young age (18-24 years) - by the method of individual in-depth interview F2F. When considering a breakdown of responses by gender, the observation is that women practice more "swallowing" - 41.7%; men practice both "swallowing" and "smoking" - 33.4% and 35.2% respectively; Among transgender people, the most popular practices are "swallowing" and "sniffing" - 40.0% for each category, respectively. For more detailed data, see Table 1.1.2.3.

27 In this table answers to three questions are presented: age, methods and experience of PS use. When asked about the use of NPS, respondents had the opportunity to choose several answers at once. Therefore, the total number of answers in this table cannot equal to the total number of respondents.

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Table 1.1.2.3. Breakdown of answers about the method of using PS (by gender)

Gender All responses Respondents' answers* Male Female Transgender person N % N % N % N % Swallowing 98 33.4% 48 41.7% 2 40.0% 148 35.8% The method of using Smoking 103 35.2% 31 27.0% 1 20.0% 135 32.7% PS/stimulants Sniffing 82 28.0% 30 26.1% 2 40.0% 114 27.6% Injecting 10 3.4% 6 5.2% 0 0.0% 16 3.9% Subtotal 293 100.0% 115 100.0% 5 100.0% 413 100.0% * respondents had the opportunity to choose several answers

In fact, depending on how the PS are used among the TGA the responses distributed as follows: SW primarily practice “swallowing” - this was indicated by 52.9% (n = 18); MSM also practice "swallowing" - 36.7% (n = 36); for transgender people "swallowing" and "sniffing" are equally popular - 40.0% respectively; equal number of PWUD who do not attribute themselves to any KP practice "swallowing" and "smoking" - 33.9% (75 respondents); SW and MSM are prone to "sniffing" - 35.0% (n = 14); clients of female SW equally practice "swallowing" and "smoking" - 40.0% respectively. More detailed information is given in Table 1.1.2.4. Table 1.1.2.4. Breakdown of answers about the method of using PS (by category)

Categories of respondents PWUD who do Clients of Transgender not attribute SW and Respondents' answers* Sex worker MSM female SW All responses person themselves to MSM any KP N % N % N % N % N % N % N % Swallowing 18 52.9% 36 36.7% 2 40.0% 75 33.9% 11 27.5% 6 40.0% 148 35.8% The Smoking 11 32.4% 30 30.6% 1 20.0% 75 33.9% 12 30.0% 6 40.0% 135 32.7% method of Sniffing 5 14.7% 30 30.6% 2 40.0% 60 27.1% 14 35.0% 3 20.0% 114 27.6% using PS Injecting 0 0.0% 2 2.0%: 0 0.0% 11 5.0% 3 7.5% 0 0.0% 16 3.9% Subtotal 34 100% 98 100% 5 100% 211 100% 40 100% 1 100% 413 100% * respondents had the opportunity to choose several answer options

The FGD participants also described methods of preparation and how drugs were used: - (K) “We sniffed. We ate "blotters", LSD "; - (K) “And we cooked them by ourselves. - Steamed (laughter)"; - (O) "I smoke psychogenic substances"; - (O) "I'm having fun, drinking pills, sniffing"; - (O) “There are even those who manage to cook non-injectables and inject them. Now there is such stuff called "klep". For example, you dilute "fen" with water and - into the muscle". Comparing "junk" and "gvynt", participants shared conflicting experiences of their use: - (K) “I was released from prison, it was 10 years ago. I was then addicted to "junk". Due to taking "gvynt" I forgot what "junk" is. "It's stupid"; - (K) "And after "junk" I forgot what "gvynt" is"; - (K) "I know that "junk" and "gvynt" were used more than once"; - (K) “I tried it for the first time, my first drug was "gvynt". Six months, eight months... In Crimea. - Because in Crimea there is no normal... - And only after six months, when I started to get high, I was almost 17 years old, I met friends who cooked at home. But in Crimea there were no poppy fields or poppies. That's why there were certain gypsies who... They had "checks" (a pack of drugs). And they sold this "check" for 100 rubles... And you come home, warm it up in a

33 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

ladle. On a spoon... And that's it. And I remember three sites I used... I probably went for three days for the first time"; - (K) “When I started going crazy after "gvynt", I was offered "junk". Otherwise I would not have stopped. It’s due to "junk" that I didn't go crazy"; - (K) “It interrupts, blocks. Of course. It is quite possible to jump off "junk" while using "gvynt". Two days... After that you will even inject "junk"... ”; - (K) “A man says: I have "gvynt". Well, I didn't know what it was. The guys told me: "gvynt, gvynt…". But how it works, this I did not know. He came, cooked. He taught me to cook. And I understood: all is clear, you forget about "junk". I guess we did not sleep for nine days then, I think. Well, how long is hungover from "junk" – three days. I then fell asleep, woke up - okay. I forgot about "junk" for a year and a half." Period of use of NPS/stimulants Respondents’ experience of using NPS looks as follows: the prevailing number of respondents use narcotic substances over a period "from 1 year to 5 years" - 44.5% (n = 93). Responses regarding this indicator - period of drug use – were similar for both cities. Moreover, the percentage of those who use PS for less than a year and those who use them over 21 to 30 years is the same - this is 7.7% of all respondents. For more information, see Table 1.1.2.5. Table 1.1.2.5. Experience of using NPS/stimulants (breakdown by city of residence) Cities Total Respondents' answers28 Kyiv Odesa N % N % N % Less than 1 year 5 4.8% 11 10.6% 16 7.7 From 1 to 5 years 47 44.8% 46 44.2% 93 44.5 Experience of using From 6 to 10 years 33 31.4% 25 24.0% 58 27.8 NPS/stimulants From 11 to 20 years 13 12.4% 11 10.6% 24 11.5 From 21 to 30 years 7 6.7% 9 8.7% 16 7.7 More than 31 year 0 0.0% 2 1.9% 2 1.0 Subtotal 105 100.0% 104 100.0% 209 100.0%

When responses are disaggregated by gender, it can be concluded that among ‘beginners’ (those who use "less than 1 year") men prevail (with 10.5% versus 1.6% of women). Women are more represented in the groups "from 1 to 5 years" and "from 11 to 20 years" - 46.9% and 35.9%, respectively. Men in the groups "from 1 to 5 years" and "from 11 to 20 years" - 42.7% and 24.5%, respectively. In other categories of drug use experience, men predominate over women. See Table 1.1.2.6 for more information. In general, this angle – experience of drug use for various gender groups - is quite interesting to research. After all, in a way, we have a breakdown where there are twice less women than men. This may be due to the fact that: - women are reluctant and afraid to talk about using PS/stimulants; - women are generally less likely to use PS/stimulants. Table 1.1.2.6. Experience of using NPS/stimulants (by gender) Gender Total Respondents' answers Male Female Transgender person N % N % N % N % Less than 1 year 15 10.5% 1 1.6% 0 0.0% 16 7.7 From 1 to 5 years 61 42.7% 30 46.9% 2 100.0% 93 44.5 Experience of From 6 to 10 years 35 24.5% 23 35.9% 0 0.0% 58 27.8 using NPS From 11 to 20 years 18 12.6% 6 9.4% 0 0.0% 24 11.5 From 21 to 30 years 12 8.4% 4 6.3% 0 0.0% 16 7.7 More than 31 years 2 1.4% 0 0.0% 0 0.0% 2 1.0 Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.00%

28 The time intervals in the scale were set on the basis of the respondents' answers to an open-ended question, and they were formed in a way to avoid large discrepancies in the data; the key principle for defining these intervals was to ensure shift or loss of information, or discrepancies.

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Experience of narcotic substances use is spread evenly between respondents’ groups (this may be due to possible linkage between respondent's age and his/her period of substance use). There was only 1 respondent in the age group "18-24 years", who has experience of using NPS from "11 to 20 years" – such individual cases of early use of NPS should rather be studied separately. The assessment identified a tendency: the number of "beginners" (those who have experience of use "less than 1 year") is decreasing when comparing different age groups. In the age group "18-24 years" there are 23.5% of those who use PS "less than 1 year". In the age categories "25-29 years" and "30-34 years" - 6.0% and 2.6%, respectively – out of those who use PS "less than 1 year". Therefore, the older the person is, the less likely he or she is to start using PS/stimulants (if he or she has not done so before certain period of time). See Table 1.1.2.7 for more information. Table 1.1.2.7. Experience of using NPS/stimulants (by age)

Age Total Respondents' answers 18-24 years 25-29 years 30-34 years 35-39 years 40-59 years

N % N % N % N % N % N %

Less 12 23.5% 3 6.0% 1 2.6% 0 0.0% 0 0.0% 16 7.7 than 1 year

From 1 to 5 years 32 62.7% 33 66.0% 13 34.2% 12 33.3% 3 8.8% 93 44.5

From 6 to 10 years 6 11.8% 14 28.0% 17 44.7% 9 25.0% 12 35.3% 58 27.8 Experience of using NPS From 11 to 20 years 1 2.0% 0 0.0% 6 15.8% 6 16.7% 11 32.4% 24 11.5

From 21 to 30 years 0 0.0% 0 0.0% 1 2.6% 9 25.0% 6 17.6% 16 7.7

More than 31 years 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2 5.9% 2 1.0

Subtotal 51 100% 50 100% 38 100% 36 100% 34 100% 209 100%

Thus, according to the data obtained in the survey, respondents who do not attribute themselves to any of the KP are represented in all categories describing experience of PS use - from "beginners" (less than 1 year) to "more than 31 years". Among SW, the major share of respondents use drugs "from 1 to 5 years" and "from 6 to 10 years" - 61.1% and 33.3%, respectively. There are few "beginners" among SW - only 5.6%. But the respondents who are MSM and the group "SW and MSM" - on the contrary, have smaller experience of using PS: in particular, the majority of respondents from the group "SW and MSM" (75.0%) and MSM (58.7%) practice use of PS over a period "from 1 to 5 years". In addition, in these categories there is a large share of beginners - 21.7% of surveyed MSM and 18.8% of respondents from the group "SW and MSM", respectively, have experience of using PS over less than 1 year. All interviewed transgender persons have experience of substance use "from 1 to 5 years". Equally interesting is the situation with clients of female SW - most of them have experience of using PS "from 11 to 20 years", moreover, among them there are no people who have just started using PS. See Table 1.1.2.8 for more information.

35 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Table 1.1.2.8. Experience of using NPS/stimulants (by categories)

Respondent's category PWUD who do Clients Transgender not attribute SW and Total Respondents' answers Sex worker MSM of female person themselves to MSM SW any KP N % N % N % N % N % N % N % Less than 1 1 5.6% 10 21.7% 0 0.0% 2 1.7% 3 18.8% 0 0.0% 16 7.7% year From 1 to 5 11 61.1% 27 58.7% 2 100% 40 33.1% 12 75.0% 1 16.7% 93 44.5% years From 6 to 10 6 33.3% 8 17.4% 0 0.0% 42 34.7% 1 6.3% 1 16.7% 58 27.8% Experience of years using NPS From 11 to 20 0 0.0% 1 2.2% 0 0.0% 19 15.7% 0 0.0% 4 66.7% 24 11.5% years From 21 to 30 0 0.0% 0 0.0% 0 0.0% 16 13.2% 0 0.0% 0 0.0% 16 7.7% years More than 31 0 0.0% 0 0.0% 0 0.0% 2 1.7% 0 0.0% 0 0.0% 2 1.0% years Subtotal 18 100% 46 100% 2 100% 121 100% 16 100% 6 100% 209 100%

1.2. Alcohol consumption by users of psychoactive substances Consumption of low-alcohol beverages is quite popular among respondents - 70.8% of respondents indicated that they drink low-alcohol beverages from "every day" to "1-3 times a month". Most frequent answer was that they drink low-alcohol beverages "1-2 times a week" (26.3%). Medium-alcohol drinks are less popular: 48.3% of all respondents said that they drink them from "every day" to "1-3 times a month". Most frequent answer was that respondents drink medium-alcohol beverages "1-3 times a month" (21.5%). Half (54.0%) of all respondents reported that they drink high-alcohol beverages from "every day" to "1-3 times a month". Most frequently respondents drink such beverages "1-3 times a month" (32.1%). The use of "homemade moonshine and tincture" is unpopular among the respondents – only 4.8% indicated that they drink such beverages. Looking at distribution of responses by cities of residence, there is a tendency of lower alcohol consumption among respondents from Odesa (see Table 1.2.1.). In general, in Odesa, the share of those who reported that they had not consumed alcohol in the last 30 days is higher – regardless of the type of alcoholic beverage. Distribution between different categories of frequency of alcohol consumption by cities of residence duplicates the general distribution described above. Table 1.2.1. Alcohol consumption (by city of residence) Cities Total Respondents' answers Kyiv Odesa N % N % N % Every day 8 7.6% 5 4.8% 13 6.2% 3-4 times a week 19 18.1% 21 20.2% 40 19.1%

Alcohol consumption: 1-2 times a week 33 31.4% 22 21.2% 55 26.3% Low- alcohol drinks 1-3 times a month 20 19.0% 20 19.2% 40 19.1% Hasn't drunk in the last 30 days 24 22.9% 36 34.6% 60 28.7% Difficult to answer 1 1.0% 0 0.0% 1 .5% Subtotal 105 100.0% 104 100.0% 209 100.0%

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Every day 2 1.9% 1 1.0% 3 1.4% 3-4 times a week 7 6.7% 12 11.5% 19 9.1%

Alcohol consumption: 1-2 times a week 17 16.2% 17 16.3% 34 16.3% Medium-alcohol drinks 1-3 times a month 28 26.7% 17 16.3% 45 21.5% Hasn't drunk in the last 30 days 50 47.6% 56 53.8% 106 50.7% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 1 1.0% 2 1.0% 3-4 times a week 10 9.5% 9 8.7% 19 9.1%

Alcohol consumption: 1-2 times a week 15 14.3% 10 9.6% 25 12.0% High-alcohol drinks 1-3 times a month 38 36.2% 29 27.9% 67 32.1% Hasn't drunk in the last 30 days 39 37.1% 55 52.9% 94 45.0% Difficult to answer 2 1.9% 0 0.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 3 2.9% 2 1.9% 5 2.4% Alcohol consumption: 1-2 times a week 1 1.0% 0 0.0% 1 .5% Homemade moonshine/ tinctures 1-3 times a month 1 1.0% 3 2.9% 4 1.9% Hasn't drunk in the last 30 days 99 94.3% 97 93.3% 196 93.8% Difficult to answer 1 1.0% 2 1.9% 3 1.4% Subtotal 105 100.0% 104 100.0% 209 100.0%

Alone 38 18.0% 20 9.8% 58 13.9% With my wife/husband 7 3.3% 9 4.4% 16 3.8% With a partner (in relationship) 26 12.3% 27 13.2% 53 12.7% With a business partner 26 12.3% 12 5.9% 38 9.1% In what company do you With friends 81 38.4% 72 35.1% 153 36.8% drink alcohol? With casual acquaintances 8 3.8% 19 9.3% 27 6.5% With a casual sexual partner 12 5.7% 25 12.2% 37 8.9% With relatives 2 0.9% 3 1.5% 5 1.2% I do not use it at all 11 5.2% 18 8.8% 29 7.0% Subtotal 211 * 100.0% 205 * 100.0% 416 * 100.0% * respondents had the opportunity to choose several answers

According to the data obtained, respondents most often drink alcoholic beverages "with friends" (36.8% of all respondents), "alone" (13.9%), "with a partner" (12.7%), "with a business partner” (9.1%) and “with a casual sexual partner” (8.9%). Consumption of alcoholic beverages "with relatives" (7.0%) and "with a wife/husband" (3.8%) are not very popular. Distribution of answers by cities of respondents’ residency shows that it is generally more or less even, except for the categories "With casual acquaintances" and "With a casual sexual partner" (in Kyiv fewer respondents drink alcohol with casual acquaintances or partners than in Odesa).

37 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Respondents-participants of the FGD confirmed the practice of using alcohol and PS: - (K) “Do you have cases when you can use both alcohol and narcotic substances? - Of course. - We are always under the influence of drugs! [General laughter]". However, respondents indicated that they drink alcohol quite rarely and in small doses: - (O) "I get loaded only once a year"; - (O) “A little bit every time. Coffee with cognac, 50 grams"; - (O) "I get loaded very rarely." Some respondents reported abstaining from alcohol: - (O) "No, I am a non-injecting drug addict"; - (O) "I do not use"; - (O) "I used to drink a lot, I haven't drunk for 10 years and I try to avoid women who drink"; - (O) "I had no relationship with a woman who drank"; - (O) "I do not drink alcohol at all"; - (O) "I do not drink alcohol as a matter of principle, it is a taboo for me"; - (O) “I also try not to drink [alcohol]. I had an experience - I did not drink or smoke anything for a year. Dissatisfaction with alcohol itself. Of course, this has happened throughout my life"; - (K) "Did not use yet"; - (K) "I drink alcohol very rarely"; - (O) “I used to drink a lot with my ex. Now everything is being replaced by "dopy" (dops). One of the reasons for abstaining from alcohol is that the consequences of such use are much more unpleasant than from the use of PS: - (K) “I stopped drinking more than half a year ago because I felt really bad. PS do not affect me destructively. Over those six months, I realized that most of the substances I used did not cause me much harm to my health, unlike alcohol. Alcohol was the main cause. Because, usually, I feel bad after drinking alcohol ... In my specific case, it was the only thing that made me feel bad. Everything else is fairly well controlled when following a good diet. I do not use".

1.3. Environments where NPS/stimulants are used

Let us consider in which contexts and environments respondents use narcotic substances – where and with whom. The most popular places to use NPS/stimulants 14.1% of all respondents (n = 40; 13.0% in Kyiv and n = 39; 15.4% in Odesa) use narcotic substances "In nightclubs/ bars/discos". Moreover, they do it together with friends and/or with their regular partners. In fact, clubs are the most popular public place to use PS/stimulants among respondents. Other popular place for taking NPS/stimulants is home ("At home") - this was reported by almost a third (29.6%) of all respondents (n = 83; 26.9% in Kyiv, and n = 83; 32.8% in Odesa), "At someone’s place" - 20.0% of all respondents (n = 57; 18.5% in Kyiv, and n = 55; 21.7% in Odesa) , "In nightclubs/bars/discos" - 14.1% (n = 40; 13.0% in Kyiv, and n = 39; 15.4% in Odesa), "In nature, parks, recreation areas, beaches, etc.) "- 12.7% (n = 39; 12.7% in Kyiv, and n = 32; 12.4% in Odesa),"In hotels" and "In a country house"- 5.3% of all respondents, each (in particular,"In hotels": n = 22; 7.1% in Kyiv, and n = 8; 3.2% in Odesa; "In a country house": 20 respondents (6.5%) in Kyiv, and 10 respondents (4.0%) in Odesa); "At festivals" - 4.8% (n = 16; 5.2% in Kyiv, and n = 11; 4.3% in Odesa), "In saunas" - 4.3% (n = 22, 7.1% in Kyiv, and n = 8; 3.2% in Odesa). Other places are not very popular for NPS use among the respondents, but provide an understanding of the general picture and peculiarities of the use of PS/stimulants. For detailed information, see Table 1.3.1.

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Table 1.3.1. Places where respondents use PS/stimulants (by cities of residence)

Cities All responses Respondents' answers Kyiv Odesa N % N % N % Home 83 26.9% 83 32.8% 166 29.6% At someone’s place 57 18.5% 55 21.7% 112 20.0% In nightclubs/bars/discos 40 13.0% 39 15.4% 79 14.1% In hotels 22 7.1% 8 3.2% 30 5.3% At festivals 16 5.2% 11 4.3% 27 4.8% Places where In a country house 20 6.5% 10 4.0% 30 5.3% respondents use PS/ In saunas 18 5.8% 6 2.4% 24 4.3% stimulants In nature (parks, recreation areas, 39 12.7% 32 12.6% 71 12.7% beaches, etc.) In a car 1 0.3% 6 2.4% 7 1.2% In a street 7 2.3% 1 0.4% 8 1.4% At work 2 0.6% 1 0.4% 3 0.5% In the entryway of home 3 1.0% 1 0.4% 4 0.7% Subtotal 308 * 100.0% 253 * 100.0% 561 * 100.0% * respondents had the opportunity to choose several answers

The details about usual places where narcotic substances are used demonstrate that women are more prone to use drugs at "Home" and "In nature (parks, recreation areas, beaches, etc.)" than men - 30.5% and 17.8% respectively. Men prefer drug use "In nightclubs/bars/discos", "At festivals", "In a country house"- 15.1%, 5.4% and 6.6%, respectively. For a detailed breakdown of drug use by gender, see Table 1.3.2. Table 1.3.2. Places where respondents use PS/stimulants (by gender)

Gender Transgender All responses Respondents' answers Male Female person N % N % N % N % Home 121 29.5% 43 30.5% 2 20.0% 166 29.6% At someone’s place 82 20.0% 28 19.9% 2 20.0% 112 20.0% In nightclubs/bars/ 62 15.1% 15 10.6% 2 20.0% 79 14.1% discos In hotels 22 5.4% 8 5.7% 0 0.0% 30 5.3% At festivals 22 5.4% 4 2.8% 1 10.0% 27 4.8% In a country house 27 6.6% 2 1.4% 1 10.0% 30 5.3% Places where In saunas 16 3.9% 8 5.7% 0 0.0% 24 4.3% respondents use In nature (parks, PS/stimulants recreation areas, 46 11.2% 24 17.8% 1 10.0% 71 12.7% beaches, etc.) In a car 3 0.7% 4 2.8% 0 0.0% 7 1.2% In a street 5 1.2% 3 2.1% 0 0.0% 8 1.4% At work 2 0.5% 1 0.7% 0 0.0% 3 0.5% In the entryway of 2 0.5% 1 0.7% 1 10.0% 4 0.7% home Subtotal 410* 100.0% 141* 100.0% 10* 100.0% 561* 100.0% * respondents had the opportunity to choose several answers

39 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Distribution of places where NPS are used depending on age groups is as follows. Age categories "35-39 years" and "40-49 years" are more likely to use PS at "Home" or "Someone’s place"; younger age groups "18-24 years", "25-29 years" and "30-34 years" are also likely to use substances at "Home" or "Someone’s place", but, in addition, they use it in public places ("In nightclubs/bars/discos", "In hotels") more than older age groups do. For more detailed breakdown, see Table 1.3.3. Table 1.3.3. Places where respondents use PS/stimulants (by age) Age All responses Respondents' answers «18-24» «25-29» «30-34» «35-39» «40-59» N % N % N % N % N % N % Home 39 22.7% 38 24.2% 31 30.1% 29 45.3% 29 44.6% 166 29.6% At someone’s place 33 19.2% 32 20.4% 24 23.3% 10 15.6% 13 20.0% 112 20.0% In nightclubs/bars/ 25 14.5% 31 19.7% 18 17.5% 4 6.3% 1 1.5% 79 14.1% discos In hotels 14 8.1% 7 4.5% 3 2.9% 3 4.7% 3 4.6% 30 5.3% At festivals 10 5.8% 11 7.0% 4 3.9% 1 1.6% 1 1.5% 27 4.8% In a country house 12 7.0% 7 4.5% 7 6.8% 1 1.6% 3 4.6% 30 5.3% Places where respondents use In saunas 9 5.2% 7 4.5% 2 1.9% 2 3.1% 4 6.2% 24 4.3% In nature (parks, PS/stimulants recreation areas, 24 14.0% 21 13.4% 10 9.7% 9 14.1% 7 10.8% 71 12.7% beaches, etc.) In a car 1 0.6% 1 0.6% 2 1.9% 2 3.1% 1 1.5% 7 1.2% In a street 3 1.7% 1 0.6% 0 0.0% 1 1.6% 3 4.6% 8 1.4% At work 1 0.6% 0 0.0% 1 1.0% 1 1.6% 0 0.0% 3 0.5% In the entryway of 1 0.6% 1 0.6% 1 1.0% 1 1.6% 0 0.0% 4 0.7% home Subtotal 172* 100% 157* 100% 103* 100% 64* 100% 65* 100% 561* 100% * respondents had the opportunity to choose several answers

Thus, distribution of responses regarding places where PS are used, by categories of respondents, corresponds to the specifics of the KP. The FGD participants described the use of PS in clubs, and attitude to this of the club's management and the police. One of the explanations for drug use in clubs is - specific music which is played there: - (O) “Now the culture of electronic music is spread. In the first few hours you can listen to it, but then only drugs"; - (O) “Technomusic is equal to drug. If you know what techno is, there are definitely a lot of people under the influence of "fen". Also "salt", ecstasy and all together. According to respondents, clubs ignore the use of PS by visitors, referring to the fact that there is control at the entrance: - (K) "Constantly there is this drive. In clubs"; - (K) "It's difficult with clubs here [all together started talking about clubs]"; - (K) “Clubs try to pretend that no one uses anything inside the club. For example, I was in [club name, bad to hear] two years ago or so. But I was there in the days when they had visits of "maski show" (police raid)… I was put face to the floor… It was also a wonderful experience when you were put face to the floor and you lay like that for an hour. - Moreover, you're sober! (General laughter). - Yes! The saddest thing is that they came before I managed to use something. You just came,... and that’s all… And then you are also checked when you exit"; - (K) “In the clubs they are trying to pretend stupid: here we have control, we check everybody. And anyway we do not need to inform, because none uses (drugs) at our place"; - (K) “This is a topic not only in Ukraine. There are many famous big clubs in which, if, say, a person gets an overdose, the easiest way out is to simply throw him/her out through the back door. That’s it. And there is one club in the Berlin, where a certain number of people die every season simply because of an overdose". At the same time, respondents from among the participants of the FGD gave examples of responsible attitude of clubs to ensure safety of PS users and provided assistance in case of overdose: - (K) “For example this new club, it sets new safety standards for visitors, because there are also special rooms where

40 CHAPTER 1

they may accommodate people who have used too much, so they are accompanied to these rooms and receive necessary assistance. - This is the only club… - Yes. - What is its name, tell me, please? - Well, it has no name"; - (K) “I had a story with this club for the New Year Eve. Two boys were dragging, sorry, a girl who was under effect of substances. They passed by security. And because I have a tough character, I was like, "Hey. Get her back where she was. Who are you? Give her medical help." - Can anyone get there? - Not everyone... There is face control. I drew the attention of the people who work in this club that assistance should be provided not by some strangers, but by someone in the club". Co-use of NPS/stimulants The data obtained through this assessment show that the interviewed TGA in most cases use drugs together with “friends” - this was indicated by almost a third (30.4%) of all respondents. No less popular is the use of drugs when "Alone" (26.4% of all respondents). 11.1% of all respondents indicated that they take NPS in the company of "sexual partners". In general, answers were similar for both cities of respondents’ residence, except for the categories “With casual acquaintances” and “With casual sexual partner” - in Kyiv fewer respondents use PS with casual acquaintances or partners. For a detailed distribution of responses, see Table 1.3.4. Table 1.3.4. Co-use of PS/stimulants (by city of residence) Cities All responses Respondents' answers Kyiv Odesa N % N % N % Alone 61 26.1% 52 23.0% 113 24.6% With wife/husband 8 3.4% 11 4.9% 19 4.1% With a partner (no formal marriage) 15 6.4% 17 7.5% 32 7.0% Who do you usually take With a business partner 25 10.7% 11 4.9% 36 7.8% PS/stimulants with With friends 76 32.5% 64 28.3% 140 30.4% With a sexual partner 25 10.7% 26 11.5% 51 11.1% With casual acquaintances 11 4.7% 18 8.0% 29 6.3% With a casual sexual partner 13 5.6% 27 11.9% 40 8.7% Subtotal 234* 100.0% 226* 100.0% 460* 100.0% * respondents had the opportunity to choose several answers

Women are less likely to use PS when "alone" (16.3%) than men (27.6%). Women tend to use PS in a company of close people: "With a wife/husband" (8.09%), "With a partner (no formal marriage)" (10.6%), "With a business partner" (12.2%). Men, in turn, prefer to use PS with friends (31.8%) or when alone (26.7%). For a detailed distribution of responses, see Table 1.3.5. Table 1.3.5. Co-use of PS/stimulants (by gender) Gender Transgender All responses Respondents' answers Male Female person N % N % N % N % Alone 92 27.6% 20 16.3% 1 25.0% 113 24.6% With my wife/husband 8 2.4% 11 8.9% 0 0.0% 19 4.1% With a partner (no 19 5.7% 13 10.6% 0 0.0% 32 7.0% formal marriage) With a business partner 21 6.3% 15 12.2% 0 0.0% 36 7.8% Who do you usually take With friends 106 31.8% 32 26.0% 2 50.0% 140 30.4% PS/stimulants with With a sexual partner 40 12.0% 11 8.9% 0 0.0% 51 11.1% With casual 19 5.7% 9 7.3% 1 25.0% 29 6.3% acquaintances With a casual sexual 28 8.4% 12 9.8% 0 0.0% 40 8.7% partner Subtotal 333 * 100% 123 * 100% 4 * 100% 460 * 100% * respondents had the opportunity to choose several answers

41 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

1.4. Cases of overdose among users of psychoactive substances

Out of all respondents, a third (n = 35; 16.7%) said that in the last 12 months they had cases of overdose due to using PS. The distribution of these answers by categories (Fig. 1.4.1.) and by age (Fig. 1.4.2) is given below.

Fig. 1.4.1. Distribution of answers about cases of overdose, % by categories

On average, the difference in percentage of overdose cases among TGA is not significant. Thus, 7.7% ofthe interviewed MSM had experienced overdose of PS, as well as 6.2% of SW, 5.7% of those who take PS but do not attribute themselves to any KP, and 1.4% of interviewed clients of female SW.

Fig. 1.4.2. Distribution of responses regarding overdose cases, % by age

The answers show that overdose is most spread among the youngest age group "18-24 years" - this was mentioned by 6.8% of those who answered this question, from this age group; the same number of cases of overdose was reported by the respondents from the age groups "25-29 years" and "40-59 years" - 2.9%, respectively. 2.4% of respondents from the group "35-39 years" and 1.0% from the group "30-34 years" also mentioned such situations. Responses regarding PS which caused overdose are presented in the Table below. Table 1.4.1. Distribution of answers to the question "What narcotic substances did you use when you last experienced overdose?"

I used one drug: All responses Amphetamine "Salt" Ketamine Mixtures "Fen" Ecstasy (MDMA) N % N % N % N % N % N % N % 2 5.7 3 8.6 3 8.6 1 2.9 8 8.6 3 8.6 20 57.1

42 CHAPTER 1

I used several different drugs: Total Types of drugs N % N % "Fen" + 1 2.9 1 2.9 A few "Spices" 2 5.7 2 5.7 "Fen" + Atusin 1 2.9 1 2.9 "Fen" + "Spices" 1 2.9 1 2.9 "Fen" + Tramadol 1 2.9 1 2.9 Gidazepam + Aminazine 1 2.9 1 2.9 Amphetamine + Butyrate 2 5.7 2 5.7 Amphetamine + Ecstasy + Sex Stimulator + "Poppers" 1 2.9 1 2.9 Marijuana + Ketamine + Amphetamine + Methamphetamine 1 2.9 1 2.9 Subtotal 11 31.4 11 31.4 I used alcohol with drugs: Meow- All responses Amphetamine "Salt" Cannabis "Fen" Ecstasy Butyrates Do not Meow remember N % N % N % N % N % N % N % N % N % 1 2.9 2 5.7 1 2.9 4 11.4 1 2.9 2 5.7 1 2.9 1 2.9 13 37.1 The percentage was calculated based on responses of 35 people who answered "Yes", who had an overdose in the last 12 months

Thus, almost half of those who answered questions about cases of overdose (57.1%) indicated that in that case they used only one PS; 31.4% stated that they had used several different drugs; 37.1% used alcohol together with narcotic substances.

1.5. Needs related to the use of NPS

1.5.1. Access to NPS/stimulants

The issue of obtaining the necessary psychoactive substances/stimulants (availability) remains relevant for their users. Respondents' answers to these questions are given in Table 1.5.1.1. Table 1.5.1.1. Distribution of answers regarding ways to obtain PS/stimulants

Cities All responses Respondents' answers Kyiv Odesa N % N % N % I buy from dealers, acquaintances 33 32.0 23 22.8 56 27.5 "Drop-offs" 20 19.4 29 28.7 49 24.0 I get through friends 21 20.4 19 18.8 40 19.6 I order online (Telegram) 11 10.7 5 5.0 16 7.8 I buy at the pharmacy 5 4.9 5 5.0 10 4.9 Ways to get PS In clubs 2 1.9 4 4.0 6 2.9 I get it from sex partners 1 1.0 2 1.9 3 1.5 I order by phone 1 1.0 0 0.0 1 0.5 Through Nova Poshta (post delivery service) 0 0.0 1 1.1 1 0.5 Now I do not get PS and do not use them 2 1.9 2 1.9 4 2.0 Other 7 6.8 11 10.9 18 8.8 Subtotal 103 100.0% 101 100.0% 204 100.0%

43 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Respondent's category* PWUD who do Transgender not attribute Clients of female Sex workers MSM person themselves to any SW Ways to get PS KP % of all % of all % of all % of all in % of all in N in the N in the N N N in the the category the category category category category I buy from dealers, acquaintances 7 20.6 16 26.7 1 50.0 31 25.0 2 33.3 "Drop-offs" 11 32.4 16 26.7 0 0.0 30 24.2 2 33.3 I get through friends 6 17.6 11 18.3 1 50.0 26 21.0 0 0.0 I order online (Telegram) 8 5.9 1 1.7 0 0.0 8 6.5 0 0.0 I buy at the pharmacy 0 0.0 8 13.3 0 0.0 7 5.6 1 16.7 In clubs 0 0.0 1 1.7 0 0.0 5 4.0 1 16.7 I get it from sex partners 1 2.9 1 1.7 0 0.0 1 0.8 0 0.0 I order by phone 0 0.0 0 0.0 0 0.0 1 0.8 0 0.0 Through Nova Poshta 2 5.9 3 5.0 0 0.0 0 0.0 0 0.0 (post delivery service) Now I do not get PS 4 11.8 3 5.0 0 0.0 11 8.9 0 0.0 and do not use them Other 1 2.9 0 0.0 0 0.0 4 3.2 0 0.0 Subtotal 34 100.0 60 100.0 2 100.0 124 100.0 6 100.0 * respondents had the opportunity to choose several answers in the category to which they belong

Responses regarding ways to get NPS/stimulants showed that most popular are procurement through dealers or acquaintances, in particular, this was reported by 56 respondents (27.5% of all respondents), while 33 of them (32.0 %) were from Kyiv and 23 (22.8%) from Odesa. Answers to the same question regarding channel for getting NPS/stimulants, where the baseline survey participants had the opportunity to choose several answers, confirm that this way of accessing NPS/stimulants is the most popular among all TGA. In particular, this option was chosen by: 31 PWUD who do not attribute themselves to any KP (25.0% of all respondents in this TGA); 16 (26.7%) - MSM; 2 (33.3%) clients of female SW; 7 (20.6%) SW. The second most popular method is through "drop-offs" - as confirmed by 49 (24.0%) of respondents, including 20 (19.4%) from Kyiv and 29 (28.7%) from Odesa. By categories of respondents, "drop-offs" were highlighted as a main method for getting NPS/stimulants by: 30 (24.2%) – PWUD who do not attribute themselves to any KP; 16 (26.7%) - MSM; 11 (32.4%) - SW; 2 (33.3%) - clients of female SW. Furthermore, 40 (19.6%) respondents receive PS/stimulants through friends, including 21 (20.4%) from Kyiv and 19 (18.8%) from Odesa. This way of access to NPS/stimulants is preferred by the following categories of respondents: 26 (21.0%) – PWUD who do not attribute themselves to any KP; 11 (18.3%) - MSM; 6 (17.6%) - SW; 2 (33.3%) - clients of female SW. Ordering NPS/stimulants via the Internet (in particular, the most popular is the Telegram channel) is the preferred option for 16 (7.8%) respondents, including 11 (10.7%) from Kyiv and 5 (5.0%) from Odesa In particular, it is used by 8 (6.5%) respondents from PWUD who do not attribute themselves to any KP, and the same number of respondents who are SW; 1 (1.7%) - MSM. Among the participants of the baseline survey, 10 (4.9%) respondents, 5 (4.9%) from each city, indicated that they buy NPS/stimulants in a pharmacy,while 6 (2.9%) respondents (4 (4.0%) from Odesa and 2 (1.9%) from Kyiv) indicated that they usually buy NPS/stimulants in clubs. A portion of those who receive NPS/stimulants through sexual partners is – 3 respondents (1.5%), including 2 (1.9%) from Odesa and 1 (1.0%) from Kyiv. The least popular ways to get PS/stimulants in both cities are: ordering by phone and receiving them through sex partners.

44 CHAPTER 1

1.5.2. Access to NPS/stimulants during quarantine (COVID-19)

Introduction of certain restrictive measures in connection with the spread of the coronavirus epidemic (COVID-19) in Ukraine and quarantine regime had effect on access to NPS/stimulants for KP. Responses of the participants of the baseline survey regarding the impact of quarantine measures in the country on availability of NPS/stimulants are presented in Table 1.5.2.1. Table 1.5.2.1. Distribution of responses regarding availability of NPS/stimulants for KP during quarantine

Cities All responses Respondents' answers Kyiv Odesa N % N % N % Quarantine did not affect 37 36.3 41 40.6 78 38.4 The price has increased 11 10.8 11 10.9 22 10.8 I consume less 8 7.8 13 12.9 21 10.3 Impact of Because of travel restrictions, it's hard to find 11 10.8 8 7.9 19 9.4 quarantine on Clubs are closed 2 2.0 3 3.0 5 2.5 access to PS There are less orders 4 3.9 1 1.0 5 2.5 No funds to purchase 1 1.0 4 3.9 5 2.5 No, I do not use during quarantine 0 0.0 3 3.0 3 1.5 Other 28 27.4 17 16.8 45 22.2 Subtotal 102 100.0% 101 100.0% 203 100.0%

Respondent's category* PWUD who do not Clients of Sex worker MSM Transgender person attribute themselves female SW Impact of quarantine on access to any KP to PS* % of all % of all % of all % of all in % of all in N in the N in the N N N in the the category the category category category category Quarantine did not affect 11 32.4 23 38.3 0 0 44 35.5 1 16.7 The price has increased 5 14.7 8 13.3 1 50.0 11 8.9 2 33.3 I consume less 1 2.9 9 15.0 0 0 9 7.3 0 0 Because of travel restrictions, it's 4 11.8 4 6.7 0 0 11 8.9 0 0 hard to find Clubs are closed 1 2.9 0 0 0 0 3 2.4 1 16.7 There are less orders 1 2.9 1 1.7 0 0 3 2.4 0 0 No funds to purchase 0 0 0 0 0 0 5 4.0 0 0 No, I do not use during quarantine 0 0 0 0 1 50.0 4 3.2 0 0 Other 11 32.4 15 25.0 0 0 34 27.4 2 33.3 Subtotal 34 100.0 60 100.0 2 100.0 124 100.0 6 100.0 * respondents had the opportunity to choose several answers within the category to which they belong

In the answers of 78 respondents (38.4%), of which 37 (36.3%) were from Kyiv and 41 (40.6%) from Odesa, we observe that quarantine in no way affected access to PS/stimulants. This was indicated in particular by 44 respondents (35.5% of the cohort of all respondents in this TGA) from among the PWUD who do not associate themselves with any KP; 23 (38.3%) - MSM; 11 (32.4%) - SW; 1 (16.7%) client of female SW. A share of 22 (10.8%) respondents (11 respondents in each city (10.8%)) indicated that the price of PS had increased due to quarantine. Such remarks were made by 11 (8.9%) PWUD who do not associate themselves with any KP; 8 (13.3%) - MSM; 5 (14.7%) - SW; 2 (33.3%) clients of female SW. Overall, 21 (10.3%) respondents reduced use of PS - 13 (12.9%) from Odesa and 8 (7.8%) from Kyiv. This was reflected in answers of MSM and PWUD who do not associate themselves with any KP (noted by 9 respondents representing each TGA and 1 SW).

45 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Travel restrictions posed an additional barrier to access PS/stimulants for 19 (9.4%) respondents, including 11 (10.8%) from Kyiv and 8 (7.9%) from Odesa. This issue was raised by 11 (8.9%) PWUD who do not associate themselves with any KP and 4 respondents from the category "SW and MSM". In addition, 5 responses (2.5%) were allocated to each category of statements related to impact of quarantine restrictions on access to PS/stimulants: “Clubs are closed”, “There are less orders”, “No funds to purchase”. In particular, the closure of clubs was an obstacle for 3 respondents-PWUD who do not associate themselves with any KP; 1 SW and 1 client of female SW. The decrease in the number of PS/stimulant orders was indicated by 3 survey participants-PWUD who do not associate themselves with any KP; 1 SW and 1 MSM. Lack of funds was noted by 5 respondents-PWUD who do not associate themselves with any KP. Only 3 (3.0%) respondents from Odesa indicated that they did not consume NPS during quarantine. Moreover, almost a quarter of interviewed KP representatives (n = 45; 22.2%) added that they were looking for other ways to access the NPS during the quarantine period.

1.5.3. Other needs

Among the needs directly related to the use of PS, the participants of the focus group discussions listed the following: • Tests to identify quality of drugs – these shall help avoid harm caused by impurities in drugs and overdose:

- (K) "And as for what we need, it's probably tests to check quality of drug, to see if it's really the drug that was sold to you, or if it's really something that won't harm you." The issue of introducing drug quality tests requires adoption of relevant policies, because tests can be based on reagents which are precursors:

- (K) “I brought drug testing reagents from Poland, from a public organization, but then studied the legislation, and most of these reagents have [incomprehensible] acid in its pure form, which is a precursor to drugs. That is, if you test drugs, you are equated with the person who produces them. This is a very complex and comprehensive thing - the legislation". • rehabilitation services and facilities; • specialists who can provide help:

- (O) “There is a lack of specialists or people who are familiar with drug use. There are, for example, the NGO "Khvylia (Wave)", but they focus on heroin users, they are older people, ex-prisoners, they think completely differently and cannot help young people. I provide such consultations myself, but I never used "blotters", so I can't be useful and help". - (O) “There are, of course, trainings about chemsex and other things. There are no relevant specialists in the field of drug addiction, drugs, rehabilitation. Basically, rehabilitation includes only psychological support, I tell you from my experience. There are no state owned rehabs. There are some which are run by NGOs, and this is often isolation". - (O) “Self-help groups for the positive. It could be useful, but not for me, for others."

46 CHAPTER 1

The analysis of existing models and practices of using NPS/stimulants among TGA (taking into account experience, age, environment where substances are used, etc.) demonstrates that in practice there are no barriers to access NPS/stimulants for the KP. Even the artificially created restrictions in connection with the quarantine measures announced in Ukraine to prevent the spread of coronavirus (COVID-19) among the population of the country did not affect (with an exception of financial aspect) availability of NPS/stimulants. Therefore, in order to ensure greater coverage and involvement of the KP representatives in programs combating the spread of HIV/TB/HCV and other socially dangerous diseases, NGOs, community leaders, and volunteers should intensify their activities to implement: first, informational, educational and preventive work among the KP both in the hubs most frequently visited by the KP, and in Internet networks/online platforms (places where they communicate, exchange information, etc.); secondly, at work with the immediate contacts of KP representatives. Intensifying such activities can help involve the widest possible range of KP communities in prevention, treatment and motivation programs aimed at reducing cases of interruption of treatment for HIV/TB/HCV and other socially dangerous diseases. Separately, when asked about needs directly linked to the use of PS, the FGD participants voiced a need for availability of tests on quality of drug, which will help to avoid harm caused by impurities in drugs and overdose, as well as a need to fill the gap caused by the lack of specialists who can provide assistance, including rehabilitation services.

47

Chapter 2

Basic needs related to access to health services for representatives of the TGA

2.1. Use of health services by representatives of communities

In the course of the assessment participants of the baseline survey and FGD shared what they do to support own health, how often and with what purpose they visit medical facilities. 2.1.1. Visiting a medical facility, examination Analysis of answers to the question "Which medical facilities did you refer to in the last 12 months?" helps to reveal which medical facilities are most attended by the KP.

Fig. 2.1.1.1. Respondents' referral to the health care facilities in the last 12 months, %

49 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Almost half of the respondents (56.4%) usually receive medical services at clinics/centers of primary care, 16.1% of respondents referred to hospitals, whereas the AIDS centers are on the third place - only 13.5% of the interviewed KP representatives referred for services at the AIDS centers. Other (specialized) public health facilities are rarely visited by the respondents. In addition, respondents reported that during the last 12 months, they had visited medical facilities for prophylactic purposes, for examinations/tests or due to illness (for details, see below). Many FGD participants reported that they undergo medical examinations, they take it serious and do it on their own initiative: - (K) “I usually [have medical examination] when there is such an opportunity at the festival... - When mobile clinics are available. - Yes". - (K) “I do checks-ups because I am asked about my health. I do them on my initiative". Among the types of check-ups that respondents underwent in the last 12 months there were mainly blood tests, fluorography, X-rays, visits to a dentist and a psychiatrist, etc .: - (K) "Fluorography"; - (O) "Yes, fluorography"; - (O) "I also did fluorography, that's all"; - (K) "General blood test, some extended test too") - (K) "Dentist, therapist"; - (O) "I definitely visited a dentist"; - (K) "Surgeon"; - (O) "Surgeon"; - (O) "Infectious disease specialist, tests"; - (O) "Psychiatrist"; - (O) "ENT doctor"; - (O) "Ophthalmologist"; - (K) “Yes. To a surgeon, a dentist"; - (K) "Dentist, therapist, eye-sight correction"; - (K) "Yes, to a psychiatrist, a dentist"; - (K) “Endocrinologist. Tests. Ultrasound. Psychiatrist"; - (K) "Dentist, endocrinologist, neurologist, traumatologist, surgeon, ultrasound"; - (K) "X-ray, tomography, hormones"; - (K) "ENT doctor, tests". Among the main reasons for the medical examination, the FGD participants indicated the following: • On my own initiative (because of the habit to have regular examination, or because of existing or suspected diseases): - (K) “I had a suspected chronic bronchitis. I was often ill. And I went for a fluorography a little more than a year ago. I had various examinations. This usually happens when some symptoms occur and you want to check – so you go to a doctor. The doctor instructs you to do certain tests. Fluorography, X-rays or anything else"; - (K) "Psychiatrist, dentist. Because of insomnia, a problem with my tooth"; - (K) "Endocrinologist – tests for hormones. Ultrasound. A psychiatrist - just a talk”; - (O) “Yes, I took a test for syphilis in a private clinic. Reason: suspicion of syphilis";

50 CHAPTER 2

- (O) “To a private oncology clinic, to a rehab center. Reason: to fix health problems, mental problems. It didn't help much"; - (O) “Twice did MRI, there was a suspicion of encephalitis or onco. Did a prostatic smear test. Tests for syphilis, hepatitis"; - (O) “MRI, Doppler, X-rays on cervical spine, thyroid hormones. I had paranoia"; - (O) “I went to a venereology clinic. After a vacation in the Carpathians, I had some problems"; - (K) “To the dentist, therapist. Nothing unusual, I had a cold, and teeth. Everything was fine"; - (K) "With a cold, with allergy"; - (O) “I also visited a women's clinic, ultrasound. Probably because everything was fine with me, everything suited me, I visited, got the result"; - (O) "I did a fluorogram when I coughed for a long time, my mother sent me to a TB dispensary"; - (O) “My last visit was to a traumatologist. He is my old acquaintance, a good man. It was a trauma center in Shevchenko Park. A good man, he told me jokes when there was no anaesthesia"; - (O) “I took tests for HIV, for worms. I was in the polyclinic three years ago, in the narcology department, got there accidentally”; • "External" needs (for the military recruitment office, for admission to universities, employment, etc.): - (K) “It seems to me that quite often someone undergoes a medical examination. This can even be for such trivial purpose as getting a medical certificate, and so you just have a blood test for HIV. At least, so did a couple of my friends. - What year was it? – I did it just a month ago. Simply to get a medical certificate"; - (K) “I recently had an examination required for medical records (employer). A dentist, a gynaecologist"; - (O) “I did examination for my employer. A narcologist, a psychiatrist, fluorography"; - (O) “Eight months ago or so, when I applied for a job at the academy. Had a simple examination"; - (O) "Did it for employment"; - (O) "Recently visited a polyclinic No.14 to get documents for the military recruitment office, to get vaccinated and do fluorography"; - (O) “I visited because of military recruitment office and admission to the university. Reason: the need to obtain medical certificates"; - (O) “For the military recruitment office… It was a terrible experience. I quarrelled with them, I was very angry: the people behind me in a queue were the first to go to the doctor. I waited for an hour and a half for a piece of paper that could be issued in one minute"; - (O) “I remember there were medical check-ups just for formal “tick“. Fluorography"; - (O) “Fluorography. The rest – medical check-ups to “tick a box”; - (O) “Documents for LTEK (medical board which deals with certification of disabilities)“. In the questionnaire form the participants of the FGD listed different facilities to which they referred: - (K) «… Hospitals. - Ah, those where they lie in the wards. We do not refer". - (K) “Here! Mobile outpatient clinic. This was the one". - (K) "What about the last line - "Other" – can I write, for example: a dentist?" - (O) "Family doctor, routine examination". In their comments regarding the frequency of visits to medical facilities, respondents added: - (K) "Once a month"; - (K) “It depends. Whenever necessary"; - (K) "I appear to be visiting these offices all the time...";

51 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

- (K) "You touched on this topic, so interesting, I didn't think I referred often"; - (K) "We visit together with you constantly!"; - (K) "You see, I referred everywhere"; - (K) "I take an X-ray once a year… X-ray, in particular"; - (K) "I am examined every one and a half or every year - ultrasound"; - (K) "I try to be examined once every six months - once a year".

2.1.2. Testing

Getting tested for infectious diseases, on time, is of paramount importance for health of the KP representatives. The analysis of respondents' answers regarding testing for HIV, TB, VH, and STI demonstrates that there is a degree of indifference in the attitude of respondents to their own health. For the distribution of answers to these questions, see Table 2.1.2.1. Table 2.1.2.1. Distribution of respondents' answers regarding testing for HIV, TB, VH, STIs

Respondent's category PWUD who do Client Received Transgender not attribute All responses Sex worker MSM of female services person themselves to SW any KP N % N % N % N % N % N % HIV testing 5 3.0 15 9.0 1 0.6 40 24.1 2 1.2 63 38.0 Testing for 2 1.2 10 6.0 0 0 25 15.0 0 0 37 22.3 HCV, HBV Testing for STI 7 4.2 17 10.2 0 0 20 12.0 1 0.6 45 27.1 Testing for TB 2 1.2 5 3.0 0 0 14 8.4 0 0 21 12.6 Subtotal 16 9.6 47 28.3 1 0.6 99 59.6 3 1.8 166 100

First of all, it should be noted that only 166 respondents (79.4%) out of 209 respondents answered these questions. The rest (equal to almost a quarter of the total number of respondents) did not want to answer this question or did not want to be interviewed on this topic. From the cohort of those who answered this question, the following respondents confirmed that they referred for these services: - 99 respondents (59.6% of the total number of respondents who answered this question) from among those who are PWUD not attributing themselves to any KP; including 40 respondents (24.1%) who were tested for HIV, 25 (15.0%) - for HCV/HBV, 20 - for STIs (12.0%), and 14 - for TB (8.4%); - 44 respondents (or 9.6% of all respondents) from among MSM; out of these, only 15 respondents reported that they were tested for HIV, which is only 9.0% of the total number of MSM who participated in the survey; 10 respondents (6.0%) were tested for HCV/HBV, and 17 - for STIs (10.2%); 5 (3.0%) were tested for TB; - 16 respondents who are SW (9.6% of the total number of respondents), in particular: 5 (3.0%) respondents were tested for HIV, 7 – for STIs (4.2%), 2 – for HCV/HBV and TB, each (1.2%), respectively; - 3 respondents – clients of female SW (1.8%), including 2 respondents (1.2%) who were tested for HIV and 1 (0.6%) - for STIs; - 1 (0.6%) transgender person was tested for HIV.

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Respondents - participants of the FGD confirmed that: • they were tested for HIV and STIs this year (January-March 2020); and those tested in 2019 (or those who were not tested) want to do the test soon: - (O) "I did a test, on my initiative, for HIV, worms, all kinds of bacteria"; - (O) "I did for HIV"; - (O) "I had a test for HIV"; - (K) "I do not plan to [be tested] in the near future because three months have not elapsed since the previous test"; - (K) "I do not plan [to be tested] because I was tested recently"; - (O) “No, I don’t plan to. Just recently I had it (a test), and three months will not pass soon"; - (O) “I plan. Three months ago I did the test, and the "window" period is coming to an end"; - (O) “Yes, three months ago. I wanted to know if I got infected or not"; - (O) "Only did an HIV test a couple of times… I wish to know the test results every three months"; - (O) "Almost a year since the last test, I will probably do"; - (O) "I haven't been checked for five months, I'm going to do it"; - (O) "I will definitely do the test, after quarantine"; - (O) “There has been no opportunity over the last 12 months. I think I will do the test when I have the nearest opportunity"; • most respondents know the result of their HIV test: - (K) Express tests are available at the "Alliance" since recently. I know the results". The FGD participants also confirmed that they had been tested for both STIs and hepatitis, but to a lesser extent than for HIV: - (O) “I was tested for bacteria. Hepatitis B, C - no"; - (O) “I did the tests for woman health. I don't know if they include hepatitis, STIs"; - (O) "For hepatitis, if I'm not mistaken, I did not do, and for venereal infections - yes"; - (K) "Rapid tests"; - (K) "Both rapid tests and tests in a private laboratory"; - (K) "Yes, I did lots of tests"; - (K) "Yes, tests in Sinevo [private laboratory]"; - (K) "I did, including when illness was detected in one of the partners and he advised me to get examined"; - (K) "I am tested regularly"; - (O) “There was no need for that. I haven't done tests yet". Some participants had in their plans to get tested for hepatitis and STIs soon (also in connection with pre-exposure prophylaxis – see Section 2.2.3.): - (K) "I am going to do it again, both for my own confidence and because I participate in the PrEP program"; - (K) "Yes, on 20 April"; - (K) "I plan to do it in a month." The respondents also indicated that they were considering a possibility to do such tests soon:

53 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

- (O) “Unfortunately, I do not do these tests, but I really want to. Had no time for it and did not give a thought. It would be beneficial to do, of course". In addition, participants of the assessment shared their view on how often tests need to be done (some said they did not know the answer) and how often they were tested: - (O) "Every two months"; - (K) "Every three months"; - (O) "Regardless of the number of partners - once in every three months"; - (O) "Once every three months"; - (O) "Once every six months"; - (O) “I was tested for HIV and all infections. I try to get tested every six months"; - (K) "Once every six months"; - (K) "Optimal frequency - once in every three months, you can do it once in every six months, but not more, as there may be difficulties with treatment"; - (O) "At least twice a year" Respondents' choice of testing frequency depends on the following factors: • doctor's recommendation: - (K) "As per the doctor’s advice, I do once in every three months"; • depending on the test: - (K) “For HIV - every three months. For other infections - once in every six months, once a year, a full scale examination"; • period of seronegative window in the manifestation of HIV infection: - (O) "Once in every three months because this is the window period"; • casual sexual partners, work in the sex business: - (K) "I know people who, following the advice from a doctor, go once a month, they are working in the sex industry"; - (K) "If you have a lot of sex with different people - once a month. If (you have) a regular partner - once every three months"; - (K) "If one partner - once every three months, if different - once a month"; - (O) “It all depends on sexual activity. If the change of new partners is not very frequent, then every six months. With frequent change of partners - once every three months"; - (O) “If the behaviour was risky - once every three months. If not - once every six months. - (O) “It depends on sexual activity. If you do not have it, you can do once a year. If active, then once every three months"; • awareness of the possible risk of infection: - (K) “When there is a grand party, you need to be tested immediately. Especially on what manifests itself quickly: chlamydia, gonorrhoea, syphilis. HIV - once every three months"; - (O) “Depends on the contacts. I think in a month after sexual intercourse the test will show the true result"; • start/end of relationship with a partner: - (O) “I always get tested when I start a new relationship and finish. Examinations and tests". The FGD participants confirmed that they know where to get tested for HIV, STIs, hepatitis: - (K) "Just any dermal-venereal dispensary, I think";

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- (K) “In polyclinics you can [get tested for HIV]. - Rapid tests? - Yes. I was getting a medical certificate which was required to visit a swimming pool. However, maybe it's a certain clinic"; - (K) “I know, for example, that private clinics do not have the right to perform such tests… You will not be tested for HIV there. - I know, that's why I went to the AIDS center. - That's right. But in a [private clinic] you can do tests for sexually transmitted infections. - That's what I did." Some respondents have rapid tests at home: - (K) "Rapid tests are at home, I can do it any time"; - (K) “I have tests at home and I can test myself. Or when the "Alliance" will work, I can come there"; - (O) “I did not visit anything. I was tested at home, I do it regularly". The respondents reported that they use different opportunities for testing: • due to the influence of others: - (K) “I happened to have access to tests. I do it just for fun. I have a girlfriend who... informs teenagers about HIV. She has an unlimited number of all these tests. I can simply go to her office, just take it, not tell anyone about it, and do the test. I think I have such a great access. I don't even have to warn anyone that I did it. Simply did it. Just because I wanted to"; • in the mobile outpatient clinic: - (K) “I was last tested for hepatitis in Zaporizhzhia. There's this mobile thing... The booth was set up. - The mobile outpatient clinic"; - (O) “We have been tested at yoga training, quite recently. Blood was tested for HIV by rapid tests. That's why I'm not worried"; • during mass events: - (O) "Good practice: I was at the festival, and it was possible to test blood for HIV right there... It is very good that there is such a practice at festivals". The FGD participants reported that they get tested on their own initiative: - (K) "I went (testing) on my initiative"; - (K) "Did tests at my own discretion"; - (K) “I take HIV tests very regularly. It is often my decision"; - (O) “I try to take a regular HIV test. They offered it in the "Liga (League)". I knew in advance about this possibility and agreed. Began to do it regularly". The respondents named the following motives for their decision to test for HIV: • health problems: - (K) "The health situation can prompt you when something in the body is unclear..."; life situation, when, for example, it became known about the positive status of the previous sexual partner of the person with whom the respondent currently has sexual relations (including unprotected): - (K) "I had a situation where my casual sexual partner reported that he probably slept with a girl who had HIV, and that pushed me... I want to have the test done... - I apologize, did you have a safe sex with this partner? - No. - But you haven't taken the test yet" - No. - But will you go? - I'll go"; • request from relatives: - (O) “There was a situation when my mother urged me to get tested when I told her about a certain experience. And there was an unpleasant situation when I showed my mother a paper with the result that everything is fine. Then I realized the importance of this process (I was explained) and afterwards I did it not for my mother, but for myself";

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• sexual partner's request: - (K) "The first time when I took an HIV test, my partner asked me to do it, and after that I did it regularly"; • newly received information on testing (Internet, lecture): - (K) “I saw an advertisement on the Internet, I thought, why not do the test. I did it and now I do it regularly"; - (K) “I was tested for viral infections… There was a lecture on this subject, I attended it and decided that it should be done regularly. Not only for HIV, but also for any infections and hepatitis. Self-awareness came to me"; • example of friends who are regularly tested: - (K) “I have friends, close people who get tested regularly. I think they are conscious about it. And I also try to regularly [take the test] - once a year". The respondents analyzed their visits to the medical facility in terms of whether doctors offered them to be tested for HIV, STIs, hepatitis: • the doctor offered testing: - (K) “I had a dermatological disease. I was immediately told that I had to get tested for HIV, because such diseases often occur when the immune system is very weak. - That is, it was suggested by the medical personnel. - Yes. At dermatological-venereological dispensary"; - (K) “When I visited a gynaecologist, I was offered a test not for HIV, but for infections. Test for HIV was not offered"; - (O) "I was offered HIV testing at the hospital"; - (O) "Once I was offered, I did it, I realized that there was nothing special in it, and began to do the tests twice a year"; • testing was not offered: - (K) “I also visited a gynaecologist. But I was not offered. – Not for a single infection? - No. - So you just solved some of your women's issues there, and that's it? - Yes"; - (K) “I was never offered either. For HIV. When you visit a gynaecologist - I was never offered. For HIV, for any serious venereal diseases... - I was not offered either"; - (K) “They didn't offer (a test) for HIV… - Was it a state facility? - Yes… Not for HIV, but for viral infections they proposed… For hepatitis… But did you get tested? - Yes. - Did you get the result? - Yes"; - (K) “That is, if I get it right, those who did HIV tests, it was your personal decision, right? - Yes. - Or a decision made together with a partner. - Well, and with a partner, too"; - (K) "The medical staff never offered me to check my health in any way"; - (K) “It is very disappointing when you come to a clinic, for example, to a therapist, and the doctor never offers to take tests. It would be good to work at all-Ukrainian scale to raise their awareness and so they start doing it"; - (O) “It is bad when you go to a doctor, and they do not offer to take tests. I've been doing it on my own for the last year". Some respondents did not get tested, but are mentally ready for it: - (O) “I don’t have a sexual relationship. I don't inject anything. My behaviour is safe. I would like to get tested but not that I plan, it's something spontaneous. It is more likely to happen if it happens spontaneously”; - (O) “I am going to. Can I do it tomorrow? Can you tell me where? I'm ready to get tested during this week". The respondents reported not being tested for the following reasons: • did not think about it: - (O) "Didn't think about it";

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• regular sexual partner has been tested and has normal results: - (O) “I have had a stable relationship for five years. I didn't get tested for HIV, but she did. Everything is okay with her, so I am okay too. But it would be worth to get tested, really”; • fear of testing: - (K) “My husband, for example. He does not want to. He is afraid. For him, hepatitis is a ‘deep forest’ (something he cannot comprehend). He knows nothing. For him, hepatitis is like HIV”; - (O) “Fear. You live like an ordinary person… and suddenly! No, I'm not ready"; • lack of trust to those who administer the test: fear of getting a positive result which is done on purpose: - (O) “I was scared, and the queue was big. I thought that I don't have HIV, and what if they tell, on purpose, that I have it?”; • HIV-positive status: - (O) “No, because I have been HIV-positive for six years. I do not plan to get tested. I already know my status"; • no risks: - (O) “I have no reason to take the test. I don't plan to have it, I don't want to". However, some respondents shared about their lack of knowledge about testing: - (O) “Now… there is such a thing on Instagram, when you look at the list of infections on your head, and it just waves and then stops on some [infection] - you are infected. But I haven't heard of testing."

2.1.3. Treatment of diseases

One of the important components of the assessment which is aiming to determine the needs of the KP and barriers to access health services was exploration of issues related to treatment of diseases. In particular, the respondents' health problems were not discussed, but they were mentioned in the context of visiting a medical facility (see Section 2.1.1), talking about health issues with parents, friends and partners, receiving advice and assistance from them (see Section 5), as well as impact of PS on health. Thus, the respondents mentioned frequent cases when they referred to public health facilities for treatment of diseases. The distribution of respondents' answers regarding the treatment they received is presented in Fig. 2.1.3.1. and 2.1.3.2.:

Fig. 2.1.3.1. Distribution of respondents' answers regarding their treatment in public health facilities, %

57 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Fig. 2.1.3.2. Distribution of respondents' answers regarding their treatment, %, by city of residence

Thus, the analysis of responses shows that a quarter of respondents (26.0%) referred to medical facilities for HIV treatment, of which 19.2% are in Odesa and 6.8% in Kyiv; all respondents stated that they received this treatment in AIDS centers. The second most frequent reason for referral are surgical interventions and operations - 23.3%, of which 13.7% are in Odesa and 9.6% in Kyiv; 20.5% of respondents received related service at a hospital, 1.4% of respondents – at a polyclinic/center of primary care and maternity hospital, respectively. Hospitalization was required for 20.6% of respondents, including 12.3% in Kyiv and 8.3% in Odesa; Respondents were hospitalized to hospitals (16.40%), polyclinics/centers of primary care, TB dispensaries and maternity hospitals (1.4% respectively). STI treatment was received by 12.3% of respondents, including 8.2% in Kyiv and 4.1% in Odesa; 9,6% of respondents received medical care at dermatological and venereological dispensaries; at polyclinics/centers of primary care and at infectious diseases hospitals - 1.4% each. It should be noted that a fairly small percentage of respondents (KP) confirmed that they had received treatment for HCV and HBV (a total of 9.6%, including 4.1% in Kyiv and 5.5% in Odesa) and TB (5.4%, with 2.7% of respondents in each city). The smallest share of respondents indicated that they had got treatment at TB dispensaries and infectious diseases hospitals - 1.4% each, respectively. The FGD participants made additional remarks: for treatment purposes they pay great attention, in particular, to vitamins and dietary supplements; they consider this topic as relevant and often discuss it: - (K) “Are you discussing [dietary supplements]? Is it relevant? - Yes of course. This is very important. - Do you all use dietary supplements? Any vitamins too? - Every day I take at least 400 mg of magnesium. And calcium. Well, certain vitamins that may be a remedy for what may disturb those who take PS. – Do I understand correctly that you all attach great importance to supplementary nutrition, medical nutrition, vitamins? - Yes. - Is it correct, if I got it right, that your acquaintances also pay a lot of attention to this topic? Or it is only you who are so advanced? - Not necessarily"; - (K) “We are even… discussing new dietary supplements that help to get out of depressive situations. But overall, it seems to me that quite a few young people who are financially secure, are considering it. - Dietary supplements, vitamins? - Yes". The degree of satisfaction with the provided services is an important component of accessibility of medical services for the KP representatives. The analysis of the answers to this question is presented below.

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Fig. 2.1.3.3. The degree of satisfaction of respondents with treatment services, %

The general observation is that the degree of satisfaction with treatment services among the KP living in both cities, Kyiv and Odesa, does not differ much. In particular, 16.5% of respondents in Kyiv and 24.1% in Odesa are “fully satisfied” with such services, 27.2% from Kyiv and 18.4% from Odesa are “partially satisfied”, 2.5% of respondents from Kyiv and 4.4% from Odesa are “dissatisfied”. The smallest share of respondents (1.3% from Kyiv and 0.6% from Odesa) indicated that they were "completely dissatisfied" with the services received. Among the diseases they have now or had before, the participants mentioned in particular: • depression, anxiety: - (O) "I only recently realized that I have had depression for two years"; • hepatitis (in particular, in one of the FGD, eight out of ten participants indicated that they had hepatitis C (or B and C), and the rest, two participants, reported recovery from this disease): - (K) “I have had hepatitis C for 15 years. I contracted it in my first relationship. I knew that the person had hepatitis C. But somehow I did not know anything about this disease and was not particularly worried about it. Recently I have cured it fully, thank God. I feel completely different now. I am now trying to send all people for free treatment"; - (K) “I contracted hepatitis two years ago. Also through relationships. But I knew he had hepatitis. Before that, thank God, I didn't "pick it up". But here I deliberately did not protect myself... I was checked every six months"; • hepatitis and HIV infection: - (K) “I was infected – at the age of 18 or so. And the guy had HIV and hepatitis C. I didn't know about it, but he knew. We lived with him for half a year, and after he died, only then I learned that I was infected. There is both HIV and hepatitis C"; • diseases of bones and joints: - (K) “Trauma, let's say. Tendon. Some arthritis. It should not manifest at the age of 30-something, but it started. And the fluid between the joints, it started... Something is wrong"; • dental services: - (K) “Teeth should be checked. This costs money. - It's free, but I can't do it. - They don't cover dental implants but at least you can get treatment"; • respiratory diseases: - (K) “Check-ups of your lungs are mandatory. Phthisiatry. We are vulnerable because of our immune systems. Vulnerable to lung diseases, unfortunately. It’s true".

59 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

2.1.4. Refusal of medical services At present, the data received in this assessment on the practices of referral for medical services on own initiative of respondents show that the respondents have a rather poor awareness of the value ​​of their own health. The distribution of answers to questions about the reasons for not seeking medical services is shown in Fig. 2.1.4.1.

Fig. 2.1.4.1. Reasons for non-referral of respondents for medical services, % by categories

The vast majority of respondents do not seek medical services on their own, because they do not need them – this was reported by 57.1% (of which 24.2% are PWUD who do not attribute themselves to any KP, 21.2% - MSM; 12.1% - SW); others consider themselves healthy - this was stated by 23.4% of respondents (of which 12.1% - PWUD who do not attribute themselves to any KP; 7.7% - MSM; 2.2% - SW; 1.1% - clients of female SW). 14.3% of respondents practice self-medication (among them: 6.6% - are PWUD who do not attribute themselves to any KP; 4.4% - MSM; 2.2% - SW; 1.1% - clients of female SW). And the smallest share of respondents (5.2%) named high prices for medical services as a reason for non-referral. The respondents reported that in some cases they refused to receive medical services for the following reasons: • disbelief in the presence of the disease:

- (O) “I lied to myself for a long time that my problem was groundless. This was confirmed by people from my social circle. I felt sick because of depression, but I didn't go anywhere"; • hope that the disease will pass by itself:

- (O) “I also had a pain in coccyx for three months, it fractured. I thought that it would go away by itself"; • disbelief in treatment:

- (K) “It happened, and more than once. I had depression and physical problems, I did not go to the doctors because I thought they could not help me. This was almost fatal. It happened in December. I had a high fever, I overlooked double pneumonia. The consequences can be seen on fluorography";

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• fear of medical procedures:

- (O) "I did not go with my teeth: I did not want anaesthesia and incision"; • lack of funds:

- (K) "Most often - no money"; - (O) "I had a toothache and I didn't want to go because it was expensive"; - (K) "I'm a little worse off with money now, in better times I went either to Oxford Medical (clinic) or somewhere else"; - (O) "Complex tests are quite expensive, that is why I don’t visit"; - (O) “Lack of funds plays a big role. When it comes to colds, why go to the doctor if it goes away in any case? I’m saving"; • bad conditions in the institution:

- (O) “I did not get therapy for ten years. Arrived in Kryva Balka, got scared: there was such a stench. Came there with pneumonia. And I got scared, ran away and didn't take anything for ten years, until I got sick, I was hardly rescued and only then I started taking it. It was a long time ago. Now I do not object: whether you want it or not, you must take it. • inconvenient working hours of the medical institution:

- (O) “It often happens that there are certain days in state clinics for some tests, and these days are not good for me. I don’t go there". - (O) "It is impossible to go to get help, because the institutions are working at the same time when I work, I fail to coordinate". • drug use:

- (K) “When you take a drug. The drug is more important". - (O) "I did not go to the dentist because I got mashed and was not adequate at all". • other cases:

- (K) “For example, when I have no time. Or no money". - (K) "Or when you hurry to another place".

2.2. Awareness of respondents about the risks to their health and relevant medical services

In the framework of the assessment respondents were asked to discuss issues related, first of all, to their understanding of the risks to their own health associated with their use of drugs, NPS and stimulants; second, their awareness of the risks associated with drug use (in particular, injecting drug use and overdose); and, thirdly, personal motivation of respondents to protect their own health (including their involvement in prevention measures - participation in OST programs, pre-exposure prevention, medical care in case of overdose, drug dependency treatment).

2.2.1. Awareness of the risk of injecting drug use

When asked about the drugs used by respondents and their friends, some admitted to injecting drug use (see Section 1.1), while others emphasized their refusal to practice such form of drug use:

- (O) "All drugs in the world except injectables"; - (O) "All drugs except for those that are injected."

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In one of the FGDs in Odesa, participants reported that there were no injecting drug users among their friends, and explained that this method of use was outdated, unfashionable, and now they are more conscious of this:

- (O) I had an uncle, my mother's brother, my friend. He injected secretly. He is from another generation. He died. Now there is no fashion for it at all. It used to be glamorous. Now it is not fashionable to inject"; - (O) "Now the approach to it is more conscious, because there is more information"; - (O) “There used to be a lot. When I was 16, 18. It was eight years ago. I saw a lot of this, I had compassion for people. There were such people in my company, but I have nothing to do with this company anymore. I deliberately had to distance myself from these people". The respondents are aware that injecting drug users have a higher risk of infection:

- (K) “It seems to me that when you start, let's call it, "treat" [injecting drugs], after some big period of time you just lose your real self and you can ignore the issue: you just change the syringe, and so on. Of course, those who inject more, definitely"; - (K) “95% of injecting users suffer from hepatitis… Even if you inject a “bayan“ (syringe). You inject, wash it, save it at home. Then you take and fill it again, inject – and that’s all". Some respondents reported switching from injecting drugs to non-injecting drugs (possibly through harm reduction programs) and were satisfied with this fact and the changes in their lives:

- (O) “I take constantly. Now non-injecting drugs for several years. I work. I am glad that I can combine taking drugs with work, get a positive result and live normally in society, help society"; - (O) "I do not use drugs [injectable?], but I am very grateful that I get non-injectable".

2.2.2. Participation in OST programs

In the course of discussion the respondents indicated that they use opioid substitution therapy (OST) programs. At the same time, they are concerned about the situation around the OST program: the main problems are extortion by doctors, poor arrangements: - (O) "Narcology - it's awful. For an OST program to exist in Odesa, I have to provide all of Odesa with paper, on the site. In the context of coronavirus, all cities distribute substitution therapy for 10-15 days, and our doctor takes revenge: those who were on paid prescriptions, she returned all those to the site"; - (O) "My claims regarding the substitution therapy are linked to the fact that I’m on a paid basis. I ask for 100, not 90. Extortion is a usual practice. They (medical staff) can do 100 using one prescription. Constant extortion"; - (O) "Not everyone has the money to get paid therapy"; - (O) "In OST they torment people"; - (O) “Recently, representatives of three medical departments visited Odesa, and after they inspected narcologic facilities and OST, they gave specific recommendations to the city to which there was no response from the city. The city simply ignored all the recommendations on OST of the three agencies. The doctor at OST takes bribes, same as she did before"; - (O) "The OST program will be closed, and it’s only us who will suffer." The respondents reported being denied a referral to OST; the price to solve the issue - bribe: - (O) “Malynovsky narcology of Kyivskyi district refused to refer me to a narcologist for getting enrolled in OST. They demanded 200 hryvnias. It’s a common practice".

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2.2.3. Pre-exposure prophylaxis (PrEP)

Among the medical examinations that respondents underwent in the last 12 months, the PrEP was mentioned too:

- (K) “PrEP-examination. The will to receive pre-contact prevention".

The respondents demonstrated various level of awareness of pre-exposure prophylaxis (including HIV infection).

Many respondents said they did not know about PrEP:

- (O) "Never heard";

- (O) "We do not practice this";

- (O) "I have not heard of it";

- (O) "We have no information";

- (K) "I didn't get PrEP, I just didn't know about it before".

Some respondents heard about PrEP at the focus group discussion for the first time:

- (K) “No. It’s a first time I hear this. - So you hear it for the first time? - "Nobody offered".

Other participants confirmed that they know about PrEP:

- (O) "I know about PrEP";

- (O) "I heard about PrEP somewhere".

The participants who indicated that they knew about pre-exposure prophylaxis listed the following sources of information:

• from a narcologist at the AIDS center:

- (K) “When I was a social worker, I had a relationship with a guy who had HIV. I came to the narcologist at the AIDS center, and she advised me such a pill. Therapy. But I refused because I did not have anything with this guy";

• Internet (browsed it for information):

- (K) “I read about it in some article on the Internet. But no one told me";

- (O) “I read about PrEP on the Internet. Somewhere in "Europes" they practice it";

• friends and their professional activity:

- (K) "Some of my friends work in organizations that are also involved in prevention, so I heard from them what this thing is".

The respondents reported that they or their friends do PrEP:

- (K) “In my company everyone practices safer sex. Take PrEP";

- (K) "I take PrEP";

- (K) "Many of my friends switched to PrEP program, it saved them";

- (K) "Also my girlfriend and I take PrEP";

- (O) “In Odesa, in a clinic near the AIDS center. I am very pleased with the infectious disease doctors".

The respondents indicated that it is mandatory (and they do it on their own initiative) to be tested for HIV to receive PrEP:

- (K) "I was tested, and quite a lot, because the procedure for getting PrEP provides for this";

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- (K) “I did tests on my own. When taking PrEP - this is a procedure";

- (K) “I did tests six or seven times this year. At the "Alliance", in "Insa", - wherever I get PrEP. I do on my own initiative";

- (K) “I got tested at the "Alliance", in "Insa", also when I received PrEP. Doctors have never offered me such an opportunity, and I did it by myself";

- (K) “I did it on my own. Now I do it for PrEP".

As one of the reasons for taking the test in the near future, respondents indicated the need to comply with the PrEP schedule:

- (K) "Yes, because I will get PrEP again soon";

- (K) “I have it scheduled on 20 April. In connection with PrEP, I should be examined every three months, as my doctor advised me";

- (K) "I plan to take it in the near future, on 15 April I will receive PrEP and take an HIV test";

- (K) “I’m planning, for PrEP”;

- (K) "Yes, [I am going to get tested], for PrEP".

The respondents from Kyiv described their experience of receiving pre-contact prophylaxis in medical facilities and NGOs (medical office "Dovira" near "Livoberezhna" metro station, hospital No.5 near "Zhytomyrska" metro station, NGO " Alliance", private facilities):

- (K) "Medical office "Dovira" near the metro station "Livoberezhna". I am satisfied with the quality";

- (K) "I get PrEP near metro "Livoberezhna" in the medical office "Dovira". I am satisfied with the work of medical staff. I came, there were a lot of people, and they asked who is in line for PrEP. At first I was tested for HIV and was given PrEP without a need to wait in a queue”;

- (K) “I get PrEP. I saw this information on the Internet, wrote to the site, and specified that I was from a small town (I lived there at the time), they still haven't answered me. Prep.сom.ua. PrEP's problem is that it is available only in big regional centers and most people do not have access. Now I have found another opportunity and am getting PrEP, but the application I sent is still not responded. I am getting through the "Alliance", at the hospital No. 5 near metro "Zhytomyrska";

- (K) "Yes, I participate in the PrEP program by the clinical hospital No. 5 near "Zhytomyrska". Satisfied with everything";

- (K) "Yes, at the HIV prevention center near "Zhytomyrska". Initially through the "Alliance";

- (K) "I received PrEP – this was at the (AIDS?) Center";

- (K) “I am receiving it at the hospital No.5. All is well, except that there are long queues sometimes. Laboratory assistants disappear somewhere, and you have to look for them";

- (K) “PrEP is not very well organized. The hospital No.5 near "Sviatoshyno" (metro station), nurses go out to smoke, so they are absent for a long time, I complained to the chief doctor, and after that everything was normal. While receiving PrEP, there wasn’t a single time when I did not quarrel with them, because the procedure is poorly arranged. As always, there are pros and cons, but overall I am satisfied";

- (K) "The only prevention I received was PrEP. "Alliance";

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- (K) "Alliance" - PrEP, contraceptives and lubricants";

- (K) "Gay Alliance" – I am getting PrEP";

- (K) "Alliance" - PrEP;

- (K) “Yes, I do receive. At the private clinic "Jason and Jason". Satisfied with the services";

- (K) "I regularly refer to private clinics for PrEP and testing";

- (K) "[I refer] to the clinic where I receive PrEP. Everything is fine everywhere, because I go to private clinics, I pay money. I do not visit state clinics".

Some respondents indicated that they do not receive PrEP because:

• do not see the need for this:

- (K) "I did not receive prophylaxis, there was no need for it".

- (O) “No, I did not receive PrEP. I don't need it".

- (O) "I do not consider it necessary in the absence of sexual activity".

- (O) "It was unnecessary".

PrEP does not protect against hepatitis, so the risk remains:

- (O) "I didn't take PrEP because it doesn't protect against hepatitis, so the old-school is better, a condom".

2.2.4. Help in cases of overdose

Those respondents (n = 35; 16.7%) who answered that they used to have cases of overdose over the past 12 months due to the consumption of PS (see Section 1.4.) also commented on the assistance which is provided in such situations – for distribution of answers see Fig.2.2.4.1. below.

Fig. 2.2.4.1. Distribution of responses regarding assistance in cases of overdose of PS, %

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In most overdose cases, assistance was provided by friends - this was mentioned by almost half of those who answered this question (55.9%) while 17.1% of respondents received such assistance from business partners. A share of those who indicated assistance from casual acquaintances or employees of institutions where they experienced overdose is 11.4% of respondents for each of these groups. From sexual partners or health workers – 8.6% of respondents. Finally, for 2.9% - assistance from family members, and 2.9% - from NGO workers/volunteers or ambulance crew.

11.4% of respondents did not seek help at all (for the reasons for refusing medical care after an overdose, see below Section 2.2.5.).

The participants of the FGD reported that they often discuss overdose in their circle. They also said that they had helped with overdose or knew how andwith what means this could be done:

- (K) “We are discussing some guys we may see at parties. Young ones. Overdosed. Or we tell some about our experiences. We share. But again, yes, often, it seems to me, it is correct to talk about the dosage in a particular situation... For example when it’s something new...";

- (K) “My friend even taught me some medical technique. How to revive a person. - Assist? - Yes";

- (K) “I had a situation when a person had an overdose of a psychoactive substance. I needed to help the person get out of this state… The person was very sick. And then the next day, when we met with this person, I just said that, first of all, it is not worth to ever do it again. And secondly, told what to do specifically in this moment, if you feel that you have the first signs of it. Where to go. And in general, how to deal with it all. Because often people drink alcohol, meet someone, he/she suggests using PS. And people often don't realize, under the effect of intoxication, that it can be very bad when you mix alcohol and PS";

- (K) “I worked in the club and brought to life others at least three times. Once even ambulance arrived. - And you, did you have such states? - No, I didn't";

- (K) “I didn't have the experience of reviving someone, but I had one moment when you are kind of drunk and your ‘brakes are already weakened’ and sometimes afterwards you don't even remember what you took and how much. I had a couple of bad times, without calling for ambulance, thank God, that is... – Did you recover from this state without external assistance? - Yes. – Or anyone helped you? - My friend took me home, I went to bed";

- (K) “I had three or four times in the past year when I revived someone. Kind of acquaintances. The third time - just a stranger at a party. He fell on me and my girlfriend. I had to help him get up. I told the guards, I told everyone. I did not find his friends. The first thing we checked - whether he was breathing, and water was given immediately. The pulse was checked. Then, as he is slowly comes to his senses, you try to get information from him: what he consumed, and then everything depends on that…».

The respondents are aware of the drugs used to recover from overdose:

- (K) "If it’s opiates, then naloxone. But this is not always the opiates";

- (K) "I know that psychedelic trips (I don't remember their names exactly) can be stopped with an antipsychotic".

Among other recipes, the FGD participants also mentioned methods which were not medically proved:

- (K) "Then I know ... There are such things ... I don't know how medically correct it is: if you overdosed of stimulants, you have to smoke and it will make you cut off and you fall asleep... – So a deep sleep is what helps? - It just makes it easier".

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2.2.5. Treatment of drug addiction

The analysis of the responses showed that a significant proportion of respondents did not undergo treatment for drug addiction - the answers are presented in Table 2.2.5.1. Table 2.2.5.1.

Distribution of answers regarding treatment for drug addiction

HAVE YOU EVER RECEIVED A COMPLETE COURSE OF TREATMENT FOR DRUG ADDICTION IN A MEDICAL FACILITY? Total Yes, I did a Only I refused to Difficult to complete No, I did not partially get treatment answer course

N % N % N % N % N % N %

Sex worker 1 0.5 2 1.0 28 13.4 1 0.5 2 1.0 34 14.7

MSM 0 0.0 2 1.0 58 27.8 1 0.5 1 0.5 62 26.8

Transgender person 0 0.0 0 0.0 2 1.0 0 0, 0 0.0 2 0.9

PWUD who do not attribute themselves to 33 15.8 12 5.7 80 38.3 1 0.5 1 0.5 127 55.0 any KP Respondent's Respondent's category

Client of female SW 3 1.4 1 0.5 1 0.5 1 0.5 0 0.0 6 2.6

Subtotal 37* 100 17* 100 169* 100 4* 100 4* 100 231* 100

* because the respondents had the opportunity to choose several answers when choosing a certain category to which they belong, the numbers correspond to the answers given in relation to the respective question

18-24 years 1 0.5 0 0.0 49 23.4 0 0.0 1 0.5 51 24.4

25-29 years 1 0.5 1 0.5 47 22.5 1 0.5 0 0.0 50 24.0

30-34 years 4 1.9 7 3.4 26 12.4 0 0.0 1 0.5 38 18.2 Age 35-39 years 11 5.3 4 1.9 20 9.6 0 0.0 1 0.5 36 17.2

40-59 years 17 8.2 4 1.9 11 5.3 2 1.0 0 0.0 34 16.3

Subtotal 34 16.4 16 7.7 153 72.2 3 1.5 3 1.5 209 100

The respondents stated that most of them (n = 153; 72.2%) did not undergo drug treatment, only 34 (16.4%) out of the total number of respondents have completed such course, 16 (7.7%) - completed partially and 3 (1.5%) respondents refused to get treatment.

The share of those respondents who have experienced overdose from NPS in the last 12 months is given special attention (see Section 1.4.). In particular, the difference between the answers of the respondents who answered "Yes" and "No" to the question "Did you refer to the public health facilities after a case of PS overdose for a course of treatment for drug addiction?" – the responses were 11.0% versus 89.0% (see Fig. 2.2.5.1.)

67 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Fig. 2.2.5.1. Distribution of answers regarding respondents' referring after the PS overdose incident to the public health facilities for treatment of drug addiction, %

A separate analysis of the answers of respondents from the group of those who answered "No" to the previous question (89.0%) allow us to detect quite different reasons why these respondents did not refer to the public health facilities after in the last 12 months, to get drug treatment.

The distribution of answers to this question is presented in Fig. 2.2.5.2.:

Fig. 2.2.5.2. Reasons for non-referral to the public health facilities after an overdose case, to undergo treatment for drug addiction, % by age

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As shown, a significant portion of respondents (27.8% of respondents representing the youngest age group "18-24 years"; 5.6% of respondents from the age groups "25-29 years" and "40-59 years"; 2.8% of the groups "30-34 years" and "35-39 years") indicated that they do not want others to know that they are PWUD. For a number of respondents it was difficult to answer this question: 25% of the age group "18-24 years"; 13.9% - groups "40-49 years"; 11.1% - "25-29 years"; 5.6% - "30-34 years"; 2.8% - "35-39 years". Only in one category, of the youngest - "18-24 years", distrust of medical workers was indicated and 11.1% of respondents mentioned it. Unwillingness to be treated was noted in almost all age categories, except for the older "40-45 years": 16.7% - "24-29 years"; 8.3% - "18-24 years"; 2.8% each in the age groups "30-34 years" and "35-39 years". The smallest cohort of respondents (2.8% of the age group "30-34 years") found it difficult to answer. At the same time, the assessment shows that the distribution of the same response by category of the KP is somewhat different - see Fig. 2.2.5.3:

Fig. 2.2.5.3. Reasons for non-referral to the public health facilities after an overdose case, to undergo treatment for drug addiction, % by category

Responses from the largest respondents group, MSM, whose representatives practice chemsex, revealed the following: 12.4% of respondents do not want anyone to know that they use drugs; 10.4% said they did not seek help because they were getting better; 6.7% - were not going to undergo treatment; 4.5% of respondents did not have funds for treatment and do not trust doctors; 2.2% - do not want anyone to know that they are associated with the KP; and 1.1% found it difficult to answer.

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The SW's answers to this question were distributed as follows: 11.2% do not want anyone to know that they use PS; 6.7% refused help because they got better; 5.6% - did not have funds for treatment; 4.5% - were not going to get treatment; 3.4% - do not trust doctors; 2.2% - do not want anyone to know that they are associated with the KP. Among those who are PWUD who do not attribute themselves to any KP, refusals of medical care were for the following reasons: 9.0% - got better; 3.4% - were not going to be treated; - reluctance of revealing that the respondent is taking PS and lack of funds - 2.2%, each; 1.1% - reluctance of someone to learn that they are associated with the KP. The respondents from the represented categories (transgender people and clients of female SW) among the reasons for refusing treatment after an overdose indicated that they did not seek medical care because either they got better, or they did not plan to get treatment - 1.1% each,.

2.3. Sources of information on HIV/STIs/hepatitis, medical and social services

The respondents informed about sources and level of detail of the information that they receive on the issues that are the subject of this assessment: how clear the information is, whether it catches attention, whether it meets the purpose, whether it was appropriate for the site where it was posted/placed, and so on. The most interesting for respondents (in the context of topics for the FGD) is information about: • safer (in some respects) drugs: - (O) “For me - about pills. What, if you have AIDS, you can take before sex"; • organizing leisure in a club (possibly drug-free): - (O) "Alternative ways to spend your time in a club"; • opportunities to receive free assistance and services: - (O) “I would like to know where you can get psychological help. It is useful for myself but also to share with others"; - (O) "Information where it is safe to take tests. For free, preferably. Guys with risky behaviour have no money"; - (O) “It is interesting to learn about all the services provided by the state in the framework of our conversation. It will improve my life and the lives of my friends. I think there is a lot of cool stuff, but I don't know about it. For example, free condoms". The respondents confirmed that most of the social advertising they saw was related to HIV/AIDS prevention, and similar information about STIs never pops up. Sources of information are: • mutual exchange of information: - (K) "There is such a thing - a phone call. We call each other, and all the information comes"; - (K) "My friend shares"; - (O) "I provide it myself"; - (O) "I received (information) and so I know, and I inform others". The respondents called "sarafan radio" (informal spreading of news) as one of the most effective sources of information. The reason is that peer-to-peer exchange is a more trusted channel for them than information from a specialist who has no experience of drug use: - (K) “What are the most effective methods of sharing information? - "Sarafan radio". - And who can be the source of this information? - We are. - And employees of non-governmental organizations. Guys who work using the approach "peer-to-peer". They understand what they are informing about. When I talked to a narcologist, at the beginning of my drug career, I thought, how can a person understand my problems if he/she doesn't use (drugs), doesn't feel what I feel? That's why mistrust"; • outdoor advertising:

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- (K) “Well, outdoor advertising. Most often"; - (K) “Yes. Visual advertisements"; - (O) "In Odesa now the fight against HIV is intensive, even billboards are shouting about it", • Internet, social networks: - (K) "There were many events, also on Facebook, with talks about it"; - (K) "Today Facebook bought Instagram, and most of advertisements I get from there… Social networks"; - (K) We tell each other or write to "Butterfly" [information project of harm reduction], "Podorozhnyk" [online magazine of the Mykolaiv local charitable fund "Unitus"]; - (K) "On the Internet about ST ..."; - (O) "I receive regular mailings"; - (O) "On the Internet"; • At work: - (O) "At work they tell… but it's about hepatitis"; • "Hotlines": - (K) "There is a hotline if any questions"; • public organizations (through websites, events, lectures - for more see Section 4.2.1): - (K) "Last summer there were quite a few events held by NGOs"; - (K) "Non-governmental organizations..."; - (O) "From the "League" and from various public entities, mass media"; - (O) "From the "League", on the Internet"; - (O) "From an employee of the "League" and from a doctor whom I know. It was professional"; - (O) "Lectures in the "League". Groups. On the Internet I come across the public announcements from "Insight"; - (O) "I learned lots of interesting information about HIV from the "League" employee". • medical workers: - (K) “Private clinic. Doctor, laboratory assistant". The respondents analyzed how information with a focus on prevention is spread in clubs - places of their leisure. In their opinion, there is not enough information, and only some clubs treat the issue of prevention with responsibility: - (K) “I think it would be nice if the clubs had a board or at least some printed materials with a mixture of information. - Is there no such thing in clubs? - No. - Absolutely nothing? - We have one club where they are very responsible, up to the fact that there are booklets about how different PS affect the body, and what dosages... - Condoms are distributed... - Yes. And there is also information about all this. But, unfortunately, most clubs are not particularly worried about it. In fact, it's very easy to organize"; - (K) “It's not easy, because the people who run these clubs are trying to protect themselves from it. Because, I think, the police work very tough here. And in general, we have a very narcophobic society in Ukraine". When providing examples of bad practices of awareness raising, the respondents pointed out that such information did not contain useful data, prevention issues were not presented by a well-known person: - (K) “I can't even mention any publication, any name. There was something. As a rule, these are negative emotions. A famous person who is absolutely unrelated to this topic for some reason connects with AIDS. I remember that there may be a famous musician who was engaged for this. And I do not remember any useful information. No short phone number I can call. No names of organizations. That is, I saw, heard, can recall. But it did not give me anything useful"; - (O) "In the format of consultations, booklets. A little dull. Hardly useful. Once again, it’s mostly a reminder, that's all".

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The FGD participants pointed out that schools are the least conducive to the effective dissemination of information: - (O) “Time is such that the way we were brought up, it does not work. Everything happens very quickly. Education needs to change, the school is traumatising. Schools can play a role in disseminating information”; - (O) “There is no education process in schools or universities now. It's just a social school that teaches interaction with others. But you do not receive knowledge as such, because you do self-education"; - (O) “If we talk about it in schools, it should not be in the format of lectures. Some interactive stuff is needed. I remember when a narcologist or someone else comes to school, it's a great reason to skip lessons". Good examples of information sharing, according to the respondents, which they have already seen or which should be introduced, are: • interesting format, good quality, focus on achieving the goal of information sharing: - (K) "I also saw advertising in the subway and all that. The most interesting content for me was a video, of quite high quality, on YouTube, they recorded it. Two women, they told about their experience, one of them was born with HIV, her mother transmitted HIV to her, and the other was a sex worker. It was all filmed quite professionally. I was curious to see. This is the content that helps people, if they watch it, somehow cope with stereotypes”; • focus on target audience: - (K) "Targeting needs to be well done"; - (K) “It is important that the material is tailored for the target audience. That is, if it is a resource for young people or for people who are interested in music, it should not be simply a kind of: "go, do the test". Give them interesting information to read"; - (O) "Targeted advertising on social networks. Everyone is staying there now"; • games, interactive formats: - (K) “I recently engaged with one project where you come and immediately take a test: you check if you can get infected or not, whether you are at risk or not. Such a format, a game, helps to reveal many facts related to stigmatization. – Does it make you interested? In this format? - Yes"; Awareness raising at large events, in clubs (because this format of leisure is preferred by drug users): - (O) “Events with a large cultural layer. For example, parties where information sharing can be organised"; - (O) “Festivals and concerts are the best place. Art and drugs are close. Expands consciousness, more sensitive to the world"; - (O) "These people [drug users] can be everywhere, but you can meet them at certain mass events"; - (O) “This topic is very relevant at electronic festivals. Now there is a risk group - boys 16-20 years old. They can be junkies for a while and then get back to normal life, or they may get stuck in it. That’s why it is important to show them that there are options. Talk about safe use: "It is not recommended to use drugs at all, but if you already use it, do it right", "Single use stuff", "Do not sniff using a banknote"; • peer-to-peer communication: - (O) "Something where you can take part, talk to people who have encountered these problems"; • new information: - (O) “I know everything. May be trainings were useful, I learned something new". According to the respondents, an important component of information dissemination is when it is combined with testing, which allows to receive the service "right now" and "without queuing", which is relevant for young people: - (O) “It is important not just to tell people “come visit us, it is not expensive”. Don't leave a choice for a person, make it immediately. Make it as accessible as possible at festivals, parties and without queuing"; - (O) "If you give lectures "About it", you can also test people right away. You need to incline people to some actions, because seems like everyone is aware"; - (O) “Brochures are great, but everyone already knows that there is such a tool. But you need to make your own decision, go somewhere. When decisions are made for you, it's great!”

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Thus, the analysis of the basic needs related to availability of medical services for the KP representatives allows us to conclude that most of TGA are not only sufficiently aware of the possibilities of referring to health care facilities, but also have a good understanding which medical institutions/departments they need to approach depending on what medical care is required. At the same time, the results of the assessment show that certain awareness of the available opportunities has little effect on the coverage of the KP by health services, and hence on the effectiveness of their treatment. Overall, in the last 12 months: a) only 79.4% (or 3/4) of the respondents were tested for HIV/TB/HCV and HCV/STIs or other socially dangerous diseases. In particular, among the main triggers that motivated respondents for testing are factors such as: health issues, difficult situation in life (e.g., revealing positive status of a sexual partner), requests from relatives or sexual partner, receiving information about testing (from Internet or after attending a lecture), an example of friends who are regularly tested; b) only a quarter of respondents (26.0%) referred to medical institutions for HIV treatment; for treatment of STIs - 12.3%; HCV and/or HBV - 9.6%; TB - 5.4%; c) only 11.0% of those who had a case of overdose of PS referred to public medical facilities for drug treatment; but in majority of such cases (55.9%) assistance was provided by people who were close, and only 2.9% received care from ambulance crews. Among the main reasons for not seeking medical services the following were identified: - participants in the basic survey: no need for these services (57.1%), 23.4% of respondents consider themselves healthy, 14.3% of respondents practice self-medication; the smallest share of respondents (5.2%) noted "high prices for medical services"; - the FG participants: disbelief in the presence of the disease, hope that the disease will pass by itself, disbelief in treatment, fear of medical interventions, lack of funds, poor conditions in the facility, inconvenient working hours of the institution, drug use by the respondent, occupation with other personal matters. Moreover, 89% of respondents who had experience of overdose (n = 35) indicated the following reasons why they did not refer to the public health facility after drug overdose for a course of treatment for drug addiction: - reluctance to let someone know that they are using drugs (12.4% of the MSM group; 11.2% of SW; 2.2% of the PWUD who do not attribute themselves to any KP); - the condition improved – the respondent got better (10.4% of the interviewed MSM; 9% of the PWUD who do not attribute themselves to any KP; 6.7% of SW; 1.1% of TG and clients of female SW, respectively; - reluctance to let anyone know about their belonging to the KP (2.2% of MSM and SW, respectively; 1.1% of the PWUD who do not attribute themselves to any KP); - were not going to undergo treatment (6.7% of MSM; 4.5% of SW; 3.4% of the PWUD who do not attribute themselves to any KP; 1.1% of TG); - lack of trust to medical staff (4.5% of MSM; 3.4% of SW); - lack of funds for treatment (4.5% of MSM; 5.6% of SW) etc. In each category of answers, there are answers which emphasize the issue of high prices for medical services or inability of respondents to pay for these services. This data indicates that respondents are unaware that these medical services are provided for free. These results confirm the need to intensify targeted interventions to raise the KP’s understanding of the value of their own health. With regard to the opinions expressed by the respondents (where they identified that the most effective methods to influence/present information for them are "sarafan radio", outdoor advertising, Internet and social networks, "hotlines", health workers, NGOs, communication "peer-to-peer”, etc.), it is deemed necessary to scale up such activities, taking into account the needs and capabilities of the target audience.

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Basic needs related to availability of social services for representatives of the TGA

In the course of this pilot assessment, the main needs related to availability of social services for representatives of the TGA were explored. The information was obtained from two sources: sociological survey (online) and focus groups.

3.1. Awareness of respondents about social services

As part of the survey, respondents answered a question: “Have you or your loved ones been offered the following services in the last 12 months? Did you get them?” The distribution of answers to this question is given in Table 3.1.1. Table 3.1.1. Distribution of respondents' answers about the possibility of receiving social services, abs.value and %

Were offered * Received * Services Total, abs. % Total, abs.value value Total Male Female Get booklets/leaflets/brochures with information about the 17 82 39 36 30 spread of diseases: HIV, TB, HBV, HCV, STIs Rapid HIV/AIDS testing 15 79 38 39 34 Get free condoms and/or lubricants 17 78 37 39 34 Individual counseling by NGO employees (psychologists, 17 64 31 31 19 social workers, lawyers) HCV and/or HBV testing 11 54 26 26 19 Attend lectures/training on disease prevention: HIV, TB, 23 53 25 24 30 HBV, HCV, STIs Free wet wipes 4 38 18 12 33 STI testing 6 32 15 16 14 Individual counseling by medical workers of NGOs 21 24 20 12 11 (infectious disease specialist, narcologist, gynaecologist, etc.) Enrollment in self-aid groups 8 19 9 6 16 Consultations on first aid in case of drug overdose 0 18 9 6 16

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Humanitarian aid 0 13 7 6 8 (clothing, footwear, food kits, medicines, etc.) Free antiseptics 0 11 5 9 14 Counseling for families by NGO employees 6 10 5 6 6 (psychologists, social workers, lawyers) Social support 8 9 4 6 5 Assistance with employment 1 4 2 3 0 Assistance with issuance/recovery of documents 3 2 1 1 0 Other services 0 2 1 1 0 * respondents had the opportunity to choose several answers

Distribution of answers in the Table 3.1.1. shows that all 209 respondents (100%) received these services, while some of them received several services, as evidenced by the total count of services received - 592. The conclusion is that respondents are quite familiar with different types of services. However, the distribution of answers to the questions in the Table 3.1.1. revealed some inaccuracies in understanding of the questions, and as a result the share of those who have actually received services is much higher than the share of those who were offered services. For example, 17 respondents were offered to receive booklets/leaflets/brochures about the spread of HIV, TB, HBV, HCV, STIs, while 82 respondents received them; humanitarian aid was not offered to anyone, but 13 respondents received it; none was offered consultations on first aid in case of drug overdose but 18 respondents received them. Event analysis showed that the most popular types of services were "Receiving booklets/leaflets/brochures about the spread of diseases: HIV, TB, HBV, HCV, STIs" - 39%; "Rapid HIV/AIDS testing" - 38%; "Getting free condoms and/or lubricants" - 37%. The second largest group of services includes "Individual counseling by NGO employees (psychologists, social workers, lawyers)" - 30%; "Testing for HCV and/or HBV" - 26%; "Lectures/training on disease prevention: HIV, TB, HBV, HCV, STIs" - 25%. The third group - "Free wet wipes" - 18%; "STI testing"- 15%; "Individual counseling by medical workers of NGOs (infectious disease specialist, narcologist, gynaecologist, etc.)" - 11%. Less than 9% of respondents received other services. When sorting the data by gender, some differences can be noticed but they are mostly within the range of statistical uncertainty. Only some of the services have distinct differences related to gender of the respondents. For example, female respondents receive the services "Consultations on first aid in case of drug overdose" and "Enrollment in self- aid groups" 2.8 times more than men; women receive more "Free Wet Wipes" (2.8 times). Men get more "Individual counseling by NGO employees (psychologists, social workers, lawyers)" (1.6 times more than women). The FGD also disclosed some inconsistencies in respondents' awareness of social services. The FGD participants showed a low level of understanding of the essence of social services, in particular, the respondents stated that they "do not know what social services are", "do not know what is social and psychological support, social counseling, peer-to- peer counseling". • do not know what social services are: - (K) “I did not refer by myself, but I know, let's say, my friends are helping the homeless people. And they periodically send them to the social care center. They collect money, pay for them to spend the night there”; • do not know what is social and psychological support, social counseling, in particular "peer-to-peer"; but know the terms "psychologist", "lawyer", "group activities", "social support", "individual and group work", and still do not use them.

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On the other hand, respondents mostly know which organizations provide social assistance: public organizations (including the one where the FGD was conducted), state "hotlines" for psychological assistance: - (O) “I don't know about all of them, but I've heard about some. There are centers where you can get free condoms, I know a couple of sites. I don't know the name"; - (O) “I know that there are psychologists for free. Anonymous meetings of drug addicts, organized by addicts to help each other. Almost everything is done by the church, but these are not church-related organizations. There is some church stuff. I went once, I was curious. My friend has been attending these meetings for many years. I came to support. "Addicts Anonymous" is its name, it is where the City Garden is. This is an international organization. Exists all over the world"; - (O) “I don't know where to come to. I need to get to know, maybe I'll visit something". In addition, the FGD participants received some social services over the past 12 months. In the list of those services some are rather related to medical services (such as testing), however they may have complemented the social services provided to the respondent: • social communication and integration: - (K) “Discussions, social integration, playing games jointly, films. "Alliance", "Transgeneration"; - (K) "Alliance", "Insight". I attended lectures, various events"; - (O) "You can probably consider it a help that "League" sent me to the project and I even received some money for it. Nice and it was so unexpected"; - (K) “I referred (for support). Once when I asked for... a psychological crisis, I was in poor health. I applied for one program, went to the Netherlands for rehabilitation. Good experience. And secondly, - I come here periodically... I used to work in this organization a few years ago and I came here to support a group of transgender people"; • social prevention (awareness raising, providing protective means) and testing: - (K) "Yes, in the "Alliance". Received information, tests, answers to questions"; - (K) “Alliance". Testing, lubrication, condoms"; - (K) "Conversations with social workers"; - (O) "Yes, the "League". Consultations, condoms, lubricants"; • psychologist services: - (O) "Received the service of a psychologist in the "League". A very good psychologist"; - (O) "[Received] the advice of a psychologist"; - (O) "Received psychological assistance"; • assistance in case of violence: - (K) “I have some acquaintances who have referred. Usually, on issues of violence… I do not remember that there were cases in the past 12 months... As a rule, this topic is intensified before the holidays. After [holidays?] they refer". Analysis of the baseline survey responses to the question "Do you know who exactly provides social activities in your community?" shows that recipients of services are largely unaware of who provides services and conducts such activities in the community - almost a third of the total number of respondents (27%) chose the answer "difficult to answer"; 31% indicated that these services are provided by NGO staff/volunteers; 12% - by representatives of the community; 4% - by representatives of religious organizations. The distribution of answers to this question by category, gender and city is presented in the table below.

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Table 3.1.2. Distribution of answers about respondents' awareness of social service providers, abs.values

Kyiv

Male Female

Gender and category of respondents MSM MSM Sex worker Sex worker SW MSM and SW MSM and Transgender person Transgender Transgender person Transgender Clients of female SW of female Clients Clients of female SW of female Clients themselves to any KP any to themselves themselves to any KP any to themselves PWUD who attribute do not PWUD who attribute do not

Employees of social. 0 7 0 15 0 2 1 0 0 7 0 0 services NGO staff/volunteers 0 10 0 12 2 0 0 0 0 2 0 0

Representatives of the 0 5 0 5 1 0 0 0 0 2 0 0 community Representatives of 0 1 0 2 0 2 0 0 0 1 0 0 religious organizations Subtotal 0 23 0 23 3 4 1 0 0 12 0 0 Odesa Social workers 0 6 0 4 1 0 2 0 0 4 0 0 NGO staff/volunteers 0 20 0 13 0 0 0 0 0 6 0 0 Representatives of the 0 9 0 1 0 0 0 0 0 3 0 0 community Representatives of 0 2 0 0 0 0 0 0 0 0 0 0 religious organizations Subtotal 0 37 0 18 1 0 2 0 0 13 0 0 * respondents had the opportunity to choose several answers

Thus, the survey demonstrated that male SW do not know who is conducting events for them. Female SW, both in Kyiv and Odesa, interact with social workers. MSM and respondents who do not attribute themselves to any of the categories work with all social service entities, with no exception. The representatives of religious organizations are the exception as females from Odesa do not work with them. Male SW and MSM work in Kyiv with NGO staff/volunteers, while in Odesa they mostly work with social services. Social services and religious organizations work with clients of female SW in Kyiv. In Odesa, respondents reported that they did not know the organizations that work with clients of female SW. Such low awareness of the respondents could primarily be attributed to the fact that, without exception, all respondents among the clients of female SW have never been clients of service NGOs and have not received social services from them. Among NGOs where respondents received services, the following organizations were mentioned: "Volna (Wave)" (10%), "Doroha do Domu (Way Home)" (6%), "Alliance" (6%), «Drop in Center» (3%), "Convictus" (3%), "Eney Club" (2%), "Vona (She)" (2%),"100% Zhyttia (100% of Life)" (2%), "Vertical" (1%), "Motyliok (Butterfly)" (1%), "Insight" (1%), "Marsh Svobody (March of Freedom)" (1%), "LGBT Organizations" (1%), "Anonimni Narkomany

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(Addicts Anonymous)" (1%), "Zhinochi Perspektyvy (Women's Perspectives)" (1%), "Nadiia ta Dovira (Hope and Trust)" (1%), "Olena Pinchuk Foundation" (1%), "League" (1%)), "Partner" (1%), "Red Cross" (1%), "Mist (Bridge)" (1%) and others. But in this regard, it should be noted that most of the NGOs mentioned by the respondents, firstly, work directly with the KP of this survey, and secondly, they assisted in recruiting respondents and carried out successful work on compiling the sample. In addition, It was relevant to explore the respondents' awareness of how often such social events take place - see Fig. 3.1.1.

Fig. 3.1.1. Awareness of respondents about the frequency of social events, %

For almost half of the respondents (54.1%, of whom 33.0% are from Kyiv and 21.1% from Odesa) it was difficult to answer the above question, which indicates their poor awareness of this aspect. Among those who answered in the affirmative: 22.5% (7.2% from Kyiv and 15.3% from Odesa) said "weekly"; 8.7% (2.9% from Kyiv and 5.7% from Odesa) - "several times a month"; 4.3% (2.4% from Kyiv and 1.9% from Odesa) - "once a month"; 6.6% (equal for both cities - 3.3% each) - "at least once a month". And 3.8% of respondents (1.4% from Kyiv and 2.4% from Odesa) indicated that such events never take place. At the same time, the FGD participants pointed out that people really need more information about social services, and they suggested these ways to disseminate information about the services: • state institutions: - (O) “Lawyers. They must inform somehow. Those who are in state organizations"; • media: - (O) "The Press"; • mobile applications: - (O) “Smartphone application. In the Playmarket, as some organizations have done. There is an application on OST, where you can find out more, including legal issues. Very comfortable"; • brochures in accessible places: - (O) “For those who do not have access to the Internet, it is possible to distribute printed versions through public organizations. In the (state office) for social services - put brochures in an accessible place";

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- (O) “My mother has never taken these brochures before, but now that I am often ill, NGOs often distribute and she goes and picks them up. She can even tell someone else". The respondents from among the FGD participants confirmed that they know where to get information about institutions that provide social services: - (K) "No problem to find information"; - (K) "I can find information"; NGOs (including those they have already approached): - (K) "I will go to the "Alliance"; - (K) “I can find if needed. For example, in the "Alliance"; • various sources of information: friends, Internet, hotlines: - (K) "Hotlines that may advise where to go, Google"; - (K) "It is not a problem to find information on the Internet, ask friends or at my university in the department of social support". Some respondents reported not receiving social services in the last 12 months: - (O) “I haven't received it yet, although it's probably necessary, but I need to mentally prepare. So far, the only alternative for me is to communicate with friends who support me"; - (O) "Did not receive". Among the services received, the participants of the FGD recalled that they received a pension due to disability and unemployment benefits. They are not satisfied with the services due to the complex mechanism of getting them, lack of information, partially paid benefits (or small amounts): - (O) "Dissatisfied, they pay little money" (this and similar statements demonstrate that the respondents are not aware of the existing scales for social benefits; therefore, we believe that such answers characterize the respondents' dissatisfaction with the amount of benefits, and so they do not represent their assessment of the services received); - (O) "One can only find out post facto that, as it turns out, you were eligible for this and that"; - (O) “I wanted to get my pension increase, six months ago, because my acquaintance with the same disability was paid UAH 200 more. It took me almost three months to make them pay what I am entitled to, and I have succeeded"; - (O) "You have to be pushy to get anything"; - (O) "We don't even know what services they provide"; - (O) "I was in the hospital, collected payslips, and they did not fully reimburse the money to me, the City Council. It was a municipal program". According to some participants, they do not need social services. The participants of the FGD expressed the greatest interest in the services of psychological support (psychologist, psychotherapist, psychiatrist) and on legal issues. In addition, among the wishes of the participants was a proposal to promote the employment of people who have served a sentence "because of drugs", to reduce stigma and discrimination which they face while trying to get employed: - (K) “Work for drug addicts. I would open a factory where I would offer job opportunities to drug addicts… A girl returns from prison. She was a seamstress there. Once you are out from prison - please go work. Why? Because people still don't understand that if you were convicted of drugs and served time, then you are a normal woman and everything is fine with your head. No! They don’t employ you. What to do? Steal?".

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3.2. The need for social services

The results of the baseline survey in Kyiv and Odesa showed that among the most popular social services received by the KP representatives are: individual counseling by NGO employees (psychologists, social workers, lawyers) - this was noted by 30% of respondents; lectures/trainings on disease prevention: HIV, TB, HBV, HCV, STIs - 25%; enrollment in self-aid groups - 9%; family counseling by NGO employees (psychologists, social workers, lawyers) - 5%; social support - 4%; etc.

Respondents' answers to questions about the extent to which such social activities meet their needs or the needs of their loved ones showed the following results (see Figure 3.2.1):

Fig. 3.2.1. Distribution of answers: "To what extent do social activities meet your needs or the needs of your loved ones?", %

In general, the respondents provide a positive assessment of the quality of services: 50% (of which 24% "fully meet (the needs)" and 26% "partially meet") versus 1% "do not meet my needs".

Among the SW, the number of answers “fully meet” and “partially meet” is 7 out of 34 respondents; among MSM - 34 out of 62; among PS users who do not attribute themselves to any category - 69 out of 127.

The quality of the received services is assessed by the FGD participants as quite satisfactory:

- (O) "The quality is okay";

- (O) "The quality is quite normal".

3.2.1. The need for psychological services

Socio-psychological support and psychological services are among the priority components of the integrated support to the KP representatives; they are drivers motivating the KP to care about own health, practice prevention of HIV/TB/VH and other socially dangerous diseases in their environment.

The analysis of respondents' answers regarding the needs for and actually received psychological services is presented in Table 3.2.1.1 .:

81 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Table 3.2.1.1. Distribution of answers regarding availability of psychological services

Services

Individual counseling Family counseling by NGO employees All responses City Offered Offered and received Offered Offered and received N % N % N % N % N % Kyiv 6 7.4 23 28.4 1 6.3 1 6.3 31 32.0 Odesa 11 13.6 41 50.6 5 31.3 9 56.3 66 68.0 Subtotal 17 21.0 64 79.0 6 37.5 10 62.5 97 100.0

18-24 years 1 1.2 18 22.2 2 12.5 0 0 21 21.6

25-29 years 6 7.4 9 11.1 1 6.3 0 0 16 16.5

Age 30-34 years 4 4.9 10 12.3 0 0 2 12.5 16 16.5

35-39 years 2 2.5 10 12.3 1 6.3 6 37.5 19 19.6

40-59 years 4 4.9 17 21.0 2 12.5 2 12.5 25 25.8

Subtotal 17 21.0 64 79.0 6 37.5 10 62.5 97 100.0

The data show that, even in cases when clients were offered a certain service, they have not always received it. Less than half (n = 97; 46.4%) of all respondents stated that they were offered and received psychological services, including 31 respondent (32%) in Kyiv and 66 (68, 0%) in Odesa. In particular, 64 of them were offered and received individual counseling (or 79.0%, of which n = 23; 28.4% in Kyiv and n = 41; 50.6% in Odesa), and family counseling were offered and received by only 10 clients (or 62,%, of which n = 1; 6.3% in Kyiv and n = 9; 56.6% - in Odesa). The distribution of answers to this question by age shows that representatives of the youngest age group "18-24 years" (n = 21, 21.6%) and of the oldest "40-45 years" (n = 25, 24, 8%) turned to psychological services. Other age categories are presented almost evenly: "35-39 years" - 19.6%; "25-29 years" and "30-34 years" - 16.5% respectively. In addition, 19 respondents (5.5%) referred to the public health facilities for the services of a psychologist during the last 12 months, including 8 MSM (2.3%), 7 (2.0%) PWUD who do not attribute themselves to any KP, 3 SW (0.9%). Additionally, the following comments to open-ended questions were received from the baseline survey respondents: - (K) "I need but do not receive psychological services"; - (K) "Hypothetically I would not mind receiving psychological help"; - (O) "We do not need psychological help". Respondents indicated that they feel the need in services of a psychological specialist: - (K) "I don't know, I might wish to approach for it if there was some quality psychoanalysis or psychotherapist"; - (K) "I need help of psychologists"; - (K) "I also go to a psychotherapist"; - (K) “I visited a public therapist for a year and a half, but not in this country. And there, when I called to find out if a therapist is available, I was told that I had to wait two or three months. And then they called me, I think, three weeks later and said that the place was vacated and I could come try. As a result, it took a year and a half. But this is not in Ukraine"; - (K) “I have such a need. But it is, rather, also a psychotherapist, psychotherapy";

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- (K) “Once a week I want to go to a knowledgeable person to open my soul. Psychological help. Gender dysphoria caused me a conflict with a psychiatrist"; - (K) "I can (visit) a psychologist"; - (O) "Maybe a psychologist [can help], but I'm not ready for this step yet"; - (O) "I need a normal psychotherapist, for free"; - (O) “Psychologist. Maybe even a group meeting, not an individual one”. The problem in obtaining the services of these specialists is that the services of a psychotherapist are not for free: - (K) “Nobody provides such free services. - Why? And what about social services? There are free lawyers and free psychologists offering counseling. - I'm not interested in a psychologist. A psychotherapist would be needed”; - (K) "And when it comes to psychotherapy (I am undergoing a course of psychotherapy now), it is a long process. You attend for a year or two. No public organization will do this for free. Usually, I know, five visits are free, or six, and then you have to pay for everything…”; - (K) "Only in private clinics, from a psychotherapist. I didn't get the help I was counting on". The respondents approach professionals who provide paid services because: • do not feel comfortable to entrust their problems to representatives of public medicine: - (K) "[Psychotherapist] Private. And my psychiatrist is private too. I’m scared to trust them... The fact that the government knows about you... Maybe it can harm me somehow”; • they visit "their" specialists, whose services they are satisfied with: - (K) "But I just found my specialists"; - (K) “My experience is that I tried five people who didn't suit me. And I found my specialist and go to him (her). - Is this a private specialist? - Yes. – You are expected to pay every time you come? - Yes".

3.2.2. The need for legal services

Lack of competence in legal aspects is a fairly common problem for the KP. However, the analysis of the answers of the TGA regarding the possibility to use legal services shows that this remains out of the focus for the half of the respondents - see Table 3.2.2.1 .: Table 3.2.2.1. Distribution of answers about opportunities to receive legal services

Category PWUD who do not Sex- Transgender MSM attribute themselves to Worker person Total Services any KP Offered and Offered and Offered and Offered Offered Offered received received received N % N % N % N % N % N % N % Individual consultations by lawyers - employees of 3 3.7 13 15.9 28 34.1 1 1.2 2 2.4 35 42.7 82 100.0 NGOs Family counseling by lawyers - employees of 1 6.3 4 25.0 0 0.0 0 0.0 2 12.5 9 56.3 16 100.0 NGOs Subtotal 4 10.0 17 40.9 28 34.1 1 1.2 4 14.9 44 99 98 100.0

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Thus, almost half (n = 98; 46.9% of all respondents) indicated that they had the opportunity to receive legal services. In particular, among those who answered this question, these services were received by: 44 (99%) of PWUD who do not attribute themselves to any KP, 28 MSM (34.1%), 4 SW (10%), 1 (1,2 %) transgender person. In the open-ended questions of the questionnaire the participants of the baseline survey added the following comments regarding their needs for legal aid:

- (K) "I want to know my own rights"; - (K) "Legal aid as a guarantee of security in future"; - (O) "Legal aid is needed by a specific person in a specific situation." The FGD participants reconfirmed their wish to have access to legal services, but rather as a form of protection "just in case":

- (K) “It seems to me that I can say it is not necessary at the moment. But we live in such a time and in such a country that it may be needed at any time. Legal aid"; - (K) “It seems to me that the state cannot provide a really smart and free lawyer or attorney who can advise. - But do you need such services? - No. Well, in general, yes, probably... – Legal services... - Yes, yes, of course". - (K) “Require – I don’t require it at this moment. But to know that there is such an opportunity and that you can approach someone in a certain situation... Rely on someone... It would be very good"; - (K) “And it would be good to know your own rights. What the police have the right to do, what they don't have to do". - (K) "For example, how to write a statement (appeal) in my case". Other issues that required legal support where rather linked to professional activities of the respondents ("Copyright") rather than their medical and social needs.

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Thus, the results of the analysis of the basic needs for the availability of social services for the KP representatives showed certain diversity in the answers in this set of questions. On the one hand, all participants of the assessment, without exception, received different types of social services. In particular, in the field of combating the spread of HIV, most often respondents received information materials (39%), were tested by rapid HIV tests (38%), received free condoms and/or lubricants (37%), received individual counseling from NGOs (30%), were tested for HCV and/or HBV (26%) and STIs (15%), participated in lectures/trainings on HIV, TB, HBV, HCV, STIs (25%) etc. On the other hand, we observe poor awareness of respondents about: - who exactly delivers respective social activities targeting the KP (for 27% it was difficult to answer this question); - how often such events occur (for 54.1% it was difficult to answer this question). At the same time, half of the respondents gave a positive assessment of the quality of services received - 50% of the total number of respondents said that these services fully or partially meet the needs of clients. Such conflicting results indicate the need: - first, to ensure the provision of social services to the KP at a more professional level, and - second, to apply new, more accessible and acceptable to the key audience, methods of informing about social interventions and events and their providers. Dissemination of such information, for example, through Internet resources or telephone applications, will not only expand the network of recipients of social services related to HIV, but could also enhance the dissemination of information about providers of these services and opportunities to get such services.

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Problematic issues and obstacles in the access of the KP representatives and their close contacts to a range of services

The respondents shared quite different opinions regarding existing barriers to obtaining medical services bythe representatives of the KP. The distribution of respondents' answers regarding issues which complicate their referral for services is presented in Table 4.1.: Table 4.1. Distribution of answers regarding obstacles which prevent respondents from referral for services, %

Respondents' answers* % (of total) High tariffs for services 32 I do not want others to know that I am a user of PS 21 My work schedule overlaps with working hours of the facilities 20 Not satisfied with the quality of services 20 I don't like the attitude of specialists/staff 17 I spend a lot of time on transfers 16 I have no information about the available services 15 Working hours of the facilities are not convenient 13 The facility’s location is not convenient 12 Police raids at service sites 1 There are no obstacles 27 I do not receive any services 13 * respondents had the opportunity to choose several answers

27% responded "There are no obstacles", but for a third (32%) of respondents the main obstacle is "High tariffs for services" (such answers similarly to evidence in the Section 2 dedicated to reasons for non-referral for medical services, are proving that the respondents are poorly informed about the opportunities to receive services for free). It should also be noted that 73.2% of the respondents are not clients of service NGOs (see Section 4.2.1 below), and therefore are not aware of availability of free services, in particular those related to HIV). Every 5th respondent (20% -21%) mentioned such obstacles as reluctance to disclose to others the fact of using PS, overlap between own work schedule and working hours of the public health facility, dissatisfaction with the quality of services.

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Moreover, 17%, 16% and 15% of respondents chose he following answers as obstacles: “I do not like the attitude of specialists/staff”, "I spend a lot of time on transfers", "I have no information about the available services", respectively. The answer “Working hours of the facilities are not convenient” was chosen by 13% of the respondents, while 12% chose “The facility’s location is not convenient”. Only 1% selected "Police raids at service sites". The male SW and clients of female SW did not identify any obstacles. The distribution of the responses of the survey participants from among MSM and PS users who do not attribute themselves to any KP highlighted the obstacles they encountered in receiving services as indicated in Table 4.2.: Table 4.2. Distribution of answers to the question: "What obstacles did you face when receiving services?», Abs.value

Category and age of respondents PWUD who do not attribute themselves to MSM Respondents' answers * any KP Total Total 18-24 25-29 30-34 35-39 40-59 18-24 25-29 30-34 35-39 40-59 High tariffs for services 10 4 1 2 2 1 26 4 5 1 8 8 My work schedule overlaps with 12 5 4 2 0 1 14 4 3 2 3 2 working hours of the facilities Not satisfied with the quality of 9 6 2 1 0 0 15 3 3 2 1 6 services I do not like the attitude of 8 3 3 2 0 0 14 2 2 1 4 5 specialists / Staff Working hours of the facilities 12 6 3 1 1 1 7 2 1 0 3 1 are not convenient I spend a lot of time on transfers 10 4 2 3 1 0 8 1 1 1 4 1 I don't want others to know that 2 1 0 1 0 0 13 2 2 2 5 2 I am a user of PS The facility’s location is not 10 4 4 1 1 0 3 2 0 0 1 0 convenient I have no information about the 2 1 0 0 0 1 12 1 2 1 4 4 available services Police raids at service sites 0 0 0 0 0 0 2 0 0 1 1 0 There are no obstacles 14 3 6 3 1 1 28 0 8 10 7 3 I do not receive any services 10 2 4 4 0 0 7 1 2 1 3 0 Subtotal 99 39 29 20 6 5 149 22 29 22 44 32 * respondents had the opportunity to choose several answers

Thus, we observe that the main problems that complicate access of the KP representatives to the integrated medical and social services are high tariffs for services (please refer to our explanation, above), inconvenient work schedule of institutions, dissatisfaction with the quality of services, inconvenient location of the organization which requires much time or extra expenses for travel to the location, negative attitude of specialists/staff to the KP, reluctance of the respondents to disclose their use of PS/drugs to others, lack of information about available services, etc. At the same time, in the course of discussion of the same issue in the FGD, the participants raised some problematic issues related to the procedures for obtaining medical services and their quality, relations with governmental and non- governmental organizations, as well as criminal responsibility for using PS.

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4.1. Provision of assistance by medical personnel, quality of medical services

Within the framework of the assessment the respondents also informed of various situations when, in their opinion, health care professionals provided insufficient assistance.

4.1.1. Respondents' perception of readiness of health personnel to provide care

The distribution of respondents' answers regarding their experience of referring for medical services is presented in Fig. 4.1.1.1:

Fig. 4.1.1.1. Distribution of respondents' answers regarding their experience of referral for medical services, % of all

The analysis reveals that among those KP representatives who sought medical services in the last 12 months (two thirds of all respondents - 73.2%), the vast majority are PWUD who do not attribute themselves to any KP (43.3% of all); MSM - 17.3%; SW - 9.5%; clients of female SW - 2.2%; transgender person - 0.9%. The distribution of answers regarding most frequent referrals for medical consultations is given in the Table 4.1.1.1.: Table 4.1.1.1. Distribution of responses regarding referrals to medical specialists over the last year

Respondent's category PWUD who do All responses Transgender not attribute Clients of Medical consultations Sex worker MSM person themselves to female SW any KP N % N % N % N % N % N % Consultations with a family 8 2.3 23 6.7 2 0.6 51 14.8 2 0.6 86 25.0 doctor/therapist Consultations with a dentist 7 2.0 23 6.7 1 0.3 40 11.6 1 0.3 72 20.9 Consultations with a 4 1.2 12 3.5 1 0.3 10 3.0 0 0 27 7.8 dermatovenereologist

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Consultations with a 14 4.1 0 0 0 0 12 3.5 0 0 26 7.6 gynaecologist Consultations with a urologist 1 0.3 10 3.0 0 0 10 3.0 2 0.6 23 6.7 Consultations with a neurologist 3 0.9 11 3.2 1 0.3 8 2.3 0 0 23 6.7 Consultations with a surgeon 1 0.3 6 1.7 1 0.3 12 3.5 1 0.3 21 6.1 Consultations with a narcologist 2 0.6 3 0.6 0 0 9 2.6 0 0 14 4.1 Consultation with a phthisiologist 1 0.3 0 0 0 0 12 3.5 0 0 13 3.8 Consultations with a psychiatrist 0 , 0 5 1.5 1 0.3 6 1.7 0 0 12 3.5 Consultation with a proctologist 0 0 7 2.0 0 0 1 0.3 0 0 8 2.3 Subtotal 44* 12.8 108* 31.4 8* 2.3 178* 51.7 6* 1.7 344* 100 * respondents had the opportunity to choose several answers

Based on the respondents' answers it is possible to identify for which medical services the KP representatives referred during the last year. First of all, the respondents indicated that they sought advice from various medical professionals, in particular: - family doctor (n = 86; 25.0%; including 51 (14.8%) PWUD who do not attribute themselves to any KP; 23 (6.7%) are MSM; 8 (2.3%) are SW; 2 transgender persons and 2 clients of female SW; - dentist (n = 72; 20.9%; including 40 (11.6%) PWUD who do not attribute themselves to any KP; 23 (6.7%) of MSM; 7 (2.0%) of SW; 1 transgender person and 1 client of female SW (0.3% respectively); - dermatovenereologist (n = 27; 7.8%; 12 (3.5%) - MSM; 10 (3.0%) - PWUD who do not attribute themselves to any KP; 4 (1,2 %) - SW; 1 (0.3%) transgender person; - gynaecologist (n = 26; 7.6%; including 12 (3.5%) PWUD who do not attribute themselves to any KP; 14 (4.1%) SW. A smaller number of respondents consulted a urologist (n = 23; 6.7%), a neurologist (n = 23; 6.7%), a surgeon (n = 21; 6.1%), a narcologist (n = 14; 4.1), a phthisiologist (n = 13; 3.8%), a psychiatrist (n = 12; 3.5%), a proctologist (n = 8; 2.3%) and other specialists. At the same time, respondents from among the participants of the FGD shared about the cases when medical workers refused (at least initially) to provide care or provided it with certain reluctance: - (O) "Infectious Diseases Department. Two persons reacted inadequately. I went out through the back door, the securities convoyed me out. It's a mystery to me why. This happened in the hepato-center. They did not refuse me, they registered me for the visit but said: you will come in a year"; - (K) “I went to a psychiatrist because of gender dysphoria, in the city where I live. He sent me to a paediatrician, even though I was already 18 years old. They started laughing at me, and I just had to leave. I went to the city hospital in Kyiv. It was easier there. I wrote to a doctor in Viber". In addition, respondents listed the following reasons for refusing assistance: • non-availability of medications: - (O) “I was taken to the hospital, where they said they did not have the necessary drug. No help was provided. They said: once you find it - come again"; • extortion: - (O) “They demanded bribes, did not provide assistance. - I constantly face it. - It was like that"; • drug use by a person in need of assistance: - (K) “Once I was bringing to life a person in the club and the doctors arrived. It was not a direct refusal, but they were hostile, so to speak. They did not want to revive a person who had done harm to him/herself. - Why? Did they say

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so? - They said that "these stupid addicts, why do we waste our time on them?". - But did they help in the end? - As a result, they provided assistance, but through the prism of their perception"; - (K) “In a simple hospital, I had a temperature, up to 40 degrees, when contracted pneumonia. And the doctor admitted me to the hospital... They didn't want it... When [name] was alive, she said: "Turn on [the phone] on the loud [connection]". I did it, she read the charter to them, listed the rights they are violating. And they allowed me (in the hospital)"; - (K) “There was an abscess on his arm, they changed four surgeons. But they didn't want to deal with him anywhere because they knew he was a drug addict. And only the fifth surgeon agreed to conduct an operation"; - (K) “When they found out that I was a drug addict, they performed an operation and I lost three fingers. The second operation was when my appendicitis burst, they put tubes. When they found out the next day that I was a drug addict, they immediately said: “That’s all, that’s all. It's all fine there". - But you were not refused! - Nine months passed, and in nine months I have pancreatitis. Not that pancreatitis, but pancreatic necrosis. In intensive care for 11 days. - And if you were not sent home back then... - So. It all gets together. As soon as [the doctor] recognized me, I was discharged from the hospital in half an hour”; • positive HIV status of a person in need of assistance: - (O) “I had a hematoma last year and I was refused surgery as soon as they got to know about HIV. They re-directed me. And then I made a noise, and I was admitted. The polyclinic in Slobidka refused me, so only an ambulance accepted me. I arrived with ambulance crew"; - (O) “A neighbour died a week ago. The ambulance refused to arrive when they found out that he was HIV-infected". However, some respondents reported that they had not been denied assistance and had never been insulted.

4.1.2. Delivery of medical services

A number of organizational issues related to the provision of medical services were identified by respondents as those that hinder their availability for the KP (see Fig. below).

Fig. 4.1.2.1. Problematic issues regarding the way the medical services delivery is organized, % of all, by categories

Among a variety of problematic issues that hinder free access of the KP to a range of medical services, the respondents identified the following:

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- inconvenient working hours - this was said by 13.8% of all respondents, in particular: 8.1% of MSM; 5.3% - PWUD who do not attribute themselves to any KP; 2.4% - SW; - inconvenient location of the institution - 13.0% of respondents, including: 5.3% PWUD who do not attribute themselves to any KP; 5.3% of MSM; 1.4% - SW; 1.0% - clients of female SW; - high prices for medical services - 1.9%, among which: 1.4% - clients of female SW; 0.5% - SW (our point of view on this statement is described above). There are no answers in the category "Transgender person". Additionally, one of the respondents commented on this issue: - (K) "I always refer each time when I get sick, and they refuse me". The respondents drew attention to some aspects of how medical care is organized which complicate the process of receiving these services: queues for admission, inability to take tests due to equipment failure, absence of a doctor and poor organization of reception of patients, improper conditions in the facility, etc.: - (O) “I am not satisfied with the district polyclinic: they make me stressed, I don't like them. Queues drive me crazy, old women, old men. You wait for a neurologist for half a day. Some doctors are available in one district, others in another, you need to travel"; - (O) “The AIDS center is terrible. They don’t take tests. Sometimes the device works, sometimes not"; - (O) “I am very dissatisfied with the TB dispensary: each time I visit, my doctor is away. Only a nurse. They send me to a new doctor each time. I had a quarrel several times. Of course, I'm not happy about it"; - (O) “Antiretroviral therapy is prescribed differently all the time. Not because of the doctor, the doctor is excellent. There are no drugs. I can take only some medications, I have allergy"; - (O) “Simply a negligent attitude to work, to people. Doctors who work long enough stop treating people as people, perceive people as some beings who come to irritate them. Doctors go eat something, have a talk with someone. Like small children, run away whenever possible. You have to look for them, and then they answer you defiantly”; - (O) “I was in infectious disease hospital after I ate shawarma. It is a very gloomy place, the walls are old, everything is old, and I think they do not follow the hygienic recommendations. I could go outside there, walk around the territory. There was a TV. In general, the rules were followed, but not completely, there was no strict control. I was lucky, I was in a separate room. There were wards with a large number of people. Quite unpleasant to stay there, everything is old, toilets are old, uncomfortable. I did not think about the professionalism of the staff, because my health was very bad. I was cured, and that's good. In general, I remained healthy, and thanks to the doctors". One of the problems that respondents admitted when visiting public medical institutions – the staff claimed it is necessary to pay a charitable fee which practically resulted in paying for services: - (K) “In state owned (facilities) I faced extortion and negligent attitude of doctors. I even sometimes had to alert journalists and call the police. It is better to go to private (clinics) or to institutes, such as those in Kharkiv. I involved journalists because of payments in favour of the hospital's charitable fund, with threats. I needed to be hospitalized, but they did not let me in without forcing me to pay 1,200 [hryvnias] for charity. Hospital of Ambulance Service, state owned hospital in Kyiv"; - (K) “The salaries of doctors need to be increased so that they do not ask us for money. In my city, you can't undergo a normal examination if you don't pay the money, I mean governmental organizations"; - (O) “Even in state owned hospitals it is necessary to pay money, there are a lot of people who cannot afford it. Not only do I come to the state hospital, I bring gloves, ethanol, cotton wool, above all this l have to pay for these tests"; - (O) "I recently did blood tests, and they took hepatic tests from my vein quite badly and, they even took money for it"; - (O) “Narcology – not satisfactory, a very greedy doctor. I gave 10 hryvnias to support his office, I did not have more, he was very dissatisfied"; - (O) "My assessment is – neutral. Most of such institutions are aimed at sucking money out of the people. I don't like their straightforward schemes. Neither good nor bad. I received services and paid my own money";

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- (O) "It is very difficult to get medical care so that you are not robbed to the extent when you have nothing to eat"; - (O) “In fact, they make good money. If you want normal quality of services, you need to go to a private clinic, not a public one. In a private one the service is worth the money"; - (O) "They wait for you to leave them money"; - (O) "There is no decent pay, and so medicine is based on bribes". However, doctors justify the lack of free services: - (K) "Some doctors say, "We don't have free medicine in the country". At the same time, respondents gave examples when doctors provided quality services despite incomplete payment or no payment: - (K) “You know, everything depends on the human factor. If the doctor is a normal person, she/he will consult well and will not take money. For example, when I had my tooth extracted, I had a fever, I paid 20 hryvnias – did not have more, and they extracted a tooth for 20 hryvnias and used anaesthesia. – Depending on the doctor you get". - (K) “It was in the polyclinic. They immediately said: "150 [hryvnias]". But I simply don't have it. And they admitted me anyway".

4.1.3. Professional level of medical personnel

The baseline survey included a set of questions on the reasons for non-referral to the healthcare facilities during the last 12 months, and the respondents were asked about lack of trust to the medical specialists of these institutions. It should be noted that such responses (confirming lack of trust) were not registered. At the same time, in their answers, the survey participants shared the following comments when they were asked an open-ended question about their opinion on the professionalism of health workers who provided assistance to the KP, in particular to users of PS: - (O) "They act in compliance with national regulations" - (K) "They lack appropriate level of competence"; - (O) "They work only for bribes". Thus, from the point of view of the respondents, the professional level of medical workers does not raise questions and is not an obstacle to the availability of medical services. In contrast to the above, the FGD participants reported cases when medical staff demonstrated low specialist skills, performed poor examination, for example: - (O) “Fluorogram. Suspicion of appendicitis. Not satisfied: they don't know anything, I can teach them. (They are) Not specialists"; - (K) “In private [clinics] I was satisfied. Psychiatrist (in a public institution) - not satisfied with the services. My problem with sleep and anxiety was solved only pharmacologically, without psychotherapy. At my request, she was ready to refer me to psychologists, but it did not fit into my understanding how ​​pills can be combined with psychotherapy. Everything else was fine"; • Inability to distinguish between HIV and AIDS: - (K) “It was the 10th year or the 11th. I… wanted to remove the mole, visited one medical office. And a young doctor... Well, young… 45 years old… And he sits like this: "What are your illnesses?" I'm in the AIDS center [registered], but I can decide not to disclose it... But zero viral load, I am not dangerous. "Oh, so you have AIDS!" I was blown away. I told him... They don't even know the difference between HIV and AIDS! Doctors! - Unfortunately yes. Although the doctor has to know"; • excessive fear of HIV infection associated with lack of knowledge about transmission routes: - (K) "And if, God forbid, you need to go for surgery, it comes to insanity. What surgeons themselves tell relatives,

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parents: "go buy gloves, there are such gloves... " - Almost with spikes ... - These gloves... They are surgical. But there in general... - They are almost made of metal. - Yes. Chain armour! Yes, chain armour gloves - they are not called like this. - Although doctors must know how it is transmitted! - And a costume! The doctor must be fully clothed. - Like leper. - Reaches insanity. It’s all the same everywhere"; • linking of the current state of health of the transgender to the intake of hormones: - (K) “I was not denied medical care. But the situation was something like this. I visit a doctor with some problem. Cholecystitis. I come to the gastroenterologist. And there I am asked to get undressed. I haven't had breast surgery yet, I'm collecting money. And here it starts: "Oh". And I have to explain, of course. And this must be explained. And it starts immediately: "You have it because of hormones!" I say, “Listen, I've been taking hormones for eight years. I started to have pain in my side a month ago. Well, that is, like, it's not connected"… The problem is that doctors... And it's not their fault... Our education is like this... Few people know about it, so we have to educate doctors. I read English and I know some things, but you don't. I recently ate too much, I have chronic cholecystitis for 20 years, and it is getting worse sometimes, and this is the reason. And it has nothing to do with hormones. And every time, no matter what bullshit happened to my health... Such a feeling, that all my sores are because of my being transgender. - That is, they didn't seem to refuse me... Yes, they didn't refuse, but every time I have to spend a lot of time and emotions on this".

4.1.4. Attitude of medical personnel, disclosure of status, manifestations of stigma The participants of FGD, describing the attitude of doctors, reported both cases of professional attitude and cases of stigma against them. Some of them gave examples of professional attitude towards them by health professionals: - (K) “All doctors know that I am a drug addict and treat me perfectly. Both the surgeon knows and the nurse knows. The therapist knows. And at the same time they behave normally"; - (O) "Physicians made it clear that this [testing] is a normal practice, they did not try to humiliate." Some doctors try to help respondents stop using drugs: - (K) "They know me for 10 years, the surgeon takes me to the lawyer of the hospital who goes to church, they try to [convince me?] to quit it..." One of the obstacles for the target groups to receive health services is stigma or inappropriate attitude on the part of health professionals (including disclosure of status), which respondents have already encountered or fear to face: - (K) “When I was in the hospital, a nurse’s aide came in, an old man was put in my ward, he was not a drug addict, nothing, but he got HIV somewhere. And he just went out somewhere for tests. This nurse’s aide comes in, our ward is full. And she's like this: "Guys, guys, be very careful! Don't drink, don't take cups, because he is HIV-infected". As soon as I heard that, and I was a social worker too, I had a bunch of tubes, but I couldn't stand it: "You hear, you", - I say... Well, not "you", but how is it... I say: - What are you doing? What right do you have?”; - (K) “And let's face the truth. When you come to the hospital,... they look at you as if normal... But only they find out that you are a drug addict - immediately... Attitude changes immediately. But if they find out you have HIV - that's all! You don't have to. You don't even have to touch this cup, all kinds of towels. That's simple". The respondents felt that the doctors were hostile towards them if they knew about their drug use or saw any traces of drug use on the body: - (O) "Yes, from absolutely all doctors"; - (O) "Yes, especially if you are a drug addict, it can be seen looking at yourself"; - (O) “Instead of taking a smear, the gynaecologist just looked at the traces of the old injections. It was very unpleasant"; - (O) "There are [doctors] who just say in your face: it’s your fault, why did you come?"; - (O) "I came up with the idea to cut a hole in the tights when I went to the gynaecologist so that no traces of injections could be seen"; - (O) “I think that not all institutions are the same. The attitude of the chief doctor to homosexuals, prostitutes and drug addicts determines the attitude of the entire medical team. If the chief doctor is an adequate person, then the staff will be trained. In private clinics, it also happens that people are more ignorant than old women".

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This has some implications for assistance: • respondents do not immediately report their positive HIV status or drug use: - (K) “I hide from everyone. I never tell a doctor that I am a drug addict. I'm sure it will change their attitude. - You are afraid. - Of course. As a last resort, if it comes to surgery and I risk either my health or the health of the doctor in some way, then first I make them familiar about myself as a person and only then I say that there is a small "minus"; • respondents postpone a visit to the doctor or referral for help: - (K) “Honestly, I have not yet filled out this declaration (registration form) to engage with a family doctor. I have a psychological reaction: it's very hard… for me to reach myself, but I want… Transgender people are a subculture, we know each other, so I'll ask someone who [from doctors] is not rude and I'll try to get there". The respondents pointed out that one of the reasons for using the services of private medical institutions and paid medical services is proper ethical attitude to them, which is absent in a state institution: - (K) “I have a little worse situation with money now. In better times I used to go either to Oxford Medical or somewhere else. What is happening then: I am a transgender, my documents are for a female, and every time I go to the clinic, I become an exhibit that all nurses go to look at. That's why I don't like to go to doctors, to be honest. Sometimes it is necessary, but... Well it is almost like that. You go to the doctor, you are examined, and, immediately, it begins: "Maria Ivanivna, I need to tell you this..." or... Well, everyone wants to see. And you stand like in an exhibition, and everyone stares at you"; - (O) “Doctors should be your friends, but in our city hospitals they don't look like our friends. They look like our enemies, all annoyed. It is clear why, but it should not be so. Recently I had to do a cardiogram of the heart, and I was just kicked like a ball. It was in a city hospital, there was no cardiologist, and they were all mad. Then I went to a private clinic, everything was fine there, everyone looks like your friend, and everything was fine"; - (O) "In private clinics, where you pay a lot of money, they are client oriented, while at the state owned (clinics) they are often indifferent".

4.1.5. Quality of medical services In general, the analysis of the answers shows that 86% of respondents are satisfied with the services they received from the public health facilities, of ​​which: 40% - "fully satisfied", 46% - "partially satisfied". Of the total cohort of respondents, 9% are dissatisfied with the services, in particular: 2% - "completely dissatisfied" and 7% - "not satisfied".

Fig. 4.1.5.1. Distribution of answers to the question "How satisfied are you with the services received in these public health facilities", %

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To compare the responses regarding medical services received in certain institutions, depending on groups of respondents, while performing the analysis the method of average values was used, where each nominal variable is assigned a numerical value (5 - "fully satisfied"; 4 - "partially satisfied"; 3 - "not satisfied"; 2 - "fully not satisfied"; 1 - "difficult to answer"), for which a scale was designed. The arithmetic mean value was calculated using the appropriate formula, while distinguishing age groups and gender, as presented below.

Fig. 4.1.5.2. Distribution of arithmetic mean values ​​of the variable "How satisfied are you with the services received in the public health facilities", by age

When assessing the activity of medical institutions and the quality of received services the highest score was provided by the respondents of the age group "25-29 years" - 4.27 on a 5-point scale; the lowest – by respondents representing the group "40-59 years" - 3.68.

Fig. 4.1.5.3. Distribution of arithmetic mean values ​​of the variable "How satisfied are you with the services received in the public health facilities?", by sex and by city of residence

Thus, the difference between the arithmetic mean among the respondents in Kyiv and Odesa (4.12 and4.18, respectively) is 0.06 points, which shows absence of difference, i.e. the respondents from Kyiv and from Odesa are equally satisfied with the received medical services. Male respondents gave significantly higher scores when assessing medical services (4.26) than females (4.04). The respondents participating in the FGD had different feedback about the quality of medical services they received in public and private institutions.

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Services in public institutions were often assessed as poor: - (K) "Quality [when we mean services] - definitely not"; - (K) "Most often everything is bad. You cannot even go"; - (O) "Issues are because of training and competence of doctors. They are sent documents from above, but they are not trained and not competent, for example, if we talk about medical reform"; - (O) "Negligence, they don’t care"; - (O) “Once I came to a medical institution and already at the reception they thought that I came to get deliverance from military service, they sent me somewhere. I was very upset, I lost the desire to return there. Although I really hope to refer there again"; - (O) “Services are not of high quality. All issues are because of funding. If the doctor is not interested in the patient, she/ he will not do anything good for the patient"; - (O) “Medicine is not very good in our country. The system is far out of date, and it cannot be made adequate. Old doctors can't do anything, new ones can't do yet"; - (O) “Old, normal doctors are retiring. Young people do not understand what they are doing. Medicine is not so great. Funding is poor". They consider private services to be of better quality and therefore refer to private institutions: - (O) “I took tests at the state clinic, and there were constant problems: they couldn't take tests, the tests didn't work out, they (the tests) were lost. I went to a private clinic, and one hour later I received the result to my mail"; - (K) "Private hospitals, various institutes. Cold, neurosurgery, dentist. In some cases, in private clinics or even in the same institute it is much better than in public clinics"; - (K) "In a private clinic I was satisfied"; - (K) "Examination, if in a private (clinic), everything is OK, but expensive. In the state clinic it is cheap, but bad"; - (K) "I stopped going to public clinics and only turn to private doctors because I am not satisfied with the quality"; - (K) “[Referred to] the dentist, gynaecologist - privately and to the hospital. It seems to me that, unfortunately, private clinics serve better than public ones”; - (O) “I liked it in a private laboratory, I didn't like it in a public one. An ordinary hospital, doctors and nurses are no good". At the same time, some participants of the FGD positively assessed the level of services in state (municipal) institutions: - (K) "When I went to private polyclinics, everything was fine, in public ones - too"; - (K) “I went to a state institution. Polyclinic... there… In principle, is quite good"; - (K) “I was ill, but a year ago. I went to the Olksandrivska hospital. It was great, by the way. I liked everything. Quick... I have very weak lungs. I often suffer from pneumonia and bronchitis. And I went to the radiologist, therapist, pulmonologist. - Were you satisfied with the quality? - Yes"; - (K) “Did you also go to the doctors? - Yes, everything went smoothly there"; - (K) "I would rate it all [quality of service] on a "four"; - (O) "Satisfied with the AIDS center, tuberculosis [dispensary] too"; - (O) "I'm fine"; - (K) “Yes. Polyclinic, because of a cold. I was satisfied. Everything was at a normal level"; - (O) “My assessment is – normal: it could have been worse, given the economic situation in the country. In a private clinic they will smile in your face and spit behind your back, and in a public one they get so little (money) that they can tell you everything they want”. - (O) "Polyclinic No.14 was very good". The respondents noticed changes that have taken place in health care facilities due to the reform (including electronic queues, free medicines): - (O) “Yes, I recently [went] to a simple clinic. Because of . Everything was pretty good. There was an electronic queue, no live queue. The visit lasted 10 minutes, they did not kick me from one office to another, (prescribed) affordable drugs. I'm satisfied"; - (O) "It's hard for me to say. Everything changes. I recently went to the clinic, I was even given free medicines, which

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surprised me a lot". Another criterion for choosing an institution - the recommendations of friends, "verified" doctor or institution: - (K) “I went to verified people and to verified clinics, following the recommendations of friends. The quality of service was good". Some respondents search for a doctor/institution on their own, if they are not satisfied with the quality of services received: - (K) "I can find a psychologist or psychiatrist myself, which is what I've been trying to do lately"; - (K) "I found help in another private clinic". To improve the quality of services in public medical institutions, the FGD participants propose the following measures: - (K) "Increase the salary of doctors, and then everything will be fine"; - (K) "Set normal salaries for doctors, and so there will be normal services"; - (K) “For example, in the institute where I referred because of health problems, medical services were not always of high quality. Finding a qualified doctor is now quite difficult. To improve the quality, you should examine the cadres (personnel). And normal salaries for specialists"; - (K) "As for the hospitals I go to, (it’s worth to) improve communication between doctors, laboratory assistants and nurses"; - (O) "They [public health services] will be of good quality if the funding is normal".

4.2. Relations with state and non-state institutions

Respondents' attitudes towards state and non-state institutions largely determine their trust in the decisions and recommendations of these institutions, their willingness to seek help there if necessary, etc.

4.2.1. Relations with public organizations: awareness, attitude, provision of services

The experience of cooperation of the KP representatives with HIV service NGOs or social services in Kyiv and Odesa is almost the same - the summary of the respondents' answers is shown in Fig. 4.2.1.1.:

Fig. 4.2.1.1. Distribution of responses regarding respondents' referral for social services or to NGOs during the last 12 months, % of all, by city of residence

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The vast majority of respondents did not seek help/services at all from social services or service NGOs - this was reported by 73.2% of respondents, of whom 36.4% are from Kyiv and 36.8% from Odesa; A quarter of respondents (25.3%, including 12.9% in Odesa and 12.4% in Kyiv) have cooperated over the past year with a purpose to get assistance from service NGOs. For 1.4% of respondents from Kyiv, it was difficult to answer this question. For distribution of answers to this question by categories of respondents, see Fig. 4.2.1.2.:

Fig. 4.2.1.2. Distribution of responses regarding referral to social services or NGOs during the last 12 months, % of all, by city of residence

The analysis data show that referral to NGOs or social services was as follows: 12.4% - MSM; 11.0% - PWUD who do not attribute themselves to any KP; 2.4% - SW; 0.5% - clients of female SW. These respondents did not refer for services at all: 49.9% of PWUD who do not attribute themselves to any KP; 16.3% - MSM; 13.9% - SW; 2.4% - clients of female SW. Among those who found it difficult to answer there were MSM - 1.0% and a transgender person - 0.5%. Focus group discussions revealed different experiences of respondents in relation to services provided by the NGO: • they do not know about the activities of public organizations; • they know about the organizations, but did not receive the required services from them, in particular because these organizations do not provide such services: - (K) "Well, if they don't do it... - There are fewer opportunities". - (K) “This relates to medicine. Again, we do not contact the organization. - We know they can't. - We do not address this one, others. And with such a problem we do refer there". • they worked in public organizations, and provided their services: - (K) "We did not receive [services of NGOs]... We provided them". • they used the services of mobile clinics during events organized by public organizations; • they used the services of public organizations: in particular, the following NGOs were named: - (K) "Alliance", "Alliance.Global", "Gay Alliance", "Eney", "Nadiia ta Dovira (Hope and Trust)", CF "Volna (WAVE)" (All-Ukrainian Association of People with Drug Addiction); - (O) "Federation of Ukrainian Yoga", "Volna (WAVE)", "Doroha do Domu (Way Home)", "League", initiative groups. Types of assistance received:

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• assistance in obtaining medical services, testing, information, as well as pre-exposure prophylaxis (see Section 2.2.3): - (O) "Treatment for hepatitis C. By now 20 people have already been treated at the request of the regional representative of "Volna (Wave)" in Odesa and the same number of people have been tested, waiting in line"; - (K) "Testing services at the "Alliance"; - (K) "In the "Alliance" and in the "Insa" - I was tested"; - (K) "Yes, the "Alliance Global" and the "Transgeneration" - for testing"; - (K) "In the "Alliance", they arranged my referral to a hospital, for PrEP"; - (O) “We always receive their [services]. Even if we go to an NGO and see a poster, it is already an information service. The same goes for communication with social workers. I mean the "League". It was the "Partners" who dealt with MSM previously, and now it is the "League", nobody else deals with it"; - (O) “I received. Condoms and lubricants. I will not name the organization"; - (O) “I received lubricants and condoms. NGO "League"; - (O) "Yes, purely advisory services"; - (O) "Yes, there have been such cases more than once: I sent both to the "League" and to private doctors"; - (O) "I sent some people to the "League" for HIV [testing]. You won't find this everywhere"; - (O) "Test, consultation, condoms, lubrication"; - (O) "The "League" constantly supplies condoms and lubricants. Otherwise I just wouldn't have money for condoms and would have sex without them. Tests are cool”; - (O) "Yes, the "League". I was tested for HIV, [received] information, booklets, lubricants, condoms. I like it a lot"; - (O) "Yes, mainly through your organization - "League". Condoms, lubricants"; - (K) "Alliance". Social workers in the format of consultations"; - (K) "In the "Alliance" when I was tested"; • legal aid: - (O) "Assistance of a lawyer"; • psychologist services: - (O) “I sent many people to the "League". I sent (people) and accompanied them to a psychologist whom I know"; • leisure, meetings with friends: - (K) "[Among friends -] those with whom I meet in the NGO "Alliance.Global"; - (K) We mainly meet in "Alliance.Global"; - (K) I spend most of my time with friends in the "Alliance"; - (K) "["Alliance Global" and "Transgeneration"] Discussions, focus group"; - (K) "Alliance.Global", individual conversations, lectures, discussions, playing games in free time, watching movies"; - (O) "Travel [journeys or trips?] in good company". The respondents also indicated that it is these organisations that provide more information about HIV than doctors: - (O) “Doctors are not very interested in HIV issues, they don’t keep up with the latest developments. It turns out that, thanks to classes, we know more information than they do. If only they were interested to learn"; - (O) "Everything I know about HIV comes from them"; - (O) “Not a single doctor tells us about HIV, only these organizations. Even in polyclinics, when doctors find out that I go to initiative groups, they ask me about HIV. For example, whether it is possible to get infected from a bite, etc.";

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- (K) "Every time social workers talk about it when I get tested"; - (K) “At the HF Center. There was useful information, I learned what I did not know before. It was just a lecture"; - (K) "The "Alliance" provides comprehensive answers to any questions. I regularly receive new information from social workers. In a variety of forms: conversation, lectures". The respondents are more positive about their relations with non-governmental organizations against the background of negative experience of communication with state institutions: - (K) “Some people who applied to government agencies that provided consultations had a bad experience. And it was a very unpleasant experience. Another thing is all kinds of public organizations that exist in Ukraine. - Would you trust public organizations more? - At the moment, yes". The respondents highly appreciate the quality of services provided by these organizations (on a five-point scale they selected highest point - five): - (O) "Satisfied with the work"; - (O) "They are our colleagues"; - (O) "It used to be worse, now it's much better"; - (K) “I have no claims about the work of these organizations. I don't even have any constructive criticism for them"; - (K) “The services are of high quality. I have no questions. It would be better if all organizations were non-governmental, then it would be easier somehow"; - (K) “Satisfied. I don't know what can be improved"; - (K) "Excellent quality"; - (K) “Fully satisfied with the help provided by the “Alliance“, “Insight“; - (K) “The service was complete and clear. No open questions left"; - (K) "Satisfied with the service"; - (O) "Normal quality of services"; - (O) "Everything is okay, everything is fine". At the same time, the respondents mentioned a number of problems in the activities of NGOs, which in one way or another affect the expansion of access to HIV services for the KP representatives: • adverse impact of insufficient funding: suspension (termination) of activities: - (K) “If there was funding - then, yes. And now it has switched to state funding - a bad situation in general. Changes for the worse. - When the Global Fund paid, it was much better"; - (K) “It's just that a lot of them were closed. Reduced… No funding. - In general, mostly when there is funding, we used to refer to them. - Of course"; • lack of experience and capacity to implement programs: - (K) “Let's say, for the provision of harm reduction services to injecting drug users - the drop-in center won the tender. That’s all. - Although they do not have such capacities. - No one provides such services anymore"; - (K) "For example, the one on sex workers – it was won by... [name, unclear]. Plus they have a contract with “Eney“ Club. But then again, how will it all go? How will it work? They have just won. - They haven't started yet. People suffer because of some projects”; • lack of information on the activities of HIV service NGOs: - (K) “We know this [about the scope of services of a particular NGO]. But not everyone on the street knows. Need more advertising. If people are not users... - I'm talking about users who are on the street". This statement proves that HIV service NGOs mostly focus on those KP representatives who have been clients of these NGOs for some time. But the NGOs’ efforts to attract "new" clients from among the representatives of the KP and their environment, as well as to deliver preventive work among them, are insufficient;

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• unethical behaviour of management or employees (the examples given in this aspect are not typical, as they are mentioned by the participants of one FGD and relate to a specific NGO; however it is these situations that prevent new clients from approaching HIV service NGOs for services): - (O) “Do not be rude to clients and employees. I don't visit because of one employee and I know people who don't want to go because of some employees"; - (O) “(It is necessary) For the management not to be rude to their employees. Some employees at “League“ spoil its reputation, they should be removed"; - (O) "Indeed, the “League“ has pros and cons. Advantages - the atmosphere, cosy as at home, you feel like in a family, you can open up. Good specialists. Disadvantages - [female name]. Once you see her - you want to vomit. Too cheeky snout, feels like a queen"; - (O) “If we talk about the "League", there are pros and cons. The downside is [female name] - you want to run away as soon as you see her. - The previous comment is so cool, I agree. Everything else is fine"; - (O) “I want to tell everyone that you lack tolerance. I, in principle, also do not really like [female name], but it has absolutely nothing to do with the organization. I have no issues with regard to the organization. I would wish - it would be nicer to see smiling consultants more often. This would be possible if everything is fine in their life". The respondents suggested that there is a need to intensify operation of service NGOs in order to increase the access of the KP to HIV services: • to intensify advertising of NGO activities, informing about its services: - (K) “What do you think can be done? – Money is needed... to engage social workers, to pay these people who are involved. If we speak about that drop-in-center, they work on a "peer-to-peer" basis. Money is needed. First of all, in order to hire staff who will be doing outreach and talk... Some postcards, business cards and so on and so forth. Information materials. This also requires money. Everything depends on money. No one will work for free"; • to support professional development of NGO staff (and, accordingly, the quality of their services) through training: - (K) “In order to improve quality of these services, it is necessary to conduct trainings. – People need to be trained. - Recruit specialists who will conduct these trainings and teach them. Teach the people"; • implement prevention projects, not limiting activities to distribution of condoms and syringes: - (K) “Distribute condoms... - Distribute "bayany" (syringes). - In addition to distribution of "bayany", you also have to advise, test, collect and register information and fill in questionnaires, provide support. You just need projects, and give money for these projects. I don't know what else can be done"; • to improve the material base of NGOs: - (K) "Enhance material base". • expand the list of services provided by NGOs: - (K) "I would like to be able to get tested for gonorrhea at the "Alliance".

4.2.2. Relations with the police

In the baseline survey’s set of questions related to obstacles encountered by the TGA representatives in obtaining medical services, respondents were asked to choose the answers they considered necessary (see Table 4.1.); The possible obstacles which were listed there included the issue of police raids at service points. Overall, 125 respondents (59.8%) provided answers; only 2 people (0.9%) from the category of PWUD who do not attribute themselves to any KP reported that police raids in places of service provision are a barrier to accessing these services. At the same time, it should be noted that despite the fact that respondents were given the opportunity to answer open-ended questions to explain the reasons for these obstacles and what specifically they implied, no comments were provided. This suggests that these respondents are not fully aware what police raids are and how they complicate access to HIV services.

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Relations with the police (as well as with medical institutions) were named by the FGD participants as one of their biggest problems: - (K) “Do your friends, colleagues, buddies also have unresolved issues? - Ministry of Internal Affairs, Ministry of Health. – Medical area and police. - These are the main problems of all drug addicts". In their relations with the police, respondents indicated more negative aspects than positive ones. Most often it related to distrust of the actions of the police: - (K) "It's probably more about lack of trust. And it gets worse with each new case". Distrust of the police was expressed by the FGD respondents, referring to situations from life experience when police officers did not arrive to the call about domestic violence ("… our police do not come to the call about domestic violence or in same complex cases"), did not respect the limits of their authority (in particular, there were cases when Methadone was confiscated from the KP members), planted the drugs or intentionally abused their authority in order to meet their performance indicators of combating drug crime, punished PS users while not touching the dealers ("Until the state becomes concerned about the need to arrest drug dealers, while a simple 18-year old guy who leaves a club with half a gram of amphetamine is equated to a drug lord carrying kilograms of amphetamine, the situation will not improve, unfortunately. This is where all our problems are"). Such situations not only provoke distrust of law enforcement agencies ("We cannot trust the state, we cannot believe that what the state offers is beneficial for us or will help us get out of certain situations") and fear of seeking the HIV services, coupled with criminalization of PS use. An important factor in misunderstandings with the police for a transgender person who changes gender, due to possession of a passport which was issued for the "initial" gender of the TG: - (K) “I have a photo in my passport that doesn't look very much like me. It says: "[female name and patronymic]". - So it’s for a woman... - And they [the police] could not understand the situation at all. - Yes… I'm afraid of the police. Honestly... Someone is calling [the police], but I can't be a witness because I have to explain to all these wonderful people why I have such a passport, and so on”; - (K) “I received the driver’s license in my city, and according to my passport I am Anastasia. I was just kicked out of there to see a psychiatrist. I passed this attestation in Kyiv, it turned out to be cheaper and without any problems". At the same time, respondents indicated ways which may improve relations with the police: - (K) “Need to conduct trainings for doctors and police officers. To protect the people who work in this field. For them [policemen] not to get anxious and not to file a case because of two tablets of methadone».

4.3. Criminalization of the use of psychoactive substances

While discussing drug-related criminal liability, respondents expressed the opinion that the drug policy developed at the state level does not actually transform practices towards (and thus does not create opportunities for increasing KP’s access to HIV prevention services) which is in line with international practices, and instead it serves someone’s financial interests: - (K) “In general, I believe that there is a global problem. The Ministry of Internal Affairs blocks decriminalization which is set in national drug policy until 2020. Now the issues of drug policy are in the hands of the Ministry of Internal Affairs. Surely, it’s not too strict. But for a small amount of substance you can get a criminal sentence. Imprisonment"; - (K) “Unfortunately, little attention is paid to statistics, for example medical, available at the Ministry of Health. Instead, too much attention is on criminology and criminal offences"; - (K) “When against the background of bigger news, the police and their press center speak about confiscated drugs for a certain amount of money, when they talk not about the amount or something else, but about money - it is politics. When they say that certain drugs have been seized in a certain amount and not for a certain amount of money, then they have no interest. This is lobbying"; - (K) “If they legalize marijuana, they will lose gains of alcohol, because there is correlation, they will lose gains on cigarettes, they will lose the basis to charge excise duty. Now. But they do not understand the long-term perspective". The respondents also suggested that drugs that are currently illegal may be useful (at least harmless):

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- (K) “CBD" is a real panacea. I have a friend who has epilepsy. And that's part of his "tripping". He can't get it legally at all. It is very expensive to order. You can't stigmatize substances, half of which are known worldwide as medications used to cure most diseases. They say "CBD" and "Aderal", which are in the States... - And not only in the States. - It is illegal in Europe. "Aderal". As far as I know"; • over-the-counter drugs are of proven quality and therefore less dangerous to health: - (K) " [In Rotterdam] You can buy weed, and you know for certain what you are buying, what variety... I... I don't know who produces it… That is, I used to have a man, let's say, whom I knew. I knew he was growing marijuana. Now this man has left the market. I don't particularly trust ‘khachiks’ [foreigners]: you are buying a pig in a poke. When it is more or less legalized, there are some quality standards. When it comes to health: it does affect. The same with other substances. You never know what was mixed in there"; - (K) "Amphetamines are often of quite high quality and so they do not wash calcium and magnesium out of my body"; • decriminalization leads to a reduction in injecting drug use and, consequently, slows down the spread of HIV infection among PWUDs and their partners: - (K) “Increasing the amount of substance you can have with you... Following the example of other countries. Let’s take Portugal. They had a policy promoting decriminalization. The amount of injecting drugs and HIV-infected people immediately dropped there. And I believe that in our country this should be implemented too"; • decriminalization reduces corruption risks in the police: - (K) “It eradicates corruption in the police. It is now convenient for the police to implement the targets they set in their plan of detentions"; • decriminalization removes the rush of demand for the "forbidden ": - (K) “Positive motivation always works, it is used in schools, in progressive countries, among junior pupils. You stop forbidding something - it becomes socially acceptable, it stops being stigmatized, it is not used as a protest, a "forbidden fruit". - Which you really want. – Those teenagers were taking (drugs) because it’s forbidden, stop taking it". • some PS can serve as doping for work and leisure: - (K) “PS which we are talking about now, is usually doping, most often in my life, for my work, for my life, for my creativity. Periodically - for my hobbies. It's more fun to listen to music and watch movies. Who would not agree with this? (General laughter). I can work on the same task for a long time. With all this, I have extra focus,... I can focus and work on one task, which I cannot do quite often when sober".

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In general, among the main problematic aspects that hinder the access of the TGA and their close people to a range of HIV services, the following were identified: • in public health facilities: - high tariffs for services (this was indicated by 32% of respondents). We believe that these barriers - high tariffs – same as in Section 2 (see: reasons for non-referral for medical services), are evidence of poor awareness of the respondents about the possibility to receive HIV services free of charge; - unwillingness to let others know that he is a PS user (20%); - overlap of work schedules of the public health facilities and respondents (20%); - dissatisfaction with the attitude of specialists/staff of the public health facilities (17%); - lack of information on the available services (15%); - inconvenient location, etc.; - and for 27% of respondents there are no obstacles to receiving medical services, and almost 86% of respondents are generally satisfied with the services received at the public health facilities; • other problems preventing access to medical services: - unethical treatment of the KP representatives, - problems with law enforcement agencies and criminalization of PS; • in NGOs a) according to the participants of the FGD: - complications due to insufficient funding (suspension/termination) of activities; - lack of information about NGO activities; - unethical behaviour of NGO management or staff; b) 73.2% of respondents are not clients of service NGOs and did not seek help/services from NGOs at all, which explains their lack of knowledge about availability of HIV testing services at the NGOs. With reference to the above, it can be concluded that in order to improve and raise effectiveness of provision of HIV services to the KP representatives, service NGOs need to intensify: - informational and educational activities among the KP and their close people by disseminating information on the possibilities of obtaining counseling and HIV testing services; - information sharing about the services provided by NGOs; - introduction of educational interventions to improve professionalism of employees; - by raising funds (grants), enhance material and resource base of NGOs, in particular to equip and support activities, programs and projects in the field of HIV; - take action to expand the list of services provided by NGOs.

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Chapter 5

Ways to attract new clients from among the TGA to receive medical and social services

The respondents analyzed relationships with three categories of their close people - sexual partners, relatives (parents) and friends – regarding conversations about health issues, readiness to provide support or assistance, involvement in testing, degree of risky behaviour, and so on. Respondents' relationships with representatives of these categories largely influence the obtaining of medical/social services by the KP, expanding the range of users of these services, the level and dynamics of risky behaviour with friends and partners.

5.1. Attitudes towards people who change their behaviour to a healthier one The respondents indicated that they knew people who had stopped using drugs. The number of such people among respondents’ closest people ranged from ‘many’ to ‘a few’: - (O) "Yes, but these are a few, those who used to take and have quit"; - (O) "Those who have quit – they are rare people"; - (O) "Very few people stopped with drugs"; - (O) "Few have stopped"; - (O) "Very few of those who no longer use"; - (O) "There are many"; - (O) “I have colleagues who are former heroin addicts and so on. There are some who used (drugs) and now they have a break until a certain event"; - (O) “I had an acquaintance who used poppy seeds, weed, etc. I think he will resume it"; - (O) “There are those who used (drugs) and took temporary leave. Detox”; - (O) “I have a friend who introduced me to the world of psychoactive substances. Then she quit, and I stayed in this world".

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The respondents were generally neutral about these cases: they did not accuse their friends, but at the same time did not express much enthusiasm: - (K) “Are there people who used drugs before and have stopped using them? - Yes. - Are these people a kind of example for you? - (Answer options): Not necessarily. Yes. To some extent. Depends on the individual. Depends on the situation, and on what (drug) they stopped using". Some respondents took long breaks in using drugs and revealed a relation between these breaks and the presence of users in their social circle: - (O) “Yes, I have plenty of such friends [who use drugs]. Now my circle of people I communicate with has narrowed, and this allows me to stay without taking drugs for a long time. I stopped using weed, cigarettes, alcohol, although the craving was intense. Now I sniffed weed - it was so cool, and I can keep on without drugs for another two months. It was always like this: when I tried to quit, I found myself in a company of those who use. Now there are no such people in my circle". The respondents also included those who stopped using drugs: - (O) "Now - no [do not use], it’s over".

5.2. Involvement of a sexual partner in protected sexual relations, testing and medical examination

First of all, it should be noted that the vast majority of respondents in the baseline survey already had sexual experience in the last 12 months: n = 193 (92.8% of those who provided answers to this question, of which 63.5% (n = 132) are men, 28.8% (n = 60) - women, 0.5% (n = 1) - transgender person. Only 7.2% (n = 15) of those who responded had no sexual contact during the last year - see the Table below. Table 5.2.1. Distribution of answers about sexual experience, % by sex Did you have a sexual intercourse in the last:

Gender 12 months All responses 30 days All responses Yes No Yes No N % N % N % N % N % N % Male 132 63.5 11 5.3 143 68.8 116 60.1 16 8.3 132 68.4 Female 60 28.8 3 1.4 63 30.3 54 28.0 6 3.1 60 31.1 Transgender person 1 0.5 1 0.5 2 1.0 1 0.5 0 0.0 1 0.5 Subtotal 193 92.8 15 7.2 208 100 171 88.6 22 11.4 193 100

Respondents' answers regarding sexual contacts over the past 30 days were distributed as follows: of all those who answered this question (193 respondents), 171 (88.6%) respondents said "Yes", including 116 men (60.1%), 54 women (28.0%) and 1 (0.5%) transgender person; 22 respondents (11.4%) did not have sexual intercourse during this period. The FGD participants discussed the issues of safe sexual practices and awareness of a sexual partner’s health. The focus group discussions showed that respondents are interested to know about the state of health of their sexual partner and, in turn, are ready to inform about their status (in particular, about presence of HIV infection). - (O) "If sometimes I happen to have casual partners, I tell them I'm HIV-positive".

5.2.1. Drug sharing

First of all, with relation to this issue it should be noted that in most cases respondents indicated that they use PS together with persons who they have sexual contact with, in one way or another - see Fig. 5.2.1.1.:

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Fig. 5.2.1.1. Distribution of responses about NPS sharing with partners, %

In particular, the respondents reported that they use PS with sexual, commercial and casual sexual partners - 40.0% in each group of respondents, respectively; 14.3% - with a partner (no formal marriage); 8.6% - with a wife/husband. The respondents from among the participants of FGD indicated that some of them practice sharing drugs with their sexual partner: - (O) “Always, for the sharpness of feelings. Together with a partner - this is the norm"; - (O) "Very often - with a partner"; - (O) "Most often - with a partner"; - (O) "Yes. Together with a partner"; - (O) "Together with a partner"; - (O) "We use drugs together with a partner"; - (O) "We drink alcohol together"; - (O) "Almost always with a partner"; - (O) “I used to, with my partner. But then, under the (effect of) psychedelics (LSD) she discovered the fear of death. She experienced these feelings and stopped using drugs. In four years she can smoke a little or eat two mushrooms"; - (K) “Yes. Not very often"; - (K) "Once a month or two"; - (K) "Often, to forget about my flaws… Partners drink more than use drugs"; - (K) "Happens periodically"; - (O) "Yes, sometimes we smoked"; - (O) “My first drug, other than weed, was with my sexual partner. Although I was against drugs, it went into a three- day "trip". Then I "got hooked". The next two or three years of my life were horrible. The relationship with this person was regular all this time, regardless of whether there were other partners or not". Another aspect of this issue is the specifics of a relationship with a partner who is not using drugs:

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- (K) "If you start a relationship with a person who does not use, it becomes a stumbling block..."; - (O) "No [did not use drugs together], he is categorically against drugs". In the relationship of partners, one of whom uses drugs, and the other – does not, there is often a need to choose between drug use and the relationship with a partner. During the discussion the respondents showed that in this difficult situation, you can make different decisions: - (O) "It didn't happen, although I was offered, but I looked at that partner and thought I didn't want to be like what I see now"; - (K) “I think that people who use drugs should not start a relationship with those who do not use them. Most often you will pull on the bad side... - On the contrary. - What is the opposite? It turns out the relationship will be grounded on secrets and mysteries, on deception. - No, look. When you value a person, this means that you put a drug, injecting, on the second place. - But this is your disease! How can you rearrange it to another place? I cannot. - My wife will find out, anyway". One of the respondents described her situation in which she started using drugs, because she followed the example of her husband, who was an addict: - (K) “When I did not use, got rid of it, my husband, RIP, he did use, he was on the program [OST?]. Our relationship started from the moment when we completely trusted each other, and we didn’t have sex yet, nothing. I immediately said that I had this and that disease and I did not use. And he said that he had this and that disease... He also had… When we married, my husband, he was on the program, was a user, while I did not use. But I was aware that he was using. So. And I secretly began to use. Why? Because I saw him every day, he came torn, and...". Another respondent reported difficulties in disclosing the diagnosis to his partner (non-user), while explaining why he needed to use a condom, etc.: - (K) "I had a case that my wife and I – we both were users. Then my wife seemed to stop it, but I continued… I began a new relationship with another girl. She does not use at all. And how to even tell her that you are on the program [OST?], Hepatitis C, this and that. Why you can't do without a condom... It's very problematic. How to explain this to a person who is not stupid, in principle, understands something, suspects, constantly sees that you are at home, and seems to be sober. And such cases happen. But my wife, when we lived together, treated me calmly". However, at the end of his story, the respondent reported that this relationship prompted him to stop using drugs: - (K) “I started injecting. Twenty years... For the last 20 years I have stopped injecting. In general… I stopped completely thanks to that summer... Knock on wood”.

5.2.2. Sexual relations and use of alcohol/psychoactive substances

The analysis of responses regarding sexual contacts of respondents and alcohol and/or PS sharing for the last 12 months is presented in the Table 5.2.2.1 .: Table 5.2.2.1. Distribution of responses regarding sexual activities and alcohol and/or PS sharing for the last 12 months

ALCOHOL Difficult to Gender Always Sometimes Never All responses answer N % N % N % N % N % Male 10 5.2 99 51.3 23 11.9 0 0.0 132 68.4 Female 10 5.2 28 14.5 22 11.4 0 0.0 60 31.1 Transgender person 0 0.0 0 0.0 0 0.0 1 0.5 1 0.5 Subtotal 20 10.4 127 65.8 45 23.3 1 0.5 193 100

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DRUGS Male 15 7.8 99 51.3 18 9.3 132 68.4 Female 15 7.8 38 19.7 7 3.6 60 31.1 Transgender person 0 0.0 1 0.5 0 0.0 1 0.5 Subtotal 30 15.5 138 71.5 25 13.0 193 100

ALCOHOL AND DRUGS Male 3 1.6 62 32.1 64 33.2 3 1.6 132 68.4 Female 2 1.0 30 15.5 28 14.5 0 0.0 60 31.1 Transgender person 0 0.0 0 0.0 0 0.0 1 0.5 1 0.5 Subtotal 5 2.6 92 47.7 92 47.7 4 2.1 193 100

Overall, 193 respondents (92.4% of all respondents) answered this question. Of those who answered, the practice of using alcohol before sexual intercourse was confirmed as follows: “sometimes“ - by 65.8% (n = 127, of which 51.3% (n = 99) of men, 14.4% (n = 28) of women), “always“ - 10.4% (n= 20, with 5.2% (n = 10) of women and men, respectively), “difficult to answer“ - 1 person (0.5%), and “never use it“ - 23.3% (n = 45, including 11,9% (n = 23) of men and 11.4% (n = 22) of women. A total of 68.4% (n = 132) of men practice drug use before sexual intercourse, among them: 51.4% (n = 99) use drugs “sometimes“, 7.8% (n = 15) - “always“, and 9,3% (n = 18) “never“; 31.1% of women (n = 60, among them: 19.7% (n = 38) use drugs “sometimes“, 7.8% (n = 7.7%) - “always“, and 3.6% (n = 7) - “never“), and 1% (n = 0.5) transgender person. The same proportion of respondents practice sexual intercourse after using a combination of alcohol and drugs. The FGD participants discussed the relationship between alcohol/PS use and sexual activity. The answers reveal that: • some respondents practice (with various frequency) alcohol consumption before sex: - (K) “It depends on the situation. Sometimes. Depends on the mood: beer, wine, tincture"; - (K) "Low alcohol drinks and very rare. Partners can drink - cognac or anything stronger”; - (K) "Yes, sometimes whiskey"; - (K) “Yes. Once in every 10 sexual contacts"; - (K) "Yes, rarely, but I do sometimes, to relax"; - (K) “Yes, quite often. Alcohol is one of methods to relax. Mostly it is low alcohol drinks, but sometimes stronger"; - (K) "There have been cases where partners consumed alcohol to relax"; - (K) “Yes, but on purpose. And not regularly. It happens"; - (O) “[Male name] loves alcohol. We had sex under the effect of alcohol, it was cool. For me it was rather an exception - sex after alcohol, but the experience was fun"; - (K) “And before sexual intercourse [do you drink alcohol, including low-alcohol drinks with your partners]? And after? - We do not use. - Both before and after (laughter). And in the course of… too"; - (O) “I intentionally don't drink alcohol before sex, but it happens sometimes, yes. Occasionally this happens"; - (O) “We deliberately did not drink before sex. "Dopes" drive us well enough"; - (O) “Sometimes yes. Once my partner was under the effect of mushrooms. Alcohol - yes. We deliberately drank to relax and then we had intercourse. But it is better when you are sober";

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- (O) "Quite often"; • in some respondents alcohol consumption led to sex: - (O) "We drank sometimes, which led to sex"; - (O) “Unintentionally. There wasn’t a plan to get drunk before sex. But when we drank, it led to sex". However, some respondents noted that they try to separate alcohol and sex for the following reasons: • they do not drink alcohol (at least now): - (O) "Absolutely not. Earlier - yes. Now we are both on drugs that cannot be mixed with alcohol. Besides, I stopped drinking and my partner has never drunk at all"; • try not to drink alcohol before sex because they do not like sex after alcohol: - (O) “I really don't like drinking alcohol before a sexual experience. Less sensitivity, not high enough. If you choose to take some psychotropic substances before sex, they should at least increase sensitivity, and not to deaden them"; - (O) “More than half of sex experiences were under the effect of alcohol. There are technical problems in this regard"; • by mutual consent: - (O) “I usually drink alcohol and low-alcohol drinks. We started relationship with my partner quite recently and so far we do not drink before sex". As for the connection between sexual activity and the use of PS, according to the respondents, sexual intercourse happens regardless of the use of PS: - (K) "Well, if it's drugs, it's not intentional, but it can happen by accident"; - (K) "Unplanned"; - (K) “Do you use drugs with your sexual partner before sexual intercourse? How often? - [Answer options]: Always. - Constantly. - Every day. Several times a day." In some cases, the respondents shared that the use of PS prompted them to have sex: - (K) “Sometimes I wanted to do so after taking certain substances. I didn't use (substances), but I just wanted to do it - use this substance together with my partner and...”; - (O) "Sex happens more often after smoking, but sometimes when I am sober"; • there were cases when after drinking alcohol/using PS sex was unprotected: - (O) "Yes, this happened"; - (O) "I had [unprotected sex] as a result of drug use"; - (K) “And does it happen when you use all this and have sex without a condom? Do you control yourself in this situation or not? - It happens. Anything happens"; - (K) “Do you have sex without a condom after injecting drug use? If so, how often? - It happens. But we have a disease. - With my sexual partner"; - (O) "It happens"; - (K) “I haven't drunk for a year. And when I had a drink, there were situations when you find out in the morning after that the condom, apparently, was not there... - That is, there were such situations. - Indeed, but in the past"; - (K) “As often as drug use. I do not use drugs unless in a sexual intercourse, and I do not buy them"; - (K) "This was only three times in my life";

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- (O) “They smoke and have sex without condoms. I know about the positive status of a person, and he engages in group sex. There are people who go to techno parties, do not use (drugs) themselves, but they seek out for those who do use, to take advantage of their condition"; - (O) "Takes "shyshky" and does without a condom"; - (O) "All chemsex cases bear such a risk"; - (O) “I am protected in 70% of cases. In other cases, there is either no condom or I'm too intoxicated"; - (O) "Yes, it is extremely rare"; - (O) "I wanted to, but I controlled myself". For some respondents, unprotected sex after the use of PS had additional prerequisites: • commitment to this type of sex:

- (K) "Sex without a condom - I do not mind"; - (O) “Yes, this happened. The concept of condoms did not exist for us in principle. Always"; • confidence in the partner:

- (K) “This is possible only if I am confident in my partner. This happened”; - (K) "Yes, but only with the person I'm sure of". In some cases, the respondents deliberately practiced unprotected sex after using PS:

- (O) “Sometimes it happens, but it is extremely rare. I always do it with full awareness, even if I'm on drugs. I never lose consciousness, I never get intoxicated to the level of unconscious. Even if I’m totally under its effect, I remain conscious"; - (K) "Yes, but usually the decision is made before taking drugs, we discuss it and decide whether to be with a condom or not"; - (O) "It happened a couple of times, but it happens deliberately"; • some respondents cared about safer sex which followed after taking drugs:

- (K) “Once we drank a lot… And we came home, and everything developed towards sex. But I urgently realized that there are no condoms at home. We went out, bought condoms and came back"; - (O) "With condoms only";

- (O) "It’s unreal without a condom"; - (O) "Before I got sick, I used to do it only without a condom, but not anymore". When asked about the presence of sex workers among their friends, the respondents gave an example of the possibility of providing sex services in exchange for drugs:

- (O) "There are people who have sex in exchange for drugs and they do not consider themselves sex workers". While discussing their diseases, the participants confirmed that they were infected through sexual transmission and they know about it:

- (K) "We do not inject, so mostly through sexual intercourse..."; "I was infected – when I was about 18 years old. And the guy had HIV and hepatitis C. I didn't know about it, but he knew. We lived together for half a year, and after he died, I only learned that he was infected. Both HIV and hepatitis C".

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5.2.3. Condom use

The responses of the interviewed KP representatives regarding the use of condoms by them or their sexual partners during the last sexual intercourse are introduced in Fig. 5.2.3.1 .:

Fig. 5.2.3.1. Distribution of answers "Did you (or your sexual partner) use a condom during the last sexual intercourse?", %

As a result, 59% of respondents answered in positive – they used, 33% - did not use, 7% - do not remember. The answers to the questions about the reasons for not using a condom during the last sexual intercourse were distributed as follows (see Fig. 5.2.3.2):

Fig. 5.2.3.2. Distribution of answers to the question “Why did not you (or your) sexual partner use a condom during the last sexual intercourse?“, % of all

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It appears that a condom was not used by the respondents during the last sexual intercourse for the following reasons: - 22.1% of all respondents fully trust their sexual partner (14.4% of men, 7.7% of women); - when using a condom, 8.6% do not enjoy sex (including 6.7% of men and 1.9% of women); - 5.7% (3.8% of men and 1.9% of women) did not think about it; - 3.8% were under the effect of PS and did not control themselves; - 2.8% were under the effect of alcohol and did not control themselves; - 2.9% of respondents did not have a condom available; - 2.4% indicated that the sexual partner insisted on sexual intercourse without a condom; - 1.0% (only women) said they would like to get pregnant. Transgender people did not provide answers to this question. Separately, this distribution of responses with a breakdown by the TGA is given in the Table 5.2.3.1: Table 5.2.3.1. Distribution of answers on condom non-use during the last sexual intercourse (by category)

Respondent's category* PWUD who do Transgender Clients of female Sex worker MSM not attribute person themselves to SW Reasons for not using condoms any KP % of all % of all % of all % of all % of all N in the N in the N in the N in the N in the category category category category category I completely trust my sexual partner 1 5.5 12 38.7 0 0.0 34 54.0 0 0.0 When I use a condom, I don't enjoy sex 0 0.0 4 12.9 0 0.0 14 22.2 3 37.5 Was under the effect of alcohol, 4 22.2 1 3.2 0 0.0 2 3.2 2 25.0 did not control myself Was under the effect of drugs, 5 27.8 2 6.5 0 0.0 3 4.7 3 37.5 did not control myself My sexual partner insisted on sexual 4 22.2 2 6.5 0 0.0 0 0.0 0 0.0 intercourse without a condom There was no condom available 0 0.0 3 9.7 0 0.0 3 4.7 0 0.0 Didn't think about it 3 16.7 6 19.4 0 0.0 5 7.9 0 0.0 I do not want to answer 1 5.5 1 3.2 0 0.0 0 0.0 0 0.0 I want to get pregnant 0 0.0 0 0.0 0 0.0 2 3.2 0 0.0 Subtotal 18 100.0 31 100.0 0 0 63 100.0 8 100.0 * respondents had the opportunity to choose several answers for the category to which they belong; % was calculated for each category of respondents who have marked the answer out of the listed reasons

It turns out that the category of PWUD who do not attribute themselves to any KP, prevails - 63 respondents from this group did not use a condom during the last sexual intercourse; same practice was confirmed by: 31 MSM, 18 SW and 8 clients of female SW. For the FGD respondents condom use is associated with several factors, but there is no direct dependence on these factors. 1. Trust in the partner: • the respondents trust their partners and at the same time practice both protected and unprotected sex:

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- (K) “Yes [I use a condom], but not always. If a person is reliable, then I think that it is possible without all this"; - (O) “There was an experience without a condom. And with a condom too. No specific reasons"; - (K) "In different ways: we use and we do not use. And we also use lubricants, and sometimes we don’t. Prevention…"; - (O) “Trust depends on the type of sexual contact. I like people of different genders. If vaginal or anal contact, then with a condom. Oral sex - depending on how much I trust my partner, sometimes you can skip protection"; - (O) “I trust. We use, but not in all cases, 50/50"; • always use a condom (even if they trust a partner): - (K) “I don't like condoms, but I still use them. And I also use a lubricant gel. - Is it for the purpose of pregnancy prevention? - Prevention of pregnancy. And yes, I trust my partner"; - (O) "I always protect myself"; - (O) “Yes [I trust]. I always use condoms"; - (O) "Yes, I trust, but I use condoms"; - (O) "I use condoms"; - (O) "Yes, I always use"; - (O) “Sex without a condom has not been banned, but it is better to be safe. Everything happens, you never had something… and – bang! – it appears. Better to use condoms and lubrication"; • trust a partner and do not use a condom: - (O) "I never use a condom"; - (K) "We do not use condoms and I trust my partner"; - (O) “Yes [I trust]. We do not use condoms"; - (O) “I trust. I do not use condoms and have never used them"; - (O) "Yes [I trust], I do not use condoms"; - (O) "Yes [I trust], without condoms"; • do not trust a partner (especially casual) and therefore always use a condom: - (K) “I always use lubricants and condoms, I always have them with me. I don't trust anyone"; - (K) “I don’t trust… Condoms - almost always”; - (O) “There were casual partners - I used a condom. I use almost in all cases. Occasionally, I did not use it, and this is not because of negligence, but a well-thought decision"; - (O) "I did not trust, so I used, I tried to always [use a condom]"; - (O) “Casual [partners] - no. Without a condom and lubricant - no way, if it is not available, we come up with something else"; • use a condom if the partner has other sexual partners: - (K) “I trust. If I know that my partner does not have sex with anyone without protection, I can have sex without a condom. If there are other sexual partners, then contraception is used.“ 2. Pre-exposure prophylaxis (PrEP): the respondents who take PrEP feel more secure (confident that they are not HIV-positive and do not transmit infection to others), so they allow themselves skipping the use of condoms: - (O) “I'm on PrEP, I can allow myself to be without condoms with some people, when I know their social contacts. But I'm very careful with that"; - (K) “I can believe that my sexual partners may have other partners and be potentially dangerous. I don’t use condoms regularly because I take PrEP and I get tested on a regular basis”; - (K) “No, I don't use it at all times. It’s a matter of my conscience. I'm on PrEP, so I can feel more secure. Although this only applies to HIV infection";

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- (K) “Yes, I trust. Sometimes I have sex without a condom and lubricants because I'm on PrEP"; - (K) “Even though I'm on PrEP, that doesn't mean I'm with everyone without a condom. At times I didn't want to do without a condom. I don't trust anyone". 3. Respondents are waiting for test results (or do not know their results) and therefore use a condom: - (O) "I was not tested this time, so I use condoms"; - (O) "Trust, but check, so it's best to use condoms before the tests". The respondents take decision on whether to use a condom based on a talk with a partner. Cases of sexual intercourse without a condom and without taking into account the partner’s opinion happened when there were attempts of committing a rape: - (K) “I had a similar bad situation [attempted rape], but a long time ago. But usually I agreed with people [on condom use]”; - (K) “If I use condoms, it is because it’s a conscious choice. This is happening with the consent of both parties"; - (K) "These issues are discussed when you first get to know each other, and then when you have a private meeting you decide whether to sleep with him with a condom or not".

5.2.4. Use of lubricants

Regarding the use of lubricants in a sexual intercourse, the answers of the respondents in the baseline survey were distributed as follows:

Fig. 5.2.4.1. "Do you (or your sexual partner) always use lubricants (gels) in sexual intercourse?", %

The analysis of responses showed that 21% of respondents use lubricants “always“, 39% - “sometimes“, 36% “do not use at all“. The FGD participants shared the following additional comments: - (K) “I used contraceptives for pregnancy prevention. I used to have a very long-lasting relationship. And lubricants too"; - (K) "I use lubricants in 90% of cases"; - (K) "Lubricants - always, it is too difficult without them"; - (K) "Sometimes I have sex without a condom and lubricants…".

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5.2.5. Examination

An important factor motivating a sexual partner to be tested for HIV, TB, HCV/HBV, STIs and other socially dangerous diseases is discussion of health issues with him/her. For the distribution of respondents’ answers to this question, by gender, see Fig. 5.2.5.1:

Fig. 5.2.5.1. Distribution of respondents' answers to the question: "Do you discuss with your sexual partner issues related to your and your partner’s health?", % by gender

Thus, the majority of respondents stated that they discuss with their sexual partner issues related to their health - this was reflected in the answers of 31.6% of male respondents and 17.6% - female; 23.8% of men and 7.8% of women discuss this “sometimes“; an equal number of men and women - 2.1%, cannot recall such episodes. But 10.9% of men and 3.6% of women do not discuss such topics at all. The distribution of respondents' answers to this question by age categories is given in the Table 5.2.5.1. Table 5.2.5.1. Distribution of respondents' answers to the question: "Do you discuss with your sexual partner issues related to your and your partner’s health?", % by gender

Do you discuss issues related to your health? We discuss, Age We discuss We do not discuss I don't remember All responses sometimes N % N % N % N % N % 18-24 years 18 9.4 13 6.8 17 8.9 1 0.5 49 25.7 24-29 years 22 11.5 6 3.1 14 7.3 5 2.6 47 24.6 30-34 years 17 8.9 3 1.6 18 9.4 0 0.0 38 19.9 35-39 years 24 12.6 1 0.5 6 3.1 1 0.5 32 16.8 40-59 years 12 6.3 5 2.6 7 3.7 1 0.5 25 13.1 Subtotal 93 48.7 28 14.7 62 32.5 8 4.1 191 100

Out of the total number of respondents, this question was answered by 191 respondents. Of these, 93 respondents (48.7%) discuss health issues with their sexual partner, including: 24 respondents (12.3%) in the age category "35- 39 years", 22 respondents (11.5%) – from the group “24-29 years", 18 respondents (9.4%) – from the group "18-24 years", 17 respondents (8.9%) – from "30-34 years", 12 respondents (6.3%) – from "40-59 years". This topic is discussed

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“sometimes“ by 62 respondents (32.3%), in particular: 18 respondents (9.4%) from the age category "30-34 years", 17 respondents (8.9%) – of "18-24 years", 14 respondents (7, 3%) – of "24-29 years", 7 respondents (3.7%) – of "40-59 years", 6 respondents (3.1%) – of "35-39 years". Finally, 28 respondents (14.7%) do not discuss this topic at all and 8 respondents (4.1%) do not remember if this was ever discussed. And as for what particular topics related to health the survey participants discuss with their sexual partner, the information is presented in the Table 5.2.5.2. Table 5.2.5.2. Distribution of answers to the question "What specific aspects of your and your partner’s health do you discuss with your sexual partner?" Respondent's category* PWUD who do Transgender Clients of female Sex worker MSM not attribute person themselves to SW Respondents' answers any KP % of all % of all % of all % of all % of all N in the N in the N in the N in the N in the category category category category category About the need to have a safer sex 8 14.5 32 14.2 1 100 59 11.8 2 25.0 About the need to use condoms 8 14.5 33 14.7 0 0.0 52 10.5 2 25.0 About the need to use lubricants 5 9.1 30 13.3 0 0.0 14 2.8 0 0.0 About the need for regular medical 4 7.3 19 8.4 0 0.0 65 13.0 0 0.0 examinations About reproductive health 0 0.0 6 2.7 0 0.0 38 7.6 0 0.0 About family planning 1 1.8 4 1.8 0 0.0 32 6.4 0 0.0 About the first medical aid with 0 0.0 3 1.3 0 0.0 33 6.6 2 25.0 overdose of PS On routes of transmission of HIV, 2 3.6 24 10.7 0 0.0 47 9.4 0 0.0 HCV, HBV, STIs On treatment of HIV/AIDS, HCV, 1 1.8 13 5.8 0 0.0 22 4.4 0 0.0 HBV, STIs About a healthy lifestyle 3 5.5 14 6.2 0 0.0 65 13.0 0 0.0 About high prices for medical services 1 1.8 16 7.1 0 0.0 49 9.8 0 0.0 On the need for pre-exposure 1 1.8 14 6.2 0 0.0 9 1.8 0 0.0 prophylaxis We do not talk about health at all 21 38.2 17 7.5 0 0.0 14 2.8 2 25.0 Subtotal 55 100 225 100 1 100 499 100 8 100 * respondents had the opportunity to choose several answers for the category to which they belong

Almost half of all respondents (50%) discuss with their sexual partner the need for safer sex, 47% - the need to use condoms, 45% - the need to undergo regular medical examinations, 42% discuss healthy lifestyle. To the second group of priority problems respondents attribute a set of topics including ways of transmission of HIV, HCV, HBV, STIs (this was mentioned in 37% of responses) and the high prices for medical services (34%). Almost a third (18% - 24%) of respondents discuss such topics as: the need to use lubricants, reproductive health, family planning, first aid in drug overdose, treatment of HIV/AIDS, HCV, HBV, STIs. The need for pre-exposure prophylaxis is discussed by 12% of sexual partners. And in the answers of a third (33.5%) of respondents it is stated that they do not discuss health at all (in this regard the assumption can be made that this cohort includes those respondents who discuss the above topics with their sexual partner, as respondents had the opportunity to choose several answers). The respondents reported that they undergo examination and encourage their sexual partner to do so, especially when they abstain from using condoms:

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- (K) “I don't really like condoms in general. And before I started sleeping with my regular sexual partner without a condom, I had done a test, and asked him to do a test as well"; - (K) “Well, I have a permanent partner relatively recently. We raised this topic, we raised this issue. But we haven't done the examination together yet. - But did you talk about it? – Yes, of course"; - (K) "No, prior to starting the relationship - no [were not examined]… Before we started the relationship we hadn’t talked about it, but in the course (of relationship) we had examinations"; - (K) "When I had more or less permanent relationship, yes, we did it".

5.2.6. Testing for HIV, hepatitis, STIs

The health related topics that respondents discuss with their sexual partners include such aspects as: routes of transmission, testing and treatment for HIV, HCV, HBV, STIs and other socially dangerous diseases. The distribution of answers to these questions is shown in the figure below:

Fig. 5.2.6.1. Distribution of respondents' answers regarding discussions with a sexual partner on the transmission, testing and treatment of HIV, HCV, HBV, STIs, % by category

The question about discussing routes of transmitting HIV, HCV, HBV, STIs with their sexual partner, was answered by only 78 respondents, including: 5.8% of MSM; 4.4% of PWUD who do not attribute themselves to any KP; 1.8% of SW. As for the treatment of HIV, HCV, HBV, STIs, only 56 respondents answered this question, including: 10.7% of MSM; 9.4% of PWUD who do not attribute themselves to any KP; 3.6% of SW. The respondents said that they had recommended their partners (or vice versa) to be tested for HIV, hepatitis, STIs and explained the need for testing: - (K) "Yes, I offered"; - (K) "If you have one partner, then it will not hurt to do the tests once in every three months"; - (K) "We haven’t done tests together, but in general I advise to do the tests every three months"; - (K) “Yes, I motivated. How many partners - I do not remember"; - (K) “When it comes to sex, I always have a question about health. There are those who have never been tested, I recommend them where to go"; - (K) “Of course [I motivate for testing]. I do not trust anyone at all, even my close partners. They get examined regularly, every six or three months. We have an open relationship, that’s why we are cautious. We use contraceptives"; - (O) "If it does not spoil the relationship, then, of course, it is necessary. I motivated (a partner) for HIV test";

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- (O) “I propose. People do the tests. In most cases I test my partners myself”; - (K) "I often motivate my partners to get tested together with me or just get tested for HIV"; - (O) “When it comes to casual partners, this is not a question. When a permanent relationship was evolving, this question arose, but it was never resolved. Some time long ago we did go for a check-up"; - (O) "I brought a lot of former partners"; - (O) “Yes, but he himself knows that prevention and examination are needed. I'm also being checked. Twice a year is mandatory"; - (O) “If he is not stupid, he does it himself. I also send for an examination". The respondents provided the following arguments when motivating partners to test: - (K) “I say that in most cases you just can’t guess that your partner is contagious. That is why it is necessary to get tested”; - (O) "I motivate, I say that there is the HIV epidemic, irresponsible partners"; - (K) "There was no reason, just to be confident"; - (O) “I immediately started with the fact that you need to check yourself, for your own knowledge and to prevent paranoia about it. And also simply as etiquette requires"; - (O) “Yes. I want it"; - (O) “When I was in a relationship, of course, I offered. Sex with a condom is same as life in a plastic bag". The partners mostly agreed to be tested (at least for HIV): - (O) “I offered my partners to take HIV tests, they agreed. Whether they did tests for hepatitis B, C – this I did not clarify"; - (O) "I proposed, they agreed". The partners confirmed to the respondents that they had done the test, and the respondents knew about it: - (K) “If you recommended to get tested, were you informed afterwards of the test result? - All of them did the test (everyone confirmed: and same with me)"; - (K) "Got tested in the “Alliance“ - for HIV, STIs, hepatitis"; - (O) "I ensured all of my people got tested"; - (O) "Yes, always [I know they have done the test]"; - (O) "No medical certificate - no conversation"; - (K) "I offered, and each of them did the test"; - (O) "Yes, of course, they did"; - (O) "Some of my friends whom I brought to the “League“, I offered them, and they did the test the same day"; "You can catch the infection not only through sexual route, so once in every six months you need to be examined, get tested". However, some respondents sometimes did not know whether their partner had done the test: - (O) “I advised (to get tested), but I did not insist. I don't know whether they did the tests or not"; - (K) “When I’m getting to know someone, I always ask when the person was tested last time and what he/she thinks about own health. If I am not happy with the answers, I can advise to do the tests. Whether this person will do the test – this is what I don’t know"; - (K) "I propose, but whether they go or not, I do not know". The respondents were tested for HIV/hepatitis/STIs together with their partner or individually:

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- (O) "I take partner’s hand and walk him/her there"; - (K) "We went together [with a partner]"; - (K) "We went separately"; - (O) “My husband and I are getting therapy together. We are being examined together". In most cases the respondents confirmed that they knew the result of partner’s testing: - (K) “Sometimes they say [test result]. I don't trust people much"; - (K) “I can't say yes or no. Some of them told me later that they had been tested and everything was fine, but you can't trust it"; - (K) "I know [test result]"; - (K) "Yes, we went to have the examination together and learned the result"; - (K) "The people were examined and told me the result"; - (K) “In most cases it becomes known to me if I make the partners interested in a longer relationship. I motivate to get tested and primarily know the result of the examination"; - (K) "People who are close to me - yes. I do the tests more often. My close people have done the test, I was present. I know the result. I don't know about others"; - (K) “Yes, I know. Sometimes I personally bring them to the AIDS center, hospitals, the “Alliance"; - (O) "I'll be sure to ask afterwards, or the person tells me, if this person went there [for testing]"; - (O) "Did the tests, I know the results"; - (O) “They told me [about the test result]. But it’s not the first thing I require from my partners. I say that if there is nothing bad and I do not need to worry, you cannot let me know"; - (O) “I know. They told me what the results were"; - (O) “Yes. And not only they told me about the results, but also proved by a photo of the tester"; - (O) "Yes, they shared [the test result]"; - (O) “Yes, I know [the test result]. All is fine. I go with him, and he tells me right away"; - (O) "While we are in the relationship - yes, I know"; - (O) “The reason for the lack of information – we don’t go there. It is necessary to get examined soon. I did not do tests – I never have time". In some cases, the respondents do not propose their partners to get tested. The FGD participants provided the following reasons: • the respondents do not wish to be officious and burden with advice: - (O) “I do not scatter my advice. If a person doesn't ask me, I don't speak. If a person asks, I will advise"; • the partners get tested on their own decision: - (K) “I rarely offer partners to be examined. In most cases, these are people who do regular tests themselves”; • short-term relationship (with safe sex or accompanied with the PrEP): - (K) “I have different partners. To some of them [I propose testing], to others - not. In case of a longer relationship, I propose. If it's a commercial or one-time relationship, then no". At the same time, the respondents reported their partner's refusal to test: - (O) “I did the test, but the guy did not. I told him that he should"; - (K) “I have an unusual case: a guy does not want to be checked. I suspect he has hepatitis. I told him that I have hepatitis. He told me a lot of bad and ugly things about me - I listened. He doesn't want to, and I can't make him go

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to check. He just doesn’t want to. This is stupidity, this is absolute ignorance. And he does not want to know, to receive information from me. Unusual case, but it also happens. Reluctance". The reasons for refusal given by the partner: • bad attitude towards doctors: - (O) "She offered me, but since childhood I have a bad attitude towards doctors"; • protected sex: - (O) "In some cases I offered, but the person refused, because we are having sex with a condom, anyway"; • distrust of medicine (in particular to the ability to cure the disease after it is diagnosed): - (O) “If I believe that I will be cured, then I will go there. And if they put a cross on you (consider incurable)... for example when it’s about HIV. It's just so insecure with our medicine". The partner's refusal to test is a reason for the respondents to suspend the relationship: - (K) “I don’t do it straightforward [I do not motivate to do the test], because it may not be entirely correct. It’s necessary to gradually move on to this conversation. If I have any questions, I say that I do regular tests, I know where one can get tested, and then give advice to get tested. If a person is not interested, then I have a question whether it is worth dealing with such a partner“.

5.3. The impact of communication with parents (relatives) on the use of services

The FGD participants said that the attitude of their parents (relatives) to the fact that they use PS varies - while some are accepting it, others condemn the user; while some have open discussions, others have to conceal the PS use. The communication model influences, in particular, whether PS users discuss their health problems or receive advice, support or assistance from their relatives.

5.3.1. Models of interaction with parents (relatives)

1) Non-disapproving attitude: parents know about the respondent’s use of PS, do not express disapproval, introduce these PS to them, practice shared use, and give advice on caring for health:

- (K) “My father, in principle, is fully aware of my use of psychoactive substances. - Do you have trust-based relationship? - Absolutely. I first heard about psychoactive substances from my father... And it seems to me that this was one of the reasons for their divorce from my mother. - She did not accept his view? -… This was one of the main reasons"; - (K) “I basically have the same story with my father. We could smoke weed together. And my mother is also fine about psychoactive substances"; - (K) “My parents are doctors. So it didn't make sense for me to hide (laughs; friendly laughter). My parents also know about my experience, in principle, I trust them. I tell them about it, and they understand me. – They do? - Yes, they know, it's important for them that I trust them as much as possible, and that's why they had to accept it"; - (K) “I have good relationship in my family. Very good. I am lucky to have a good family. And I told my mother about the use of psychoactive substances. I was living abroad at the time when my older sister was taken to rehab, and now she has schizophrenia due to taking certain psychoactive substances. Unfortunately, rehab didn't help, so I had to tell my mother what I was taking, in what amounts, to help her deal with the situation"; - (O) “This is a person with whom I can be open. Just say what I think. These are mostly not relatives, but friends. Although my mother has also recently become close to me"; - (O) “My mother and I are the best pals. She knows all my secrets".

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2) Disapproving attitude: parents (close relatives) condemn the respondent’s use of the PS. In this situation, respondents have the following variants of relationship: • immediate relatives condemn the use of PS, by default, they do not know that the respondent uses PS, and the latter, in turn, does not inform the relatives about it: - (K) “My mother is a typical elderly post-Soviet woman who is afraid of everything. She is like "They smoke their weed and then go kill someone". So here I'm rather trying to just not tell her anything. We live in different cities, and this makes the situation easier"; - (K) “I want to say that my family does not know at all what psychoactive substances are. And they have no idea at all that I can use anything or that I am somehow familiar with it. Because for them it’s like: "Oh God, these are some drug addicts..." And they, in my opinion, don't even understand that it is possible. For them, these are people who sleep on the ground near a fence. Like this. And their whole life has already gone downhill"; - (O) “Everything is very vague with my relatives. In reality, against the whole background of what is happening, they perceive everything differently. And you even feel sorry for them, and on the other hand, if you tell them everything, there will be a conflict, and that's why you hide certain things from them"; • immediate relatives know and disapprove the fact of PS use by the respondent: - (K) "My husband's sister lives in the next room…, she also does not use… and she is against it. And she knows that I use, she disapproves it, although I do not invite anybody home, do not get too much, do not make a hellhole there, nothing"; • despite the disapproval of relatives, the respondent does not refuse to use: - (K) “I have a sister. She does not use. We have conflicts with her because of this, because she is very worried about me… Everything turned upside down: the longer I use, the worse our relationship. But this does not make me stop using"; • the respondent uses PS, but lies to others saying that he/she has quit: - (K) “I use. But I told her [mother-in-law] that I had stopped. She seems to be suspecting, and the relationship becomes very bad. - Despite you don't do anything bad to her, you don't ask for money. - I'm not asking for anything from her"; • the respondent lives separately from relatives so as not to upset them with his/her use of PS: - (K) “I have to leave the house so that my family does not worry about me. Every day I come home – they say: "You were seen there, there and there." And so I'm going away for them to stop worrying"; • the respondent tries to "remain normal" in the presence of a child (refuses to use PS or takes a minimal dose to stay in controlled condition): - (K) “My daughter is five years old. So I try not to use PS when I’m with her. I do it secretly. And I try to be in a more normal state, adequate to go for a walk with her, to chill out". 3) Respondents do not inform about their use of PS: - (K) "We have good relations, but they do not know about PS, I hide it"; - (O) “I can talk about everything with my husband. My mother does not know that I used to take PS. She doesn't know that I'm enrolled in the program either. Only my husband will help". The respondents who are MSM have similar family relationships: - (O) “When it comes to any household related requests, illnesses or whatever – I share, because they are close people and so I can ask them. But anything personal - no, because they do not yet know about me, and I'm afraid to tell. We all live together, everything is fine". 4) Indifferent attitude of relatives to the respondent’s drug use: - (O) "My mom knows, but she is indifferent".

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5.3.2. The impact of relationships on discussion and resolving of health issues

The respondents' relationships with their family members greatly affect the extent to which they discuss health issues, seek advice, and seek medical assistance. The respondents shared that they follow the advice of their relatives differently: • the respondents ask for advice and act on it, seek help: - (O) “I can ask for help. They always help with advice and money"; - (O) "I can ask for help, but not for advice"; - (O) "I trust my brother the most and I can rely on him"; - (O) “My parents are super-duper, they are great… My parents will always help me and give me tips for any challenges in life. I'm fine in this regard"; - (O) “Yes. More in household related matters"; - (O) "Over the years, I have just started listening to them"; - (O) "Yes, very much"; - (O) “In different ways. In most cases, yes"; - (O) "I used to ignore (advice), but as I was getting older I began to listen to my mother's words, because I understand that my mother will not wish anything bad"; - (O) "Sometimes I listen to her, sometimes she listens to me"; - (O) "I listen to my husband"; - (O) “I have a relationship with a long-distance partner. I ask for advice on how to do something if I have health problems. But financially I provide for myself in this regard"; - (O) "My son fully supports me – anything about me, with all my imprisonment cases"; - (O) “If anything, only mom and dad will be next to me. But I try to keep them away from my lifestyle, as much as possible”; - (O) "Relatives support me, and I always try to listen"; - (O) "I listen, and they support me in absolutely everything"; - (O) "If something happens in terms of health, the main advisor is my mom"; - (K) "All moments of life - with mom: health, treatment"; - (K) “I listen, I rely on the advice. This advice is not of paramount importance to me, but I pay attention to it"; - (K) "I listen to the advice of family and friends"; - (K) “Yes, I ask for advice if the decision is very serious. For example, in case of a very serious medical intervention, I will consult"; - (K) "Yes, I listen to it"; - (K) "I consult on serious matters"; - (K) “With my grandmother, if something is serious. When I had a medical intervention, she drove 600 km to me to stay with me throughout my recovery period"; - (K) "If I have a situation where I have to see a doctor about my addiction, I would like my close friends to contact my parents and tell them about it, because I myself will never tell them about it"; - (O) "I try to listen to them, because they have life experience"; - (O) "Whenever possible, I try to listen";

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- (O) "When I am depressed, I delegate the right to make decisions to my close people"; - (O) “There are situations when you can't help yourself, then I ask my mother to do it. For example, when I'm sick, she can do something I can't do at the moment"; - (O) “When I get sick, I turn to my relatives. Sometimes they say that it will go away without external help, sometimes we treat it by ourselves. We rarely go to the hospital"; - (O) “It is always difficult for me to make a decision. I always postpone the deadline for taking a decision. I try to ask everyone for support, advice, opinions. And still it is very difficult for me to choose. I always ask for support"; - (O) “Although I no longer live with my parents, my mother gives a lot of advice - to which doctor to go to, what medication to take. I will listen if I do not have such experience. Not always, but it happens". In some cases, the reason for seeking help (advice) from relatives is not only good family relationships, but also because the relatives have relevant knowledge (e.g., medical education): - (K) “In my case my parents are doctors, so first of all I consult with them. And this is logical. - That is, everything is fine, you don’t have to hide. - Yes"; - (K) “I actually have a similar situation. In my family, some family members have medical education. Therefore, quite often, if there are any questions, if there are health problems, I can consult with my grandmother, mother, find out from them where you can go periodically to check if everything is OK"; - (O) "Yes [I listen] if I see that this person understands this and does not have his/her own thoughts and experiences about it"; - (K) “I have my opinion, as well as information from various sources. Despite this, I often consult with my grandmother, because she is a doctor. She has known me since childhood, so I'll rather tell her. I can talk to her about drugs, but she has little experience with such a topic, so she doesn't know how it works"; - (O) "If competent in this area, then yes". The respondents also shared that they do not always listen to the advice of their relatives (or do not ask for such advice) due to the fact that: • relatives are less knowledgeable of the topic: - (O) “I don't listen at all times. It seems to me that I am smarter, I know better, more"; - (K) "Sometimes I consult with parents, but more often - with friends whose opinion I consider relevant"; - (O) "50 to 50. Depending on the person"; • they prefer to rely on information from the Internet: - (K) “I listen to the opinion, but it doesn’t form my final decision. I get information on the Internet"; • relatives neglect their own health, are too focused on self-medication: - (O) “In our family we have a therapy. The people endlessly absorb pills, take preventive measures. Yes, I trust"; - (O) “My mother is an economist, but she passed some basic medical course, and she can advise me about certain things, she understands a bit. She behaves badly with her health, has a lot of diagnoses, she doesn't go for medical examinations, despite my requests. It’s not a usual practice in our family to take care of own health. That's why I learn more about care and health from my girlfriend-wife, we have been together for five years"; - (O) “Of course, I will ask if I am interested in something. But at the same time, I am quite sceptical of their advice, because I watched how they eat pills and it is not scientifically justified. They have some rational ideas, but you need to check everything again. But as an additional source of information - why not? Additional, not the main"; • the respondents prefer to consult a specialist: - (K) “If I need to make a health related decision, I would rather go to the doctor than to anyone for advice. I think that medical workers are more qualified in these matters"; - (K) “Most often I go to a specialist, I do not need help of someone external. I will discuss this with my boyfriend or girlfriend as much as possible”;

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- (O) “I do not address my relatives on this. I have a close friend, a doctor, and for 10 years I have been asking him questions. So far I have not experienced any health problems"; • cannot comprehend the advice given and forget it when being under the effect of substances: - (O) “I try to listen, but not always. Sometimes I just forget or when you're under some kind of substances, you won't remember it later. When I’m under the effect of alcohol, I generally have memory lapses"; - (O) "You can listen to but still not hear advice, especially while you are under the influence of substances"; • peculiarities of a person’s character coupled with awareness of harmful behaviour: - (O) “I try to listen, but often a mechanism inside me starts doing the opposite. You have your inner sense of justice, something prevents you from doing it, you understand it, but you still do stupid things. I often try to listen, but it works the other way around. Now I listen more than before. The saddest thing is when they warned you and you did not believe them. I have a lot of such bad experiences". The respondents also spoke about the family's willingness to offer assistance if necessary, provide advice and support: • the family is not indifferent to the respondent's health and cares about him/her: - (K) "I discuss health issues, roughly speaking, every day. Why? Because I think that the family are the closest people I have. And they are very much worried about me. I can even say that I don't care as much for someone in my family as they do for me. And as for health – they ask every day: how do you feel? How are you?… They worry more about me because they know that I am, so to speak, an unhappy being”; • the family supports the respondent and is ready to provide assistance if needed: - (K) “How often are you supported by family and friends in difficult situations? - Constantly"; - (K) "My family supports me"; - (K) "I feel supported"; - (O) “I deeply respect my mother, I consider her the best woman on the planet. An optimistic icon, my mother is awesome. She may not always [give] advice, but I can definitely ask her for help and I know that I will get it. I am counting on this person, I do not know, of course, whether she is counting on me"; - (O) “[Father]… lives separately, he has his own wife. I can tell him everything. I come to him, I can ask for help"; - (O) "My mother has now become a psychologist and lives in her little world and wearing pink glasses. I have a good relationship with her, but I can't fully understand her. I ask her for advice as a psychologist, too. And she, too, strangely enough, asks me for advice and help. We help each other"; - (O) “I have wonderful parents. My mother is a psychologist, my father is a businessman… Now I am quite close with my mother, I tell her a lot. Time flies and forces them to get used to and be interested in what used to cause disgust and fear. I can ask my mom and dad about everything too, both of them help me”; - (O) “All my relatives know about me, I can talk to everyone, but my mother helps me the most. If something happens, everyone gets engaged and helps"; - (O) “My mother has already suffered so much with me. Whatever happens, she will always help. I try not to talk to my mother about drugs, but if I need support, I say it”; - (O) “Everyone knows about me too. I can talk about everything, but not about drugs. Support can be provided only in extraordinary cases"; - (O) "At least they try to help, and that's good"; - (O) “They help. It depends on the situation, in some situations no one can help, only sympathize"; - (O) “Yes, they supported and keep on supporting. I'm sorry for not appreciating it before. Now things are a little better with this"; - (O) “In some periods - yes, in other - no. If I can't handle it myself, I ask for help".

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However, some respondents reported that despite good family relationships, over time parents become less worried about the health of the respondent who uses PS, they do not notice when he/she needs help: - (K) “I used to be supported. And now, they probably got tired of supporting me. It’s my fault. They almost stopped. They smile, of course, they love, but I really can't ask for any help"; - (O) "It becomes hard to ask for help from my father… He exists in harmony and sometimes it's even nice to watch him, but it hurts that he may not notice that I need help"; - (O) "They don't help". On the other hand, some respondents indicated that they do not inform their relatives about health problems, treatment and medications they take, they do not seek their help. The reason for that can be either their own attitude, or the attitude of the family: • the respondents rely only on themselves, decide on their own: - (O) “I filter advice I receive because it can't always be applied to my reality. Sometimes I do things my own way”; - (O) “If I ask for advice, I listen. If I don't need advice, it's better not to come to me with it, my relatives know about it"; - (O) “My environment (close people) is not as authoritative as it was a few years ago. I do not give advice myself if I am not asked what to do. In my youth, my circle of friends had a great authority with me, and now I am my own mentor and support"; - (O) “I try not to announce that I need help. I decide for myself"; - (O) “I am in solidarity with [male name]. By myself"; - (O) “I have an intuitive attitude to everything. In general, I always had good health. When I realized that something was wrong, I resolved it by myself"; - (K) “In the past, when there was such an opportunity, my family helped me. Now they don't help much, because I'm independent and I'm very far from them"; - (K) “I can listen to all parties, but I always have my own opinion on everything. The last conclusions remain with me"; - (O) "Sometimes I close myself from others. No matter what they say, I don't listen. And sometimes something useful comes in"; - (K) "In most cases, I do not turn to anyone"; - (K) "I rely only on myself"; - (K) "I don't tell anything to my parents, they find out from my grandmother when all is already done with me"; - (O) “I always re-assess based on my life experience. There was a period of complete denial"; - (O) “Nobody solves these issues except me. I am self-sufficient"; - (O) "No decisions are made for me"; - (O) “I am an independent person. I don't know what issues may make it necessary for my parents to help me. I am responsible for myself. Unless I'm in a coma, then the decision will be up to the parents. Otherwise the decision will be mine"; - (O) “When I had such situations, I tried not to let the family know. Other relatives supported, and I am very grateful for that"; - (O) “No. I always solve problems by myself”; • unfriendly family relationships, territorial remoteness: - (O) “I have a big family. They play an important role in my life. I see them every 5-6 years. We do not ask each other for help"; - (O) "I do not listen to them because my relatives are living not close to me";

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• the reaction of the family will not help to solve the problem, but will complicate it: - (K) “It all depends on what kind of sickness I have and how it goes. If it's just that I feel bad, then I can tell. But now, for example, I'm taking , and my parents don't know about it. They don't know that I may have depression right now and I can't tell them about it at all… I just have a very anxious family and it seems to me that they may have a reaction, like: it's all bullshit, it’s all in your head, in fact you need to calm down, go to work, play sports... Don't stay at home. Or vice versa, they can get so involved and start to worry so much about me that they will take me to their place and just lock me in their apartment, and I'll just sit there"; • the respondents prefer not to seek help from some parents, although they can help (reasons for non-referral: relatives are not competent in these matters, lots of reproaches and preaching towards the respondents): - (O) “I take decisions until the very last moment. When I realize that there is no way out, I refer to them. Often they are not competent in these matters, and I am very upset that I put myself in a dependent position. They start endless preaching about me doing everything wrong"; - (K) “If you ask for money [to get medical assistance] - no, they will not help. Although they can help, but then there will be so many accusations that it is probably better not to even ask"; - (O) “I can talk to my family about everything, but drugs are taboo. I can't ask for help or advice. I received treatment seven times, was taken everywhere. I am considered a failed person. My parents can't help or support me. Only my husband and his mother can". Some participants, in addition to drug use, had another practice of HIV-risky behaviour - they were MSM. The models of their relations with parents (relatives) are similar to the models of relations shared by users of PS: some of them are described as full of understanding and mutual assistance, others – as cases where the users are refused help due to the homophobic views of relatives: - (K) “The closest people in the family are my mother, my father and my sister. I can turn to them for help and advice. They will help and will not leave. My relationship with my family is good"; - (K) “I can turn to them for help at any time, but I prefer to solve everything by myself. In a critical situation, I can turn to them"; - (K) "They are all very close to me, and we have a good relationship. I can count on them. When the family found out about my preferences, they did not turn their back on me, I think it can be considered as support"; - (K) “I have almost no contact with my family. I communicate only with my grandmother. I can ask my family for help, but since I don't communicate, I don't want to do it. My grandmother is very far away - in Crimea, so I tell her everything that happens to me, but [she] is limited in her ability to help me physically. I can get moral and psychological support from her, but we have very different experiences, in view of the difference between the generations. Therefore, in many situations, she can support me, sympathize, but cannot fully understand. If it was necessary in a critical situation, I could turn to my parents, it's just my choice not to do it"; - (K) “My stepfather, he accepts me as I am, we spend free time together. We don't get along very well with my mother"; - (K) “If anything, I turn to my grandmother. I do not turn to my relatives because they are homophobic”; - (K) “My parents. The relationship is good. I am sure that they will support me in any situation"; - (K) "Very good relationship with parents… If necessary, I'm sure they will help me".

5.3.3. Involvement of relatives in testing and medical examination

The respondents reported that they involved their relatives in testing and even conducted testing at home: - (K) "I tested my relatives at home"; - (K) "I also tested my relatives by myself"; - (K) “I even got my mother tested. All of them"; - (K) “If you recommended to someone to do a test, were you informed of the test result? – All of my people have done the test [everyone: "Same with me"].

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5.4. Involvement of friends in discussing and resolving health issues

The respondents described their friends, in particular in terms of their belonging to the target groups of this assessment (SW, MSM, drug users). The FGD demonstrated that: - among friends there are both representatives of the target groups and those who do not belong to them; - the ratio of these categories of people among friends has no regularities: from (O) "No, and never was" to (O) "Yes, among my friends only this kind of people"; - The respondents treat representatives of target groups who are friends with understanding, without condemnation: - (O) “They don't talk about it at all, but I just know about their preferences. I accept them as they are, we do not communicate on intimate topics". - among friends there are both those who use drugs and those who do not use them; - the ratio of users and non-users among friends is spontaneous (whether a person is a user or non-user is not a criterion determining whether the respondent is interested in this friendship); - friends include people who have stopped using drugs; in relation to them, the respondents did not express condemnation or ridicule. Thus, in the course of the FGD and the survey, a number of factors have been identified that may be prerequisites for involving these individuals in receiving medical and social services and changing their behaviour to less risky.

5.4.1. Discussion of the issues with friends

The respondents pointed out that among the interests that are common to them and their friends, drugs are considered as a significant topic: - (O) “Drugs. It would be desirable to have it when you are 20, when you are 50, but when you are 50, nobody gives them without money"; - (O) "Common interests - drugs, nothing more"; - (O) “I worked in a pharmacy. Many acquaintances come for advice. Common interests - drugs"; - (K) "I have two friends with whom I can talk about drugs". The respondents confirmed that they discuss health issues with their friends: - (K) When I have pain somewhere, and we are getting older now, each of us has pain quite often, we (discuss) each other's diseases... Every friend knows each other's diseases. I know what pain has [woman's name-1], and [woman's name-1] knows what pain I have. [Woman’s name-2] knows what I suffer from, I know what [woman's name-2] suffers from. Every day like that"; - (O) "I am not good at it, but such conversations are plentiful"; - (O) “When there is a problem, it can be discussed. But in general everything is fine"; - (O) “It’s a little strange question. Of course, we discuss, it is critical for us. When I have pain in the side, I ask people what it can be"; - (O) “Yes. I rather ask people for advice"; - (O) "We all share experiences"; - (O) "The most painful topics that you see on the surface, those which are worrying and disturbing"; - (O) "Sometimes (we discuss) who has which pain"; - (O) "We consult with each other".

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The main topics for discussion are – how to preserve physical and mental health (including through yoga, sports, healthy food, etc.): - (O) "Yoga"; - (O) "Physical health. Now I go to sports, I urge everyone to do it"; - (O) “For example, something gluten-free. Food supplements»; - (O) "We go to sauna (baths)"; - (O) “I am more worried about mental health. We exchange on what is on our mind"; - (O) “I think a lot about mental health and I discuss it. I figure out what affects it and how"; - (O) “My girlfriend is crazy about it and I was influenced. Care for mental and physical health"; - (K) "We are currently discussing the coronavirus"; - (O) “More often than I would wish to. From issues that cause headaches, to specific medical issues"; - (O) "Medical, hygienic issues of some kind. There are no topics to be ashamed of"; - (O) "We discuss that we are getting old, as well as medical, intimate and lethal diseases"; - (O) “We discuss periodically. Colds, sanitary measures, coronavirus, how to look after yourself, creams"; - (O) "Any health problems, , back pain"; - (O) "He often advertised the "League", invited me to get tested there and to hang out with me. About the window period, etc."; - (O) "Yes, health, medical issues". In the context of this assessment, the respondents discussed the following issues: • HIV infection, hepatitis, tuberculosis (including testing): - (K) "STIs, drugs and health in general"; - (K) "We are talking about STIs, other infections do not bother us"; - (O) "Shared advice – invited to be examined for any bad illnesses"; - (O) "HIV, hepatitis B, C, tuberculosis"; - (K) “We may also touch on the problem of HIV and so on. - What exactly are you discussing on the topic of HIV? – When was the last time when each of us got tested. That’s the only thing I can discuss with the people I communicate with”; - (K) “Out of my 76 people, 6 guys died of HIV and tuberculosis. I saw it all… I worked as a social worker. And in six months I buried six friends. And because of that, I realized how serious it all is. It's very motivating"; - (O) "A friend said he knew where to get tested for free because he did that test"; - (O) “No such topics have been observed recently. But if someone is getting checked, he tells about it"; - (O) “We were checked, even showed the papers. It’s same normal practice, as going to the store for bread"; - (K) "If the topic of sexually transmitted diseases, HIV, hepatitis is raised"; - (K) “Sometimes we talk about testing, but very rarely. - Yes, not often"; - (O) “In a smoking room, very often, when they find out that you are related to health issues or right defenders, this provokes lots of questions. I am actively educating others. Friends then try to pull me out, but then they reach out to me via Direct (messenger). At parties last year, I handed out more condoms than I used for myself”; - (O) “We tell, we educate. And at each group gathering we do so. I distribute condoms"; - (O) "Yes, related to whether to use protection or not";

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- (O) "Yes, I'm talking about protection, condoms and chlorhexidine"; - (O) “I ask a person whether he/she was checked, I like to scare a person, then to growl at him. Then they run to get checked"; - (O) “We discussed what and how is transmitted, that testing is necessary. A standard set of questions"; - (O) “I asked when was the last time they were tested for at least HIV, not to mention hepatitis. There are those who have been tested, but not many. I tell them that it is necessary to be checked, I accompany some of them to the testing site"; - (O) “I keep talking about it, I have tests. We are constantly tested"; • gradual suspension of the use of PS: - (K) “There is another topic about ... substitution. And further support to your body… How to quit using psychoactive substances, with no consequences after that"; • safer sex, risk of getting infected by a sexual partner: - (K) “I had this situation recently. Almost a year ago, I had a lover, and after a while his girlfriend started writing to me via Instagram: "I got tested, detected that I have this and that... Go check yourself". That is, even strangers can behave responsibly. And with friends - if any infection or a gossip related to sexual life… - Yes, we talk (everyone nods, confirms)"; - (K) "My friends often have the question of how to make sure your partner is not infected"; - (K) "I discuss safer sex with everyone"; - (O) “I don’t, lately. But earlier - yes [talked about health, testing]. I even accompanied my friends to the testing site. My friend somehow ‘hooked’ syphilis. A friend called me at four in the morning to find out the symptoms of syphilis. As a former social worker, of course, I took people to where they did testing and we talked about all these topics". The respondents confirmed that they are aware of the risky nature of behaviour of some of their friends (acquaintances): - (O) "In my opinion, their behaviour is risky. Quite a lot of people are not particularly concerned about it. They pay little attention to their health. I would like them to be more conscious"; - (O) "It's a real problem, in this regard. The moment when it’s happening is important. There are times when anyone may be at risk. But in general everyone understands and bears responsibility"; - (K) "Yes, my friends appeared in risky situations"; - (K) "I have friends who have sex with different partners, engage in group sex"; - (K) “There is a dude who quit drugs and his new passion is sex. There are some risks, but he uses condoms"; - (K) "Most of people understand what they are doing and are aware of the consequences"; - (O) "Some get loaded and stop thinking about anything"; - (O) “If someone practices it, I don't know about it. I believe that anything is possible"; - (O) “In such matters it is better to be responsible for yourself, not for someone. There seem to be no [people with risky behaviour] in my small circle. Old acquaintances - yes, I had a few"; - (O) "There are people who sometimes cross the red line". The respondents gave examples of responsible attitude to their friends’ health: - (O) “Guys come to my house all the time. They can grab my bottle to drink. I say, slow down, I drank from this bottle, you can't"; - (O) “I always warn that I have infections. I am told that this is their health, but I will not allow them to use after me". The respondents compared Odesa and Kyiv in the context of drug use and risky behaviour: - (O) “Odesa is a city where it’s easy to practice risky behaviour. I think it’s more difficult in Kyiv, judging by my experience. I saw dens there. It's safer in Odesa, I mean"; - (O) “It is safer in Odesa than in Kyiv. There is a culture of the south and a culture of the north. We have a more

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positive culture. Drugs are the same, but they are used in smaller quantities". However, respondents indicated that issues related to HIV infection, hepatitis, STIs, etc., were not a special topic for discussion with friends. The main reasons for the limited interest in these topics are: • confidence that everyone is sufficiently aware of these issues and knows how to protect themselves: - (K) “In your conversations, are such topics as HIV and sexually transmitted infections raised at all? - Most often not, because the people I communicate with are already aware of the topic of HIV, hepatitis transmission and so on. And these people are often not injecting drug users. So it seems to me that they know what they are doing"; • most often these topics are discussed when they encounter a respective situation: - (K) “In the last year and a half, I have observed only five situations like this, two of which were super-accidental. They started with a simple talk about coffee, cigarettes, and finished it discussing AIDS, but usually not. Well, who will talk about HIV all the time?”; - (K) "We discussed when some risky situations occurred"; - (K) “Most often it happens when there is a real problem. Or when someone is telling some gossip...".

5.4.2. Help from friends in issues relevant for health and prevention

The respondents compared the importance of their close people and friends in receiving medical care. Some respondents trusted the family more and turned to family for help, while for others the best supporters were friends: - (K) “I can ask friends. … My boyfriend. Although I don't count on my boyfriend starting from today either"; - (K) "It turns out, as if there are two sides of one coin… I would address my family first, rather than friends"; - (K) “Friends are more concerned about me. - Yes, they are more worried than relatives. - It's not the same in each case. – Each case is different"; - (K) “One true friend and a godmother of my child help me the most, because… I don’t have anybody else. That's how it turned out". The FGD participants emphasized their readiness for mutual assistance among drug users: - (K) “Mutual assistance on health related matters - it still exists. - Of course. - We know each other. If we don't help, no one will help"; - (K) “Even if you don't know, but you can help, you will help. All these stories that drug addicts are murderers... – That they will pass by, if a person is ill – that they will step over this person, - there is no such thing"; - (K) “More open, more helpful to each other. - If someone is ill, addicts can come together and help. - We are more compassionate, even loyal. - And we don't hide it".

5.4.3. Involvement of friends in testing

The majority of respondents indicated that they actively encourage their friends to get tested, motivate them, and take them for testing: - (K) “And any advice, recommendations about testing? Do you share advice with each other? – For sure"; - (K) "I tell that testing is necessary"; - (K) “I offered my friends to get tested in the "Alliance". It would be good to get tested every three months to get rid of worries and protect yourself from risky contacts"; - (K) "I motivate them for a safer behaviour and to get tested"; - (O) "I called my friends for testing. HIV test"; - (O) “I knew one couple, I sent them for HIV (test). I sent my friend also because he was not morally ready to come to the infectious disease hospital with his problem".

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The most common way to encourage someone to go for testing is to set your own example, practice peer-to-peer communication, and share your own experiences and knowledge: - (O) “I motivated them by telling them that I would not come to their funeral if they become infected. The main motivator is when people have plans for the future and they think they will not be able to fulfil them if they get sick. Financial motivators do not work because a person does it unconsciously and will never do it again for free”; - (O) "I motivate by saying that health is the most important thing they have"; - (O) “I motivated by telling that life of my interlocutor is important to him in the first place. And that, if he kicks the bucket, he will not suffer much"; - (O) “I motivated by convincing that the earlier you get to know your status, the easier it is to survive. If you're negative, then cool, you can ensure you stay like this. If the test is positive, then you can get treatment instead of dying of unknown cause"; - (O) "I used my own example"; - (O) "I set a personal example"; - (O) "We consult each other as "peer-to-peer". Everyone has own experience, and we try to pass it on”; - (O) "I use persuasion"; - (O) “Yes, I motivated. If I see that someone is coughing, it is wise to send him for fluorography"; - (O) “I propose testing to absolutely every acquaintance of mine. I explain that if they have acquaintances, they should do the same, because this is their life. There is such a thing as a point of no return”; - (O) "It is better to avert than to cure the disease"; - (O) “I tried to [encourage for testing]. I provided examples from real life". When engaging friends, the following methods were used: • by phone call and invitations to test: - (K) “We performed testing for hepatitis and HIV. [Female name] brought us (tests). "Alliance", the car with a mobile outpatient clinic. I also helped recruit guys, and we all called friends together: come to us"; - (K) "Go, here's the car. Come on! And we call and inform each other"; • providing material incentives for doing the test: - (K) “And you motivate them to undergo a medical examination. – In terms of money, it was equal to UAH 60 because not everyone wants. Many people already know their diagnosis, so why check again?”; • providing means of prevention, as encouragement: - (K) “Distribution of, say, condoms. - Syringes, condoms – anything of this. - You just call to a harm reduction (program): come, you know that now one syringe costs 10 hryvnias. - Condoms are expensive and pills are needed. - A condom and three syringes cost 60 or 90 [hryvnias]. – Or disposable alcohol wipes". In addition, some respondents have friends who take the test responsibly and get tested: - (K) "Friends themselves are ready to be tested and do it"; - (K) "My friends do the tests themselves, they do not need to be motivated"; - (K) "People from my circle undergo regular examinations"; - (K) "I took people to the "Alliance". How many - I do not remember. If they suspected something, they went to the clinic for a more comprehensive examination"; - (K) "I brought several friends to the HF center in Lviv. They were tested"; - (K) “My friends were also tested for hepatitis in private laboratories. They have not been tested for HIV before. They did not know about the offices of "Dovira (Trust)", nor about organizations such as the "Alliance";

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- (K) “My friends and I are being examined in a private clinic. We were also examined in non-governmental organizations. Some of them went to the "Alliance"; - (K) "AIDS clinics. HIV Prevention Center. You can buy the tests yourself without any problems. Only two guys referred to the "Alliance", and I accompanied one of them"; - (K) "I motivate to take tests near metro "Livoberezhna" in the AIDS center, in the office of "Dovira (Trust)". I personally accompanied them or watched them visiting these facilities"; - (K) "Some go to the office of "Dovira (Trust)", others – somewhere else"; - (K) “Some people get tested all the time. In the narcologic dispensary, private laboratories, offices of "Dovira (Trust)". There are others, too, I don't know, whether they ever come for testing or not"; - (K) "Some tests are available at home, same as in the "Alliance", anyone willing to get tested can do it"; - (O) “I have friends who referred to a non-governmental organization. For example, in the "League"; - (O) “I know people who went to their doctor and were re-directed to some hospitals for tests. Some people went with me to the NGO "League"; - (O) “Yes, when I worked in one NGO, after I provided consultations to people, they came to me for testing. Now I don't work there anymore, but I still have tests, and I test everyone on my own"; - (O) “I know [that my friends were tested]. They are proud of it, make boast of having done the tests: look - I'm healthy, I’ve done it! I always terrorize them with this, so they always report to me". The respondents indicated that they always try to make sure that after testing their friend visits a medical facility: - (K) “If the testing is done, you are obliged to bring the person to the fifth [hospital No. 5 in Kyiv – which is a municipal AIDS center] and arrange there therapy for this person. You have to accompany this person to the final point"; - (K) "At the very least, we explain to them that they need to take therapy". However, according to the respondents, there are people who treat testing not quite rationally: • ignore advice on testing: - (O) "There are people who just can't hear you"; - (O) "It is useless to say anything to them"; • see the respondent's own interest (benefit) in the fact that he offers testing to others: - (O) “Sometimes they do me a favour, they don’t do it for their own health. I persuade, I ask them as much as I can. Anyone else would probably get offended when they often say "leave me alone". I'm not offended, I understand that people don't have time for that"; - (O) "Everyone thinks that you have some interest in it, while you just care about the person"; • try to benefit in exchange for their testing: - (O) "Sometimes people don't want to go [to be tested] if there is no incentive"; - (O) "(they say) If you pay, we will go"; - (O) "They think I have an interest in this: if you don't pay, we'll find out who will pay". The FGD participants shared that when discussing tests, their friends do not necessarily motivate them (and vice versa: respondents - their friends) to be tested for HIV, hepatitis, STIs: - (O) “If any of my acquaintances get tested, he/she will definitely tell me. I have heard about this experience of friends many times. But no one strongly recommended me the same"; - (O) “Friends do not hide it, but I can’t say they encourage me to do the same. They can just tell me about their experience"; - (O) “The issue is relevant, I don’t remember anyone who refused to get tested. It was an HIV test. In addition, I offered

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to check the blood for sugar, , etc."; - (O) “Everything I say to people is - come to the "League", get tested. I believe that a person should get information by him/herself. I don't like to motivate, I save my energy"; - (O) “I did not motivate people. I offered them, and they decided whether they wanted it or not. If you want, call me and I'll take you there. Most of them wanted to, but some refused".

Thus, the results of the assessment allow to determine the possible ways to attract new clients from among the TGA to receive medical and social services - these are, first of all, though sexual partners, relatives (including parents) and friends. It is the people from the social circle who can influence both the change in the behaviour of KP representatives from risky to safer, and motivate them to receive medical and social services related to HIV, thereby helping to expand the range of recipients of these services. Therefore, providers of HIV services, including NGOs and social services, need to: - carry out targeted informational, educational and advisory activities, work with the nearest environment of representatives of the KP, on aspects like motivation for protecting personal health and the health of loved ones, willingness to provide support or assistance, stimulating KP to reduce risky behaviour, etc.; - promote the introduction of social support for the families of the KP representatives, as well as referral to another entity that provides social services29, application of various forms and methods of work with the immediate environment of the KP representatives, with due consideration to the capabilities of the target audience.

29 According to the order of the Ministry of Social Policy of Ukraine dated 09.07.2014 № 450 «On approval of registration forms for accounting social services to families (persons) experiencing difficult life circumstances»; registered in the Ministry of Justice of Ukraine of 04.09.2014, № 1076/25853

136 Conclusions

In the course of the assessment of accessibility of HIV services for the KP representatives who use NPS/stimulants and barriers that prevent access to these services for representatives of such groups, the experience of drug use by the KP representatives and their friends or partners was analysed, as well as the attitude of people from their immediate environment, specifics of receiving medical and social services in state and non-state institutions. This analysis allows us to summarize the conclusions, as presented below. The respondents mentioned a wide range of drugs that they, their friends or partners use. They also reported that the most common way to use PS/stimulants is oral administration, also known as “swallowing”, while most of the respondents have the experience of using PS that ranges from 1 to 5 years. In addition, home is indicated as the most popular place to use NPS/stimulants followed by similar preference among certain share of respondents for practice of sharing drugs with friends. One third of respondents experienced overdose over the past 12 months as a result of using PS. Analysis shows that overdose issues are being discussed among the broader circles of FDG participants and most of them are experienced and/or knowledgeable on how to provide assistance in these cases. Additionally, the FGD participants highlighted drug quality tests that will help avoid harmful effect of impurities and overdose and increased availability of specialists who can provide assistance, including rehabilitation services, as specific needs related to the use of PS. Moreover, the results of the analysis of respondents' answers prove that there are no barriers to access NPS/ stimulants for the KP (unchanged even with COVID-19-related restrictions). Furthermore, the respondents confirmed that during the last 12 months they had visited medical institutions for prophylactic purposes, for examinations/tests or due to illness and showed a fairly high level of awareness and proactive attitude towardstesting for HIV, STIs and hepatitis. Most of them know where to go for testing for HIV, STIs, hepatitis, TB and have confidently presented the factors that determine the frequency of testing. The vast majority of those who did the test know its result. At the same time, only a quarter of respondents referred to medical institutions for HIV treatment. However, although the majority of respondents did not undergo a course of drug use disorder treatment, some of the FGD participants reported their enrolment in the opioid substitution therapy programs and expressed certain concerns about the situation around the OST program, such as extortion by doctors, poor organization of services, and cases of refusals when attempting to obtain permission for referral for OST (including cases when bribes were expected). The respondents have provided specifically insightful feedback on the main sources of information about HIV, TB, hepatitis, STIs, their quality, appropriateness and effectiveness. Analysis showed that placing information about prevention measures in clubs, locations preferred by the KP for spending free time, is not enough; and only a few clubs are taking prevention measures seriously. On one hand, according to the examples provided by the respondents, information was presented poorly when it did not contain useful data, or when various aspects of prevention were not associated with a recognized person who provided this information. On the other hand, for FDG participants, more effective presentation would be accomplished with the use of professionally produced, interesting format focused on achieving the information goal and targeting the audience in a game-based or interactive form and by raising awareness at major events and clubs. According to the respondents, an important component of information dissemination activities is the paralleled availability of testing, thereby allowing them to receive the service "right now" and "without a queue", which is very important for young people. The analysis of the respondents' awareness of available social services showed some inconsistencies. On one side, although all participants of the baseline survey confirmed that they received various types of social services, including those related to HIV , it was observed that it was difficult for respondents to answer who exactly delivers such measures and how often are they implemented. This is due to the fact that majority of respondents are not clients of HIV service provided by NGOs or social services, so they do not know about their activities. On the other side, FGD participants showed a low level of understanding of terminology and of the nature of services, thereby emphasizing the dire need for more information about social services, in particular through such channels as governmental facilities, the media, mobile applications and brochures in places where they are easily accessible. The participants expressed the greatest interest in support of mental health specialists (psychologist, psychotherapist, psychiatrist) and lawyers, since a complex mechanism for obtaining these services, lack of information, and partial reimbursement of expenses (or critically low reimbursement amounts) are often hindering the use of these services.

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While discussing the procedures of providing medical services and their quality, the respondents identified the main obstacles for referral for such services, namely: high tariffs for services, unwillingness of the respondent to reveal to others the fact of PS use and overlap of working hours of the public health facility and of the respondent. Moreover, queues for admission, inability to get tested due to equipment failure, lack of a doctor and poor management of admission process, improper conditions at the medical facility or being charged for services represent additional complicating factors. Furthermore, the respondents reported cases when health staff demonstrated low professional competences, poor diagnostics, and cases when their professional attitude alternated with manifestations of stigma against them (including disclosure of status) which the respondents have already encountered or are afraid of, unfriendly treatment by doctors who knew about their drug use or saw traces of drug use on their body. In general, although majority of respondents are satisfied with the quality of service provided by public health facilities, these are often regarded as of poor quality in comparison to private institutions which also score better on proper ethical attitude to clients. At the same time, some FGD participants positively assessed the services in state (municipal) institutions and remarked on changes which can be attributed to the ongoing medical reform (including introduction of electronic queues, provision of free medicines). Regarding the non-governmental organizations, the analysis shows that the participants had different experiences of using the services - some of them lacked knowledge about the activities of NGOs, while others actively use their services and cooperate with NGOs. Respondents indicated that they receive more information about HIV from these organizations than from doctors and emphasized benefits of their relationship with NGOs in comparison to negative experiences with state institutions. At the same time, the FGD participants pointed to certain problems in the operation of NGOs and called for improved capacity, performance and professionalism of NGOs and their staff, better advertising and expansion of services beyond activities related to distribution of condoms and syringes. The FGD participants stick to the opinion that relations with the police (as well as with medical institutions) are among their biggest problems. When talking about their experiences with the police, the respondents mentioned more negative aspects than positive ones. Most often, this was linked to lack of trust to police because of actual negative experiences, such as misunderstandings with the police for a transgender person who changes his or her gender caused by his or her passport which indicates initial gender. To improve relations with the police, the respondents suggested that tailored training initiatives are needed. While discussing drug-related criminal liability, the FGD respondents expressed the opinion that the drug policy adopted at the national level does not actually lead to transformation towards decriminalization, which is in line with international practices, and instead it sustains the arena where financial interests prevail. According to the respondents, in some cases the criminalization of PS is unjustified, and decriminalization, on the contrary, can be useful, in particular, because drugs that can be bought freely may be used to cure diseases, have proven quality and therefore are less dangerous for health; decriminalization leads to a reduction in injecting drug use and, consequently, slows down the spread of HIV; it reduces corruption risks in the police and mitigates the demand for the "forbidden fruit". Furthermore, the assessment showed that the respondents are generally interested about the health status of their sexual partner and, in turn, are willing to share about their own health condition (including HIV status). However, the FGD participants pointed out that when one of the partners uses drugs and the other does not use, it often appears that a choice needs to be made between drug use and the relationship. Regarding the relationship between sexual intercourse and the use of PS, such practices are used by 80% of respondents, and the combination of alcohol and drugs is preferred by almost a half of respondents and, according to the FGD participants, sexual intercourse happens regardless of the use of PS. FGD participants reported that they undergo medical examination and encourage their sexual partners to do so, especially when they are not using condoms. They recommended that their partners (or vice versa)be tested for HIV, hepatitis, STIs, and explained the need for testing. With regard to the use of condoms and lubricants, former is reported by more than a half of respondents, while the letter only a little over 20%. The FGD participants also reported that the attitude of their parents (relatives) to their consumption of PS varies from acceptance to condemnation, from possibility to have open discussion to the need to conceal the fact of PS use. The communication model influences whether PS users discuss their health problems or receive advice, support or help from others. In addition, the respondents themselves have different reactions to advice provided by relatives which range from asking/listening to not seeking help and not informing relatives about health problems, treatment, medication. These choices are influenced by various factors, from overall attitude of relatives, their competence, closeness and

138 quality of relationship, views, etc. For example, some FGD participants, such as MSM, who are more vulnerable to HIV exposure, reported models of relationship with parents (relatives) that are similar to relationships of people who use PS. In some cases, they are characterized by understanding and mutual assistance, in others – the respondents refused help because of homophobic views of relatives. Participants of FGD pointed out that among the interests that are common to them and their friends, drugs occupy a significant place. They confirmed discussing health issues with their friends – mainly revolving around physical and mental health issues (they include talks about yoga, sports, healthy eating habits, etc.). In the context of this assessment, the respondents discussed such topics as: HIV infection, hepatitis, TB (including testing), phasing out PS use; safer sex, the risk of contracting an infection from a sexual partner. The respondents are aware of the risky nature of behaviour of some of their friends (acquaintances). However, HIV, hepatitis, STIs, etc. are not a special topic for discussion with friends. The main reasons for the limited interest in these topics are confidence that everyone is sufficiently aware of these issues and knows how to protect themselves, and that these topics appear at the center of discussions when a real situation occurs. The respondents also assessed the importance of their immediate environment and friends for receiving medical care. Some respondents had greater trust in their family and so turned to it for help, while others relied more on friends. The FGD participants emphasized that among drug users it is quite common to help each other. The majority of respondents provided reassurance that they actively encourage their friends to get tested, motivate them and accompany them to the testing site. The most common way to encourage for testing is to set an example, communicate as "peer-to-peer" and share personal experiences and knowledge. To engage friends, the following means where listed: telephone calls and invitations to testing, providing material incentives for testing, providing means of prevention as an incentive. Active stand and reasonable views about health issues which were observed in the FGD participants can be explained by the specifics of the focus group as a research method - only those who trusted the organizers took part in it, voluntarily participated and gave their consent, were not afraid to admit their belonging to the key populations (people who use drugs, transgender, MSM, sex worker or HIV-infected) and discuss health issues. Therefore, it can be assumed that not all representatives of key populations have such a degree of readiness to disclose information about themselves, discuss and address their own health problems. And so, the results of the FGD have some limitations on the part of reliability of data, but they nevertheless reveal current trends in the environment under the analysis, and therefore may serve as the basis for additional research on any particular aspect.

139 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

References

1 “ВІЛ-Інфекція в Україні.” Державна Установа «Центр Громадського Здоров’я Міністерства Охорони Здо- ров’я України», 2019, phc.org.ua/sites/default/files/users/user90/HIV_in_UA_50_2019.pdf. 2 “Залежність Від Психоактивних Речовин.” Центр Громадського Здоров’я Міністерства Охорони Здоров’я України, 2019, https://www.phc.org.ua/kontrol-zakhvoryuvan/zalezhnist-vid-psikhoaktivnikh-rechovin. 3 “Systematic Literature Review on Stimulant Use and HIV (A).” UNODC.org, 2017, www.unodc.org/documents/ hiv-aids/2017/2_Stim_HIV_Syst_Lit_Rev_Part_2_ATS.pdf. 4 “Systematic Literature Review on Stimulant Use and HIV (A).” UNODC.org, 2017, https://www.unodc.org/ documents/hiv-aids/2017/1_Stim_HIV_Syst_Lit_rev_Part_1_methodology_and_summary.pdf. 5 “Systematic Literature Review on Stimulant Use and HIV (A) Part 3/5 Cocaine and Crack-Cocaine Risk and Transmission.” UNODC.org, 2017, https://www.unodc.org/documents/hiv-aids/2017/3_Stim_HIV_Syst_ Lit_Rev_Part_3_Cocaine_and_Crack-Cocaine.pdf. 6 “Systematic Literature Review on Stimulant Use and HIV (A ...” Systematic Literature Review on Stimulant Use and HIV (A) Part 4 /5 New Psychoactive Substances Risk and Transmission, 2017, https://www.unodc.org/ documents/hiv-aids/2017/4_Stim_HIV_Syst_Lit_Rev_Part_4_-_New_Psychoactive_Substances.pdf. 7 World Drug Report 2020 (United Nations publication, Sales No. E.20.XI.6), https://wdr.unodc.org/wdr2020/ field/WDR20_BOOKLET_4.pdf 8 “Systematic Literature Review on Stimulant Use and HIV (B) Part 5/5 Treatment and Prevention of HIV, HCV &HBV among Stimulant Drugs Users.” UNODC.org, 2017, Systematic Literature Review on Stimulant use and HIV (B) Part 5/5 Treatment and Prevention of HIV, HCV &HBV among Stimulant Drugs Users. https://www. unodc.org/documents/hiv-aids/2017/5_Stim_HIV_Syst_Lit_rev_Part_5_Prevention_and_treatment.pdf 9 “Оценка Распространенности – Косвенные Методы Оценки Масштабов Проблемы Наркотиков.” UNODC. org, 2003, https://www.unodc.org/documents/GAP/GAP%20Toolkit%20Module%202%20Final%20 RUSSIAN%2002-60054_E_BOOK.pdf. 10 “Европейский Доклад о Наркотиках .” Emcdda.europa.eu, 2016, www.emcdda.europa.eu/system/files/ publications/2637/European%20Drug%20Report_Russian_web.pdf.

140 141 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

ANNEX 1 to Section 1 Distribution of respondents' answers on the frequency of NPAR consumption, by cities of residence

Cities All responses Respondents' answers Kyiv Odesa N % N % N % Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 1 1.0% 2 1.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Tramadol (Tramal), Tram 1-3 times a month 3 2.9% 0 0.0% 3 1.4% Did not use over the last 90 days 101 96.2% 97 93.3% 198 94.7% Difficult to answer 0 0.0% 6 5.8% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 0 0.0% 1 0.5% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Heroin 1-3 times a month 2 1.9% 4 3.8% 6 2.9% Did not use over the last 90 days 101 96.2% 94 90.4% 195 93.3% Difficult to answer 0 0.0% 6 5.8% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 7 6.7% 4 3.8% 11 5.3% 3-4 times a week 2 1.9% 1 1.0% 3 1.4% How often do you use NPS: 1-2 times a week 1 1.0% 2 1.9% 3 1.4% Methadone - OST ("Med", "Kamin’", "Metal") 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 95 90.5% 92 88.5% 187 89.5% Difficult to answer 0 0.0% 5 4.8% 5 2.4% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 3 2.9% 4 1.9% 3-4 times a week 2 1.9% 2 1.9% 4 1.9% How often do you use NPS: 1-2 times a week 4 3.8% 2 1.9% 6 2.9% Street methadone 1-3 times a month 4 3.8% 4 3.8% 8 3.8% Did not use over the last 90 days 94 89.5% 87 83.7% 181 86.6% Difficult to answer 0 0.0% 6 5.8% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 2 1.9% 3 1.4% 3-4 times a week 0 0.0% 2 1.9% 2 1.0% How often do you use NPS: 1-2 times a week 1 1.0% 0 0.0% 1 .5% Street buprenorphine 1-3 times a month 1 1.0% 2 1.9% 3 1.4% Did not use over the last 90 days 102 97.1% 92 88.5% 194 92.8% Difficult to answer 0 0.0% 6 5.8% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

142 ANNEX 1

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 1.0% 2 1.9% 3 1.4% Cocaine (Crack) 1-3 times a month 7 6.7% 8 7.7% 15 7.2% Did not use over the last 90 days 95 90.5% 92 88.5% 187 89.5% Difficult to answer 2 1.9% 2 1.9% 4 1.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 5 4.8% 3 2.9% 8 3.8% 3-4 times a week 10 9.5% 6 5.8% 16 7.7% How often do you use NPS: 1-2 times a week 29 27.6% 26 25.0% 55 26.3% Amphetamine powder ("Fen", "Speed", "Ampha", etc.) 1-3 times a month 37 35.2% 28 26.9% 65 31.1% Did not use over the last 90 days 24 22.9% 40 38.5% 64 30.6% Difficult to answer 0 0.0% 1 1.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 1 1.0% 1 0.5% 3-4 times a week 1 1.0% 1 1.0% 2 1.0% How often do you use NPS: 1-2 times a week 4 3.8% 8 7.7% 12 5.7% Amphetamine in crystals (Ephedrine, etc.) 1-3 times a month 20 19.0% 7 6.7% 27 12.9% Did not use over the last 90 days 76 72.4% 85 81.7% 161 77.0% Difficult to answer 4 3.8% 2 1.9% 6 2.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 1 1.0% 6 5.8% 7 3.3% Methamphetamine in powder form (crystals) - "Met", "Lid", "Ice" 1-3 times a month 26 24.8% 20 19.2% 46 22.0% Did not use over the last 90 days 76 72.4% 77 74.0% 153 73.2% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 4 3.8% 4 1.9% 3-4 times a week 0 0.0% 9 8.7% 9 4.3% How often do you use NPS: 1-2 times a week 0 0.0% 9 8.7% 9 4.3% "Sil’" (Salt) 1-3 times a month 8 7.6% 13 12.5% 21 10.0% Did not use over the last 90 days 94 89.5% 68 65.4% 162 77.5% Difficult to answer 3 2.9% 1 1.0% 4 1.9% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.0% 1 0.5% How often do you use NPS: 1-2 times a week 5 4.8% 12 11.5% 17 8.1% Methylenedioxymethamphetamine (ecstasy, MDMA) 1-3 times a month 44 41.9% 28 26.9% 72 34.4% Did not use over the last 90 days 50 47.6% 62 59.6% 112 53.6% Difficult to answer 6 5.7% 1 1.0% 7 3.3% Subtotal 105 100.0% 104 100.0% 209 100.0%

143 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 7 6.7% 7 3.3% Mephedrone ("Speed", "Meph", "Meow-Meow") 1-3 times a month 13 12.4% 11 10.6% 24 11.5% Did not use over the last 90 days 90 85.7% 85 81.7% 175 83.7% Difficult to answer 2 1.9% 1 1.0% 3 1.4% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 1.0% 3 2.9% 4 1.9% Metcation 1-3 times a month 1 1.0% 2 1.9% 3 1.4% Did not use over the last 90 days 98 93.3% 97 93.3% 195 93.3% Difficult to answer 5 4.8% 2 1.9% 7 3.3% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 1 1.0% 1 0.5% Nalbuphine 1-3 times a month 1 1.0% 2 1.9% 3 1.4% Did not use over the last 90 days 104 99.0% 99 95.2% 203 97.1% Difficult to answer 0 0.0% 1 1.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 2 1.9% 3 2.9% 5 2.4% 3-4 times a week 2 1.9% 4 3.8% 6 2.9% How often do you use NPS: 1-2 times a week 1 1.0% 5 4.8% 6 2.9% Codterpine, codeine (substances containing codeine) 1-3 times a month 2 1.9% 4 3.8% 6 2.9% Did not use over the last 90 days 97 92.4% 86 82.7% 183 87.6% Difficult to answer 1 1.0% 2 1.9% 3 1.4% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 3 2.9% 3 1.4% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 2 1.9% 2 1.0% Coffex (drug containing codeine) 1-3 times a month 2 1.9% 4 3.8% 6 2.9% Did not use over the last 90 days 102 97.1% 94 90.4% 196 93.8% Difficult to answer 0 0.0% 1 1.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 1.0% 0 0.0% 1 0.5% Tropicamide 1-3 times a month 2 1.9% 1 1.0% 3 1.4% Did not use over the last 90 days 102 97.1% 102 98.1% 204 97.6% Difficult to answer 0 0.0% 1 1.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

144 ANNEX 1

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Glycodine 1-3 times a month 1 1.0% 3 2.9% 4 1.9% Did not use over the last 90 days 103 98.1% 100 96.2% 203 97.1% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Atusin 1-3 times a month 2 1.9% 0 0.0% 2 1.0% Did not use over the last 90 days 102 97.1% 103 99.0% 205 98.1% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 4 3.8% 1 1.0% 5 2.4% Ketamine 1-3 times a month 11 10.5% 4 3.8% 15 7.2% Did not use over the last 90 days 88 83.8% 99 95.2% 187 89.5% Difficult to answer 1 1.0% 0 0.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Calypsol 1-3 times a month 0 0.0% 1 1.0% 1 0.5% Did not use over the last 90 days 105 100.0% 103 99.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 0 0.0% 1 .5% How often do you use NPS: 1-2 times a week 3 2.9% 0 0.0% 3 1.4% Ketalar, Sodium oxybutyrate (butyrate) 1-3 times a month 4 3.8% 1 1.0% 5 2.4% Did not use over the last 90 days 96 91.4% 102 98.1% 198 94.7% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 2 1.9% 2 1.0% "Tabs ("Kolesa")" with alcohol (Hidazepam with alcohol) 1-3 times a month 6 5.7% 2 1.9% 8 3.8% Did not use over the last 90 days 98 93.3% 99 95.2% 197 94.3% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

145 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 1 1.0% 1 1.0% 2 1.0% 3-4 times a week 2 1.9% 1 1.0% 3 1.4% How often do you use NPS: 1-2 times a week 3 2.9% 1 1.0% 4 1.9% Antihistamines (Dimedrol - Diphenhydramine) 1-3 times a month 9 8.6% 6 5.8% 15 7.2% Did not use over the last 90 days 89 84.8% 94 90.4% 183 87.6% Difficult to answer 1 1.0% 1 1.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 3 2.9% 2 1.9% 5 2.4% 3-4 times a week 2 1.9% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 4 3.8% 1 1.0% 5 2.4% (including Donormil) 1-3 times a month 8 7.6% 6 5.8% 14 6.7% Did not use over the last 90 days 86 81.9% 95 91.3% 181 86.6% Difficult to answer 2 1.9% 0 0.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 1.0% 10 9.6% 11 5.3% Hallucinogens (LSD, mushrooms, "trip", salvia) 1-3 times a month 17 16.2% 24 23.1% 41 19.6% Did not use over the last 90 days 80 76.2% 70 67.3% 150 71.8% Difficult to answer 7 6.7% 0 0.0% 7 3.3% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 16 15.2% 6 5.8% 22 10.5% 3-4 times a week 21 20.0% 14 13.5% 35 16.7% How often do you use NPS: 1-2 times a week 23 21.9% 25 24.0% 48 23.0% Cannabis (marijuana, weed, "drap", "plan", "dur’", "anasha", "shyshky") 1-3 times a month 19 18.1% 19 18.3% 38 18.2% Did not use over the last 90 days 24 22.9% 40 38.5% 64 30.6% Difficult to answer 2 1.9% 0 0.0% 2 1.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 2 1.9% 3 1.4% 3-4 times a week 5 4.8% 2 1.9% 7 3.3% How often do you use NPS: 1-2 times a week 4 3.8% 6 5.8% 10 4.8% Smoking mixtures, "spices" 1-3 times a month 4 3.8% 7 6.7% 11 5.3% Did not use over the last 90 days 90 85.7% 87 83.7% 177 84.7% Difficult to answer 1 1.0% 0 0.0% 1 0.5% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Glue 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 105 100.0% 104 100.0% 209 100.0% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

146 ANNEX 1

Every day 2 1.9% 0 0.0% 2 1.0% How often do you use NPS: 3-4 times a week 1 1.0% 0 0.0% 1 0.5% Substances belonging to the group of 1-2 times a week 0 0.0% 1 1.0% 1 0.5% Pregabalin 1-3 times a month 1 1.0% 0 0.0% 1 0.5% (Gabana, Lyrica, Ogrania) Did not use over the last 90 days 101 96.2% 103 99.0% 204 97.6% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Metraginine 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 104 99.0% 104 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 1.0% 0 0.0% 1 0.5% Hydozepam without alcohol 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 103 98.1% 104 100.0% 207 99.0% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 2 1.9% 0 0.0% 2 1.0% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Buprenorphine, subitex 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 102 97.1% 104 100.0% 206 98.6% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 1.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Pregabalin 1-3 times a month 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 104 99.0% 104 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Cannabinol-containing pastries, 1-3 times a month 1 1.0% 0 0.0% 1 .5% spice cupcakes Did not use over the last 90 days 104 99.0% 104 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

Every day 1 1.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% Xanax – a drug belonging to 1-3 times a month 0 0.0% 0 0.0% 0 0.0% () Did not use over the last 90 days 104 99.0% 104 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% Subtotal 105 100.0% 104 100.0% 209 100.0%

147 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

ANNEX 2 to Section 1 Distribution of respondents' answers regarding frequency of NPS use, by gender

Gender Transgender Respondents' answers Male Female All responses person N % N % N % N % Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 0.7% 1 1.6% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Tramadol (tramal), tram 1-3 times a month 1 0.7% 2 3.1% 0 0.0% 3 1.4% Did not use over the last 90 days 136 95.1% 60 93.8% 2 100.0% 198 94.7% Difficult to answer 5 3.5% 1 1.6% 0 0.0% 6 2.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 0 0.0% 0 0.0% 1 0.5% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Heroin 1-3 times a month 4 2.8% 2 3.1% 0 0.0% 6 2.9% Did not use over the last 90 days 132 92.3% 61 95.3% 2 100.0% 195 93.3% Difficult to answer 5 3.5% 1 1.6% 0 0.0% 6 2.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 7 4.9% 4 6.3% 0 0.0% 11 5.3% 3-4 times a week 3 2.1% 0 0.0% 0 0.0% 3 1.4% How often do you use NPS: 1-2 times a week 1 0.7% 2 3.1% 0 0.0% 3 1.4% Methadone - OST ("Med", "Kamin’", "Metal") 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 128 89.5% 57 89.1% 2 100.0% 187 89.5% Difficult to answer 4 2.8% 1 1.6% 0 0.0% 5 2.4% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 2 1.4% 2 3.1% 0 0.0% 4 1.9% 3-4 times a week 2 1.4% 2 3.1% 0 0.0% 4 1.9% How often do you use NPS: 1-2 times a week 3 2.1% 3 4.7% 0 0.0% 6 2.9% Street methadone 1-3 times a month 4 2.8% 4 6.3% 0 0.0% 8 3.8% Did not use over the last 90 days 127 88.8% 52 81.3% 2 100.0% 181 86.6% Difficult to answer 5 3.5% 1 1.6% 0 0.0% 6 2.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 2 3.1% 0 0.0% 3 1.4% 3-4 times a week 2 1.4% 0 0.0% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% Street buprenorphine 1-3 times a month 2 1.4% 1 1.6% 0 0.0% 3 1.4% Did not use over the last 90 days 133 93.0% 59 92.2% 2 100.0% 194 92.8% Difficult to answer 5 3.5% 1 1.6% 0 0.0% 6 2.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

148 ANNEX 2

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 3 2.1% 0 0.0% 0 0.0% 3 1.4% Cocaine (crack) 1-3 times a month 11 7.7% 4 6.3% 0 0.0% 15 7.2% Did not use over the last 90 days 127 88.8% 59 92.2% 1 50.0% 187 89.5% Difficult to answer 2 1.4% 1 1.6% 1 50.0% 4 1.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 6 4.2% 2 3.1% 0 0.0% 8 3.8% 3-4 times a week 11 7.7% 5 7.8% 0 0.0% 16 7.7% How often do you use NPS: Amphetamine powder 1-2 times a week 35 24.5% 19 29.7% 1 50.0% 55 26.3% ("Fen", "Speed", "Ampha", 1-3 times a month 47 32.9% 18 28.1% 0 0.0% 65 31.1% etc.) Did not use over the last 90 days 43 30.1% 20 31.3% 1 50.0% 64 30.6% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 0 0.0% 0 0.0% 1 0.5% 3-4 times a week 1 0.7% 1 1.6% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 6 4.2% 6 9.4% 0 0.0% 12 5.7% Amphetamine in crystals (Ephedrine, etc.) 1-3 times a month 22 15.4% 4 6.3% 1 50.0% 27 12.9% Did not use over the last 90 days 110 76.9% 51 79.7% 0 0.0% 161 77.0% Difficult to answer 3 2.1% 2 3.1% 1 50.0% 6 2.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% How often do you use NPS: Methamphetamine in 1-2 times a week 5 3.5% 2 3.1% 0 0.0% 7 3.3% powder form (crystals) - 1-3 times a month 30 21.0% 14 21.9% 2 100.0% 46 22.0% "Met", "Lid", "Ice" Did not use over the last 90 days 107 74.8% 46 71.9% 0 0.0% 153 73.2% Difficult to answer 1 0.7% 1 1.6% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 3 4.7% 0 0.0% 4 1.9% 3-4 times a week 6 4.2% 3 4.7% 0 0.0% 9 4.3% How often do you use NPS: 1-2 times a week 6 4.2% 3 4.7% 0 0.0% 9 4.3% "Sil’" (Salt) 1-3 times a month 13 9.1% 8 12.5% 0 0.0% 21 10.0% Did not use over the last 90 days 114 79.7% 46 71.9% 2 100.0% 162 77.5% Difficult to answer 3 2.1% 1 1.6% 0 0.0% 4 1.9% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% How often do you use NPS: Methylenedioxymetha- 1-2 times a week 12 8.4% 5 7.8% 0 0.0% 17 8.1% mphetamine 1-3 times a month 56 39.2% 15 23.4% 1 50.0% 72 34.4% (ecstasy, MDMA) Did not use over the last 90 days 71 49.7% 40 62.5% 1 50.0% 112 53.6% Difficult to answer 4 2.8% 3 4.7% 0 0.0% 7 3.3% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

149 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: Mephedrone 1-2 times a week 5 3.5% 2 3.1% 0 0.0% 7 3.3% ("Speed", "Meph", 1-3 times a month 17 11.9% 6 9.4% 1 50.0% 24 11.5% "Meow-Meow") Did not use over the last 90 days 119 83.2% 55 85.9% 1 50.0% 175 83.7% Difficult to answer 2 1.4% 1 1.6% 0 0.0% 3 1.4% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 3 2.1% 1 1.6% 0 0.0% 4 1.9% Metcation 1-3 times a month 0 0.0% 3 4.7% 0 0.0% 3 1.4% Did not use over the last 90 days 136 95.1% 57 89.1% 2 100.0% 195 93.3% Difficult to answer 4 2.8% 3 4.7% 0 0.0% 7 3.3% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% Nalbuphine 1-3 times a month 3 2.1% 0 0.0% 0 0.0% 3 1.4% Did not use over the last 90 days 137 95.8% 64 100.0% 2 100.0% 203 97.1% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 3 2.1% 2 3.1% 0 0.0% 5 2.4% 3-4 times a week 3 2.1% 3 4.7% 0 0.0% 6 2.9% How often do you use NPS: 1-2 times a week 6 4.2% 0 0.0% 0 0.0% 6 2.9% Codterpine, codeine (drugs containing codeine) 1-3 times a month 2 1.4% 4 6.3% 0 0.0% 6 2.9% Did not use over the last 90 days 128 89.5% 53 82.8% 2 100.0% 183 87.6% Difficult to answer 1 0.7% 2 3.1% 0 0.0% 3 1.4% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 3 2.1% 0 0.0% 0 0.0% 3 1.4% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 2 1.4% 0 0.0% 0 0.0% 2 1.0% Coffex (a drug containing codeine) 1-3 times a month 2 1.4% 3 4.7% 1 50.0% 6 2.9% Did not use over the last 90 days 134 93.7% 61 95.3% 1 50.0% 196 93.8% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% Tropicamide 1-3 times a month 3 2.1% 0 0.0% 0 0.0% 3 1.4% Did not use over the last 90 days 138 96.5% 64 100.0% 2 100.0% 204 97.6% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

150 ANNEX 2

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Glycodine 1-3 times a month 4 2.8% 0 0.0% 0 0.0% 4 1.9% Did not use over the last 90 days 137 95.8% 64 100.0% 2 100.0% 203 97.1% Difficult to answer 2 1.4% 0 0.0% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Atusin 1-3 times a month 2 1.4% 0 0.0% 0 0.0% 2 1.0% Did not use over the last 90 days 139 97.2% 64 100.0% 2 100.0% 205 98.1% Difficult to answer 2 1.4% 0 0.0% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 4 2.8% 0 0.0% 1 50.0% 5 2.4% Ketamine 1-3 times a month 13 9.1% 2 3.1% 0 0.0% 15 7.2% Did not use over the last 90 days 124 86.7% 62 96.9% 1 50.0% 187 89.5% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Calypsol 1-3 times a month 1 0.7% 0 0.0% 0 0.0% 1 0.5% Did not use over the last 90 days 142 99.3% 64 100.0% 2 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 3 2.1% 0 0.0% 0 0.0% 3 1.4% Ketalar, Sodium oxybutyrate (butyrate) 1-3 times a month 5 3.5% 0 0.0% 0 0.0% 5 2.4% Did not use over the last 90 days 133 93.0% 64 100.0% 1 50.0% 198 94.7% Difficult to answer 1 0.7% 0 0.0% 1 50.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: "Tabs ("Kolesa")" 1-2 times a week 1 0.7% 1 1.6% 0 0.0% 2 1.0% with alcohol 1-3 times a month 4 2.8% 4 6.3% 0 0.0% 8 3.8% (Hidazepam with alcohol) Did not use over the last 90 days 136 95.1% 59 92.2% 2 100.0% 197 94.3% Difficult to answer 2 1.4% 0 0.0% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

151 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 1 0.7% 1 1.6% 0 0.0% 2 1.0% 3-4 times a week 2 1.4% 1 1.6% 0 0.0% 3 1.4% How often do you use NPS: Antihistamines 1-2 times a week 2 1.4% 2 3.1% 0 0.0% 4 1.9% (Dimedrol - 1-3 times a month 9 6.3% 6 9.4% 0 0.0% 15 7.2% Diphenhydramine) Did not use over the last 90 days 127 88.8% 54 84.4% 2 100.0% 183 87.6% Difficult to answer 2 1.4% 0 0.0% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 4 2.8% 1 1.6% 0 0.0% 5 2.4% 3-4 times a week 0 0.0% 2 3.1% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 4 2.8% 1 1.6% 0 0.0% 5 2.4% Sedatives (incl. Donormil) 1-3 times a month 6 4.2% 7 10.9% 1 50.0% 14 6.7% Did not use over the last 90 days 127 88.8% 53 82.8% 1 50.0% 181 86.6% Difficult to answer 2 1.4% 0 0.0% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 11 7.7% 0 0.0% 0 0.0% 11 5.3% Hallucinogens (LSD, mushrooms, "trip", salvia) 1-3 times a month 34 23.8% 6 9.4% 1 50.0% 41 19.6% Did not use over the last 90 days 93 65.0% 56 87.5% 1 50.0% 150 71.8% Difficult to answer 5 3.5% 2 3.1% 0 0.0% 7 3.3% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 19 13.3% 3 4.7% 0 0.0% 22 10.5% 3-4 times a week 28 19.6% 6 9.4% 1 50.0% 35 16.7% How often do you use NPS: Cannabis (marijuana, 1-2 times a week 39 27.3% 9 14.1% 0 0.0% 48 23.0% weed, "drap", "plan", "dur’", 1-3 times a month 26 18.2% 12 18.8% 0 0.0% 38 18.2% "anasha", "shyshky") Did not use over the last 90 days 31 21.7% 32 50.0% 1 50.0% 64 30.6% Difficult to answer 0 0.0% 2 3.1% 0 0.0% 2 1.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 2 1.4% 1 1.6% 0 0.0% 3 1.4% 3-4 times a week 6 4.2% 1 1.6% 0 0.0% 7 3.3% How often do you use NPS: 1-2 times a week 5 3.5% 4 6.3% 1 50.0% 10 4.8% Smoking mixtures, "spices" 1-3 times a month 6 4.2% 5 7.8% 0 0.0% 11 5.3% Did not use over the last 90 days 123 86.0% 53 82.8% 1 50.0% 177 84.7% Difficult to answer 1 0.7% 0 0.0% 0 0.0% 1 0.5% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Glue 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 143 100.0% 64 100.0% 2 100.0% 209 100.0% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

152 ANNEX 2

Every day 1 0.7% 1 1.6% 0 0.0% 2 1.0% How often do you use NPS: 3-4 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% Substances belonging to 1-2 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% the group of Pregabalin 1-3 times a month 1 0.7% 0 0.0% 0 0.0% 1 0.5% (Gabana, Lyrica, Agrania) Did not use over the last 90 days 140 97.9% 62 96.9% 2 100.0% 204 97.6% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 0 0.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Metraginine 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 142 99.3% 64 100.0% 2 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 0 0.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 0 0.0% 1 1.6% 0 0.0% 1 0.5% Hidozepam without alcohol 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 142 99.3% 63 98.4% 2 100.0% 207 99.0% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 2 3.1% 0 0.0% 2 1.0% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Buprenorphine, subitex 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 142 99.3% 62 96.9% 2 100.0% 206 98.6% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Pregabalin 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 142 99.3% 64 100.0% 2 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Cannabinol-containing 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% pastries, 1-3 times a month 0 0.0% 1 1.6% 0 0.0% 1 0.5% spice cupcakes Did not use over the last 90 days 143 100.0% 63 98.4% 2 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

Every day 1 0.7% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% Xanax – a drug belonging 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% to Benzodiazepines 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% (Alprazolam) Did not use over the last 90 days 142 99.3% 64 100.0% 2 100.0% 208 99.5% Difficult to answer 0 0.0% 0 0.0% 0 0.0% 0 0.0% Subtotal 143 100.0% 64 100.0% 2 100.0% 209 100.0%

153 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

ANNEX 3 to Section 1 Distribution of respondents' answers regarding frequency of NPS use, by age

Age All responses Respondents' answers 18-24 years 25-29 years 30-34 years 35-39 years 40-59 years N % N % N % N % N % N % Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 1 2.6% 1 2.8% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Tramadol (tramal), tram 1-3 times a month 0 0.0% 0 0.0% 2 5.3% 1 2.8% 0 0.0% 3 1.4% Did not use over the last 90 days 49 96.1% 49 98.0% 33 86.8% 33 91.7% 34 100.0% 198 94.7% Difficult to answer 2 3.9% 1 2.0% 2 5.3% 1 2.8% 0 0.0% 6 2.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 1 2.8% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 1 2.8% 0 0.0% 1 0.5% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Heroin 1-3 times a month 0 0.0% 0 0.0% 4 10.5% 2 5.6% 0 0.0% 6 2.9% Did not use over the last 90 days 49 96.1% 49 98.0% 32 84.2% 31 86.1% 34 100.0% 195 93.3% Difficult to answer 2 3.9% 1 2.0% 2 5.3% 1 2.8% 0 0.0% 6 2.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 1 2.0% 2 5.3% 5 13.9% 3 8.8% 11 5.3% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 1 2.8% 2 5.9% 3 1.4% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 2 5.3% 1 2.8% 0 0.0% 3 1.4% Methadone - OST ("Med", "Kamin’", "Metal") 1-3 times a month 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Did not use over the last 90 days 49 96.1% 48 96.0% 33 86.8% 28 77.8% 29 85.3% 187 89.5% Difficult to answer 2 3.9% 1 2.0% 1 2.6% 1 2.8% 0 0.0% 5 2.4% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 1 2.6% 1 2.8% 2 5.9% 4 1.9% 3-4 times a week 0 0.0% 0 0.0% 2 5.3% 2 5.6% 0 0.0% 4 1.9% How often do you use NPS: 1-2 times a week 1 2.0% 0 0.0% 1 2.6% 1 2.8% 3 8.8% 6 2.9% Street methadone 1-3 times a month 0 0.0% 0 0.0% 1 2.6% 5 13.9% 2 5.9% 8 3.8% Did not use over the last 90 days 48 94.1% 49 98.0% 31 81.6% 26 72.2% 27 79.4% 181 86.6% Difficult to answer 2 3.9% 1 2.0% 2 5.3% 1 2.8% 0 0.0% 6 2.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 1 2.0% 0 0.0% 0 0.0% 0 0.0% 2 5.9% 3 1.4% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 1 2.8% 1 2.9% 2 1.0% How often do you use NPS: 1-2 times a week 0 0.0% 0 0.0% 1 2.6% 0 0.0% 0 0.0% 1 0.5% Street buprenorphine 1-3 times a month 0 0.0% 0 0.0% 1 2.6% 2 5.6% 0 0.0% 3 1.4% Did not use over the last 90 days 48 94.1% 49 98.0% 34 89.5% 32 88.9% 31 91.2% 194 92.8% Difficult to answer 2 3.9% 1 2.0% 2 5.3% 1 2.8% 0 0.0% 6 2.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

154 ANNEX 3

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% How often do you use NPS: 1-2 times a week 2 3.9% 1 2.0% 0 0.0% 0 0.0% 0 0.0% 3 1.4% Cocaine (crack) 1-3 times a month 4 7.8% 5 10.0% 5 13.2% 1 2.8% 0 0.0% 15 7.2% Did not use over the last 90 days 45 88.2% 40 80.0% 33 86.8% 35 97.2% 34 100.0% 187 89.5% Difficult to answer 0 0.0% 4 8.0% 0 0.0% 0 0.0% 0 0.0% 4 1.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 2 3.9% 1 2.0% 0 0.0% 4 11.1% 1 2.9% 8 3.8% 3-4 times a week 2 3.9% 5 10.0% 4 10.5% 2 5.6% 3 8.8% 16 7.7% How often do you use NPS: Amphetamine powder 1-2 times a week 16 31.4% 12 24.0% 11 28.9% 7 19.4% 9 26.5% 55 26.3% ("Fen", "Speed", "Ampha", 1-3 times a month 15 29.4% 19 38.0% 13 34.2% 9 25.0% 9 26.5% 65 31.1% etc.) Did not use over the last 90 days 16 31.4% 13 26.0% 9 23.7% 14 38.9% 12 35.3% 64 30.6% Difficult to answer 0 0.0% 0 0.0% 1 2.6% 0 0.0% 0 0.0% 1 0.5% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 1 2.0% 0 0.0% 0 0.0% 0 0.0% 1 0.5% 3-4 times a week 0 0.0% 0 0.0% 1 2.6% 1 2.8% 0 0.0% 2 1.0% How often do you use NPS: 1-2 times a week 5 9.8% 2 4.0% 0 0.0% 1 2.8% 4 11.8% 12 5.7% Amphetamine in crystals (Ephedrine, etc.) 1-3 times a month 10 19.6% 7 14.0% 4 10.5% 2 5.6% 4 11.8% 27 12.9% Did not use over the last 90 days 34 66.7% 37 74.0% 33 86.8% 32 88.9% 25 73.5% 161 77.0% Difficult to answer 2 3.9% 3 6.0% 0 0.0% 0 0.0% 1 2.9% 6 2.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 1 2.6% 0 0.0% 0 0.0% 1 0.5% How often do you use NPS: Methamphetamine in 1-2 times a week 2 3.9% 2 4.0% 1 2.6% 1 2.8% 1 2.9% 7 3.3% powder form (crystals) - 1-3 times a month 12 23.5% 13 26.0% 7 18.4% 10 27.8% 4 11.8% 46 22.0% "Met", "Lid", "Ice" Did not use over the last 90 days 37 72.5% 34 68.0% 29 76.3% 25 69.4% 28 82.4% 153 73.2% Difficult to answer 0 0.0% 1 2.0% 0 0.0% 0 0.0% 1 2.9% 2 1.0% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 1 2.0% 0 0.0% 0 0.0% 3 8.8% 4 1.9% 3-4 times a week 0 0.0% 1 2.0% 2 5.3% 3 8.3% 3 8.8% 9 4.3% How often do you use NPS: 1-2 times a week 1 2.0% 2 4.0% 1 2.6% 1 2.8% 4 11.8% 9 4.3% "Sil’" (Salt) 1-3 times a month 9 17.6% 2 4.0% 2 5.3% 4 11.1% 4 11.8% 21 10.0% Did not use over the last 90 days 39 76.5% 42 84.0% 33 86.8% 28 77.8% 20 58.8% 162 77.5% Difficult to answer 2 3.9% 2 4.0% 0 0.0% 0 0.0% 0 0.0% 4 1.9% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

Every day 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3-4 times a week 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1 2.9% 1 0.5% How often do you use NPS: Methylenedioxymetha- 1-2 times a week 6 11.8% 4 8.0% 3 7.9% 1 2.8% 3 8.8% 17 8.1% mphetamine 1-3 times a month 22 43.1% 23 46.0% 11 28.9% 7 19.4% 9 26.5% 72 34.4% (ecstasy, MDMA) Did not use over the last 90 days 20 39.2% 22 44.0% 23 60.5% 27 75.0% 20 58.8% 112 53.6% Difficult to answer 3 5.9% 1 2.0% 1 2.6% 1 2.8% 1 2.9% 7 3.3% Subtotal 51 100.0% 50 100.0% 38 100.0% 36 100.0% 34 100.0% 209 100.0%

155 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Mephedrone 1-2 times a week 2 3,9% 1 2,0% 0 0,0% 2 5,6% 2 5,9% 7 3,3% ("Speed", "Meph", 1-3 times a month 8 15,7% 11 22,0% 1 2,6% 1 2,8% 3 8,8% 24 11,5% "Meow-Meow") Did not use over the last 90 days 41 80,4% 37 74,0% 37 97,4% 33 91,7% 27 79,4% 175 83,7% Difficult to answer 0 0,0% 1 2,0% 0 0,0% 0 0,0% 2 5,9% 3 1,4% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 1 2,0% 0 0,0% 1 2,8% 2 5,9% 4 1,9% Metcation 1-3 times a month 0 0,0% 1 2,0% 0 0,0% 1 2,8% 1 2,9% 3 1,4% Did not use over the last 90 days 50 98,0% 46 92,0% 37 97,4% 34 94,4% 28 82,4% 195 93,3% Difficult to answer 1 2,0% 2 4,0% 1 2,6% 0 0,0% 3 8,8% 7 3,3% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 1 2,6% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 1 2,6% 0 0,0% 0 0,0% 1 0,5% Nalbuphine 1-3 times a month 1 2,0% 0 0,0% 0 0,0% 1 2,8% 1 2,9% 3 1,4% Did not use over the last 90 days 49 96,1% 50 100,0% 36 94,7% 35 97,2% 33 97,1% 203 97,1% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 2 5,3% 2 5,6% 1 2,9% 5 2,4% 3-4 times a week 1 2,0% 1 2,0% 1 2,6% 2 5,6% 1 2,9% 6 2,9% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 1 2,6% 3 8,3% 2 5,9% 6 2,9% Codterpine, codeine (drugs containing codeine) 1-3 times a month 1 2,0% 1 2,0% 2 5,3% 1 2,8% 1 2,9% 6 2,9% Did not use over the last 90 days 47 92,2% 47 94,0% 32 84,2% 28 77,8% 29 85,3% 183 87,6% Difficult to answer 2 3,9% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 3 1,4% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 1 2,0% 1 2,6% 1 2,8% 0 0,0% 3 1,4% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 2,8% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 1 2,8% 1 2,9% 2 1,0% Coffex (a drug containing codeine) 1-3 times a month 1 2,0% 1 2,0% 2 5,3% 1 2,8% 1 2,9% 6 2,9% Did not use over the last 90 days 49 96,1% 48 96,0% 35 92,1% 32 88,9% 32 94,1% 196 93,8% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 1 0,5% Tropicamide 1-3 times a month 1 2,0% 0 0,0% 1 2,6% 0 0,0% 1 2,9% 3 1,4% Did not use over the last 90 days 49 96,1% 50 100,0% 37 97,4% 36 100,0% 32 94,1% 204 97,6% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

156 ANNEX 3

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Glycodine 1-3 times a month 1 2,0% 1 2,0% 0 0,0% 1 2,8% 1 2,9% 4 1,9% Did not use over the last 90 days 49 96,1% 49 98,0% 38 100,0% 35 97,2% 32 94,1% 203 97,1% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Atusin 1-3 times a month 0 0,0% 0 0,0% 1 2,6% 0 0,0% 1 2,9% 2 1,0% Did not use over the last 90 days 50 98,0% 50 100,0% 37 97,4% 36 100,0% 32 94,1% 205 98,1% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 1 2,0% 2 4,0% 1 2,6% 0 0,0% 1 2,9% 5 2,4% Ketamine 1-3 times a month 5 9,8% 8 16,0% 0 0,0% 2 5,6% 0 0,0% 15 7,2% Did not use over the last 90 days 44 86,3% 39 78,0% 37 97,4% 34 94,4% 33 97,1% 187 89,5% Difficult to answer 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Calypsol 1-3 times a month 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Did not use over the last 90 days 50 98,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 208 99,5% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 1 2,6% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 1 2,0% 1 2,0% 0 0,0% 0 0,0% 1 2,9% 3 1,4% Ketalar, Sodium oxybutyrate (butyrate) 1-3 times a month 2 3,9% 3 6,0% 0 0,0% 0 0,0% 0 0,0% 5 2,4% Did not use over the last 90 days 47 92,2% 45 90,0% 37 97,4% 36 100,0% 33 97,1% 198 94,7% Difficult to answer 1 2,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: "Tabs ("Kolesa")" 1-2 times a week 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 2 1,0% with alcohol 1-3 times a month 3 5,9% 0 0,0% 1 2,6% 3 8,3% 1 2,9% 8 3,8% (Hidazepam with alcohol) Did not use over the last 90 days 46 90,2% 49 98,0% 37 97,4% 33 91,7% 32 94,1% 197 94,3% Difficult to answer 1 2,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

157 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0,0% 1 2,0% 0 0,0% 1 2,8% 0 0,0% 2 1,0% 3-4 times a week 0 0,0% 0 0,0% 2 5,3% 0 0,0% 1 2,9% 3 1,4% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 2 5,3% 0 0,0% 2 5,9% 4 1,9% Antihistamines (Dimedrol - Diphenhydramine) 1-3 times a month 3 5,9% 0 0,0% 3 7,9% 7 19,4% 2 5,9% 15 7,2% Did not use over the last 90 days 47 92,2% 48 96,0% 31 81,6% 28 77,8% 29 85,3% 183 87,6% Difficult to answer 1 2,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 3 6,0% 1 2,6% 1 2,8% 0 0,0% 5 2,4% 3-4 times a week 1 2,0% 0 0,0% 1 2,6% 0 0,0% 0 0,0% 2 1,0% How often do you use NPS: 1-2 times a week 1 2,0% 0 0,0% 1 2,6% 1 2,8% 2 5,9% 5 2,4% Sedatives (incl. Donormil) 1-3 times a month 3 5,9% 3 6,0% 2 5,3% 4 11,1% 2 5,9% 14 6,7% Did not use over the last 90 days 46 90,2% 42 84,0% 33 86,8% 30 83,3% 30 88,2% 181 86,6% Difficult to answer 0 0,0% 2 4,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 4 7,8% 4 8,0% 2 5,3% 1 2,8% 0 0,0% 11 5,3% Hallucinogens (LSD, mushrooms, "trip", salvia) 1-3 times a month 14 27,5% 18 36,0% 7 18,4% 1 2,8% 1 2,9% 41 19,6% Did not use over the last 90 days 33 64,7% 25 50,0% 27 71,1% 32 88,9% 33 97,1% 150 71,8% Difficult to answer 0 0,0% 3 6,0% 2 5,3% 2 5,6% 0 0,0% 7 3,3% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 5 9,8% 3 6,0% 8 21,1% 5 13,9% 1 2,9% 22 10,5% 3-4 times a week 9 17,6% 12 24,0% 5 13,2% 8 22,2% 1 2,9% 35 16,7% How often do you use NPS: Cannabis (marijuana, 1-2 times a week 16 31,4% 14 28,0% 7 18,4% 5 13,9% 6 17,6% 48 23,0% weed, "drap", "plan", "dur’", 1-3 times a month 14 27,5% 7 14,0% 7 18,4% 3 8,3% 7 20,6% 38 18,2% "anasha", "shyshky") Did not use over the last 90 days 7 13,7% 13 26,0% 11 28,9% 14 38,9% 19 55,9% 64 30,6% Difficult to answer 0 0,0% 1 2,0% 0 0,0% 1 2,8% 0 0,0% 2 1,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 2 5,3% 0 0,0% 1 2,9% 3 1,4% 3-4 times a week 3 5,9% 1 2,0% 1 2,6% 1 2,8% 1 2,9% 7 3,3% How often do you use NPS: 1-2 times a week 2 3,9% 4 8,0% 0 0,0% 3 8,3% 1 2,9% 10 4,8% Smoking mixtures, "spices" 1-3 times a month 2 3,9% 1 2,0% 3 7,9% 2 5,6% 3 8,8% 11 5,3% Did not use over the last 90 days 44 86,3% 43 86,0% 32 84,2% 30 83,3% 28 82,4% 177 84,7% Difficult to answer 0 0,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Glue 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 90 days 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

158 ANNEX 3

Every day 0 0,0% 0 0,0% 1 2,6% 1 2,8% 0 0,0% 2 1,0% How often do you use NPS: 3-4 times a week 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Substances belonging to 1-2 times a week 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% the group of Pregabalin 1-3 times a month 0 0,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% (Gabana, Lyrica, Ogrania) Did not use over the last 90 days 49 96,1% 49 98,0% 37 97,4% 35 97,2% 34 100,0% 204 97,6% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Metraginine 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 90 days 51 100,0% 49 98,0% 38 100,0% 36 100,0% 34 100,0% 208 99,5% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 2,8% 0 0,0% 1 0,5% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 1 2,6% 0 0,0% 0 0,0% 1 0,5% Hidozepam without alcohol 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 90 days 51 100,0% 50 100,0% 37 97,4% 35 97,2% 34 100,0% 207 99,0% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 2 1,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 2,9% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Buprenorphine, subitex 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 90 days 50 98,0% 50 100,0% 38 100,0% 36 100,0% 32 94,1% 206 98,6% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 1 2,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Pregabalin 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 90 days 50 98,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 208 99,5% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Cannabinol-containing 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 1 2,8% 0 0,0% 1 0,5% pastries, spice cupcakes Did not use over the last 90 days 51 100,0% 50 100,0% 38 100,0% 35 97,2% 34 100,0% 208 99,5% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

Every day 0 0,0% 1 2,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Xanax – a drug belonging 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% to Benzodiazepines 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% (Alprazolam) Did not use over the last 90 days 51 100,0% 49 98,0% 38 100,0% 36 100,0% 34 100,0% 208 99,5% Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 51 100,0% 50 100,0% 38 100,0% 36 100,0% 34 100,0% 209 100,0%

159 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

ANNEX 4 to Section 1 Distribution of respondents’ answers regarding frequency of NPS use, by category

Category of respondent PWUD who do not All Transgender SW and Clients of Respondent’s answer Sex worker MSM attribute responses person MSM female SW themselves to any KP N % N % N % N % N % N % N % Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Tramadol (tramal), tram 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 110 90,9% 16 100,0% 6 100,0% 198 94,7% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Heroin 1-3 times a month 0 0,0% 1 2,2% 0 0,0% 5 4,1% 0 0,0% 0 0,0% 6 2,9% Did not use over the last 18 100,0% 45 97,8% 2 100,0% 108 89,3% 16 100,0% 6 100,0% 195 93,3% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 11 9,1% 0 0,0% 0 0,0% 11 5,3% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% Methadone - OST 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% ("Med", "Kamin’", "Metal") Did not use over the last 18 100,0% 46 100,0% 2 100,0% 99 81,8% 16 100,0% 6 100,0% 187 89,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 5 4,1% 0 0,0% 0 0,0% 5 2,4% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 4 1,9% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 4 1,9% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% How often do you use NPS: Street methadone 1-3 times a month 2 11,1% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 8 3,8% Did not use over the last 16 88,9% 46 100,0% 2 100,0% 95 78,5% 16 100,0% 6 100,0% 181 86,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

160 ANNEX 4

Every day 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: Street buprenorphine 1-3 times a month 1 5,6% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 3 1,4% Did not use over the last 17 94,4% 46 100,0% 2 100,0% 107 88,4% 16 100,0% 6 100,0% 194 92,8% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1-2 times a week 0 0,0% 1 2,2% 0 0,0% 1 0,8% 1 6,3% 0 0,0% 3 1,4% How often do you use NPS: Cocaine (crack) 1-3 times a month 0 0,0% 6 13,0% 0 0,0% 9 7,4% 0 0,0% 0 0,0% 15 7,2% Did not use over the last 18 100,0% 39 84,8% 1 50,0% 109 90,1% 14 87,5% 6 100,0% 187 89,5% 90 days Difficult to answer 0 0,0% 0 0,0% 1 50,0% 2 1,7% 1 6,3% 0 0,0% 4 1,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 2 4,3% 0 0,0% 5 4,1% 1 6,3% 0 0,0% 8 3,8% 3-4 times a week 2 11,1% 4 8,7% 0 0,0% 10 8,3% 0 0,0% 0 0,0% 16 7,7% How often do you use NPS: 1-2 times a week 6 33,3% 16 34,8% 1 50,0% 27 22,3% 2 12,5% 3 50,0% 55 26,3% Amphetamine powder ("Fen", "Speed", "Ampha", 1-3 times a month 7 38,9% 11 23,9% 0 0,0% 36 29,8% 8 50,0% 3 50,0% 65 31,1% etc.) Did not use over the last 3 16,7% 13 28,3% 1 50,0% 42 34,7% 5 31,3% 0 0,0% 64 30,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% How often do you use NPS: 1-2 times a week 1 5,6% 0 0,0% 0 0,0% 9 7,4% 2 12,5% 0 0,0% 12 5,7% Amphetamine in crystals 1-3 times a month 3 16,7% 5 10,9% 1 50,0% 11 9,1% 7 43,8% 0 0,0% 27 12,9% (Ephedrine, etc.) Did not use over the last 14 77,8% 40 87,0% 0 0,0% 96 79,3% 5 31,3% 6 100,0% 161 77,0% 90 days Difficult to answer 0 0,0% 1 2,2% 1 50,0% 2 1,7% 2 12,5% 0 0,0% 6 2,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 1 5,6% 1 2,2% 0 0,0% 3 2,5% 2 12,5% 0 0,0% 7 3,3% Methamphetamine in powder form (crystals) - 1-3 times a month 4 22,2% 11 23,9% 2 100,0% 22 18,2% 6 37,5% 1 16,7% 46 22,0% "Met", "Lid", "Ice" Did not use over the last 13 72,2% 34 73,9% 0 0,0% 94 77,7% 7 43,8% 5 83,3% 153 73,2% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 1 6,3% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

161 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0,0% 0 0,0% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 4 1,9% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 9 7,4% 0 0,0% 0 0,0% 9 4,3% 1-2 times a week 0 0,0% 1 2,2% 0 0,0% 8 6,6% 0 0,0% 0 0,0% 9 4,3% How often do you use NPS: "Sil’" (Salt) 1-3 times a month 3 16,7% 6 13,0% 0 0,0% 10 8,3% 2 12,5% 0 0,0% 21 10,0% Did not use over the last 14 77,8% 38 82,6% 2 100,0% 90 74,4% 12 75,0% 6 100,0% 162 77,5% 90 days Difficult to answer 1 5,6% 1 2,2% 0 0,0% 0 0,0% 2 12,5% 0 0,0% 4 1,9% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 2 11,1% 4 8,7% 0 0,0% 7 5,8% 3 18,8% 1 16,7% 17 8,1% Methylenedioxymetha- mphetamine 1-3 times a month 2 11,1% 25 54,3% 1 50,0% 32 26,4% 9 56,3% 3 50,0% 72 34,4% (ecstasy, MDMA) Did not use over the last 14 77,8% 16 34,8% 1 50,0% 75 62,0% 4 25,0% 2 33,3% 112 53,6% 90 days Difficult to answer 0 0,0% 1 2,2% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 7 3,3% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 2 11,1% 0 0,0% 0 0,0% 4 3,3% 1 6,3% 0 0,0% 7 3,3% Mephedrone ("Speed", "Meph", 1-3 times a month 2 11,1% 15 32,6% 1 50,0% 4 3,3% 2 12,5% 0 0,0% 24 11,5% "Meow-Meow") Did not use over the last 14 77,8% 31 67,4% 1 50,0% 112 92,6% 12 75,0% 5 83,3% 175 83,7% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 1 6,3% 1 16,7% 3 1,4% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1-2 times a week 1 5,6% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 1 16,7% 4 1,9% How often do you use NPS: Metcation 1-3 times a month 2 11,1% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 3 1,4% Did not use over the last 13 72,2% 45 97,8% 2 100,0% 117 96,7% 15 93,8% 3 50,0% 195 93,3% 90 days Difficult to answer 2 11,1% 1 2,2% 0 0,0% 1 0,8% 1 6,3% 2 33,3% 7 3,3% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5%

How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Nalbuphine 1-3 times a month 0 0,0% 1 2,2% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 3 1,4% Did not use over the last 18 100,0% 45 97,8% 2 100,0% 116 95,9% 16 100,0% 6 100,0% 203 97,1% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

162 ANNEX 4

Every day 0 0,0% 0 0,0% 0 0,0% 4 3,3% 1 6,3% 0 0,0% 5 2,4% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 6 2,9% Codterpine, codeine 1-3 times a month 2 11,1% 0 0,0% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 6 2,9% (drugs containing codeine) Did not use over the last 16 88,9% 46 100,0% 2 100,0% 98 81,0% 15 93,8% 6 100,0% 183 87,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% Coffex 1-3 times a month 0 0,0% 1 2,2% 1 50,0% 3 2,5% 1 6,3% 0 0,0% 6 2,9% (a drug containing codeine) Did not use over the last 18 100,0% 45 97,8% 1 50,0% 111 91,7% 15 93,8% 6 100,0% 196 93,8% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: Tropicamide 1-3 times a month 0 0,0% 1 2,2% 0 0,0% 1 0,8% 0 0,0% 1 16,7% 3 1,4% Did not use over the last 18 100,0% 45 97,8% 2 100,0% 118 97,5% 16 100,0% 5 83,3% 204 97,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Glycodine 1-3 times a month 0 0,0% 3 6,5% 0 0,0% 0 0,0% 0 0,0% 1 16,7% 4 1,9% Did not use over the last 18 100,0% 43 93,5% 2 100,0% 119 98,3% 16 100,0% 5 83,3% 203 97,1% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Atusin 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 2 33,3% 2 1,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 119 98,3% 16 100,0% 4 66,7% 205 98,1% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

163 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 1 2,2% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% 1-2 times a week 0 0,0% 2 4,3% 1 50,0% 1 0,8% 1 6,3% 0 0,0% 5 2,4% How often do you use NPS: Ketamine 1-3 times a month 0 0,0% 8 17,4% 0 0,0% 6 5,0% 1 6,3% 0 0,0% 15 7,2% Did not use over the last 18 100,0% 35 76,1% 1 50,0% 113 93,4% 14 87,5% 6 100,0% 187 89,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Calypsol 1-3 times a month 0 0,0% 1 2,2% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Did not use over the last 18 100,0% 45 97,8% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 208 99,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 1 2,2% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 2 4,3% 0 0,0% 0 0,0% 1 6,3% 0 0,0% 3 1,4% Ketalar, Sodium oxybutyrate 1-3 times a month 0 0,0% 5 10,9% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 5 2,4% (butyrate) Did not use over the last 18 100,0% 37 80,4% 1 50,0% 121 100,0% 15 93,8% 6 100,0% 198 94,7% 90 days Difficult to answer 0 0,0% 1 2,2% 1 50,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 1 2,2% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 2 1,0% "Tabs ("Kolesa")" with alcohol 1-3 times a month 1 5,6% 1 2,2% 0 0,0% 6 5,0% 0 0,0% 0 0,0% 8 3,8% (Hidazepam with alcohol) Did not use over the last 17 94,4% 43 93,5% 2 100,0% 113 93,4% 16 100,0% 6 100,0% 197 94,3% 90 days Difficult to answer 0 0,0% 1 2,2% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0% 3-4 times a week 0 0,0% 0 0,0% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 3 1,4% How often do you use NPS: 1-2 times a week 0 0,0% 1 2,2% 0 0,0% 3 2,5% 0 0,0% 0 0,0% 4 1,9% Antihistamines (Dimedrol - Diphenhydramine) 1-3 times a month 5 27,8% 2 4,3% 0 0,0% 7 5,8% 1 6,3% 0 0,0% 15 7,2% Did not use over the last 13 72,2% 41 89,1% 2 100,0% 106 87,6% 15 93,8% 6 100,0% 183 87,6% 90 days Difficult to answer 0 0,0% 2 4,3% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0% Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

164 ANNEX 4

Every day 0 0,0% 1 2,2% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 5 2,4%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0%

1-2 times a week 0 0,0% 1 2,2% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 5 2,4% How often do you use NPS: Sedatives (incl. Donormil) 1-3 times a month 3 16,7% 2 4,3% 1 50,0% 6 5,0% 2 12,5% 0 0,0% 14 6,7% Did not use over the last 15 83,3% 40 87,0% 1 50,0% 105 86,8% 14 87,5% 6 100,0% 181 86,6% 90 days Difficult to answer 0 0,0% 2 4,3% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 10 21,7% 0 0,0% 0 0,0% 1 6,3% 0 0,0% 11 5,3% Hallucinogens (LSD, mushrooms, "trip", 1-3 times a month 0 0,0% 20 43,5% 1 50,0% 19 15,7% 1 6,3% 0 0,0% 41 19,6% salvia) Did not use over the last 16 88,9% 15 32,6% 1 50,0% 98 81,0% 14 87,5% 6 100,0% 150 71,8% 90 days Difficult to answer 2 11,1% 1 2,2% 0 0,0% 4 3,3% 0 0,0% 0 0,0% 7 3,3%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 3 6,5% 0 0,0% 18 14,9% 1 6,3% 0 0,0% 22 10,5%

3-4 times a week 0 0,0% 10 21,7% 1 50,0% 20 16,5% 4 25,0% 0 0,0% 35 16,7% How often do you use NPS: Cannabis 1-2 times a week 2 11,1% 11 23,9% 0 0,0% 30 24,8% 4 25,0% 1 16,7% 48 23,0% (marijuana, weed, "drap", "plan", "dur’", "anasha", 1-3 times a month 2 11,1% 13 28,3% 0 0,0% 17 14,0% 4 25,0% 2 33,3% 38 18,2% "shyshky") Did not use over the last 12 66,7% 9 19,6% 1 50,0% 36 29,8% 3 18,8% 3 50,0% 64 30,6% 90 days Difficult to answer 2 11,1% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 2 1,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 1 5,6% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 1 16,7% 3 1,4%

3-4 times a week 1 5,6% 1 2,2% 0 0,0% 2 1,7% 1 6,3% 2 33,3% 7 3,3%

1-2 times a week 4 22,2% 1 2,2% 1 50,0% 3 2,5% 1 6,3% 0 0,0% 10 4,8% How often do you use NPS: Smoking mixtures, "spices" 1-3 times a month 5 27,8% 3 6,5% 0 0,0% 0 0,0% 1 6,3% 2 33,3% 11 5,3% Did not use over the last 7 38,9% 40 87,0% 1 50,0% 115 95,0% 13 81,3% 1 16,7% 177 84,7% 90 days Difficult to answer 0 0,0% 1 2,2% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

165 PEOPLE WHO USE NPS/STIMULANTS: BASIC NEEDS AND BARRIERS IN ACCESS TO HIV RELATED MEDICAL AND SOCIAL SERVICES IN UKRAINE

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Glue 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: 1-2 times a week 0 0,0% 1 2,2% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 0,5% Substances belonging to the group of Pregabalin 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% (Gabana, Lyrica, Ogrania) Did not use over the last 18 100,0% 45 97,8% 2 100,0% 117 96,7% 16 100,0% 6 100,0% 204 97,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Metraginine 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 120 99,2% 16 100,0% 6 100,0% 208 99,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

1-2 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% How often do you use NPS: Hidozepam without alcohol 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 119 98,3% 16 100,0% 6 100,0% 207 99,0% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

166 ANNEX 4

Every day 0 0,0% 0 0,0% 0 0,0% 2 1,7% 0 0,0% 0 0,0% 2 1,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5%

1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Buprenorphine, subitex 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 118 97,5% 16 100,0% 6 100,0% 206 98,6% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 1 6,3% 0 0,0% 1 0,5%

1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: Pregabalin 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 121 100,0% 15 93,8% 6 100,0% 208 99,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Cannabinol-containing pastries, spice cupcakes 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5% Did not use over the last 18 100,0% 46 100,0% 2 100,0% 120 99,2% 16 100,0% 6 100,0% 208 99,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

Every day 0 0,0% 0 0,0% 0 0,0% 1 0,8% 0 0,0% 0 0,0% 1 0,5%

3-4 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% How often do you use NPS: 1-2 times a week 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% Xanax – a drug belonging to Benzodiazepines 1-3 times a month 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% (Alprazolam) Did not use over the last 18 100,0% 46 100,0% 2 100,0% 120 99,2% 16 100,0% 6 100,0% 208 99,5% 90 days Difficult to answer 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Subtotal 18 100,0% 46 100,0% 2 100,0% 121 100,0% 16 100,0% 6 100,0% 209 100,0%

167