Analysis Results of Quantitative Study Data Conducted Among Beneficiaries partipating in Peer-Driven Intervention

STUDY REPORT

Georgian Harm Reduction Network 2019

Acknowledgements

This study report represents united efforts of many organizations and without their active involvements and support, introduction of the study results would be impossible.

We express our gratitude to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the National Center for Disease Control and Public Health for financial support of the study.

We appreciate the centers of the Georgian Harm Reduction Network for providing field works for the study, in particular, for performing face-to-face interviews and data entry:

 Psycho-Social Information and Consultation Center “New Way”-Natalia Chirikashvili (Tbilisi), Davit Porchkhidze (), Nestor Maisadze ()  Union “New Vector” –Manana Khikhadze, Dimitri Tsiklauri (Tbilisi), Elene Qajaia ()  Union “Imedi” -Tamuna Esebua ()  Union “Step To The Future”-Nino Beruashvili (), Mariam Baindurashvili, Nino Tabuashvili (Gori), Nino Shavgulidze ()  Association of National Development of Education, Social Rehabilitation and Historic Values Protection “Ordu”-Liana Topuria, Lela Kurashvili ()  Association of Young Psychologists and Doctors “Xenon” –Tsira Egutia, Medea Chichalava ().  Hepa Plus-Maka Revishvili, Tamuna Kiladze (Tbilisi), Lia Tsikarishvili ()  International Organization for Women “Akeso”-Irina Fatsatsia, Gela Lashkhia (Tbilisi)  Fenix-2009-Enri Maminashvili ()

We express many thanks to the administrative unit of the management of the Georgian Harm Reduction Network for on-line data monitoring and quality control (Khatuna Kutateladze, Guranda Jiqia, Marine Gogia).

We express special gratitude to all beneficiaries, who have taken their time and agreed to participate in the study. Without trust of each respondent and contribution he/she has made, conduction of this study would not be manageable.

The stury report has been preparated by the professor of addiction studies of Ilia State University, Irma Kirtadze (doctor).

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Table of Content

ABBREVATIONS USED 2

INTRODUCTION ERROR! BOOKMARK NOT DEFINED.

PEER-DRIVEN INTERVENTION IN ...... ERROR! BOOKMARK NOT DEFINED. STUDY PURPOSE ...... ERROR! BOOKMARK NOT DEFINED. STUDY TASKS ...... ERROR! BOOKMARK NOT DEFINED.

METHODOLOGY 5

STUDY DESIGN ...... ERROR! BOOKMARK NOT DEFINED. ETHICAL ISSUE OF STUDY ...... ERROR! BOOKMARK NOT DEFINED. INSTRUMENT ...... ERROR! BOOKMARK NOT DEFINED. SAMPLING ...... ERROR! BOOKMARK NOT DEFINED. DATA COLLECTION AND ANALYSIS ...... ERROR! BOOKMARK NOT DEFINED. STUDY LIMITATIONS ...... ERROR! BOOKMARK NOT DEFINED.

STUDY RESULTS ERROR! BOOKMARK NOT DEFINED.

RECRITMENT CHAIN OF THE STUDY ...... ERROR! BOOKMARK NOT DEFINED. DEMOGRAPHIC DATA ...... ERROR! BOOKMARK NOT DEFINED. INJECTION DRUG USE PRACTICE ...... ERROR! BOOKMARK NOT DEFINED. RISK ASSESSMENT BATTERY ...... ERROR! BOOKMARK NOT DEFINED. ASSESSMENT OF EDUCATOIN ON TRANSMISSION OF INFECTION ...... ERROR! BOOKMARK NOT DEFINED. ASSESSMENT OF EDUCATION AND PRACTICE ON TRANSMISSION OF HEPATITIS C ..... ERROR! BOOKMARK NOT DEFINED.

BASIC FINDINGS AND RECOMMENDATIONS ERROR! BOOKMARK NOT DEFINED.

BIBLIOGRAPHY 36

APEENDICES 39

APPENDIX N1. REPORT OF ETHICAL COMMISSION ...... 39 APPENDIX N2. STUDY QUESTIONARRIE ...... 39 APPENDIX N3. INFORMED CONSENT ...... 39 APPENDIX N4. PDI RECRUITING CHAIN ACCORDING TO THE CITIES ...... 39

Abbreviations

PDI Peer-driven Intervention PWID Injection drug user HIV Human Immunodeficiency Virus OST Opioid Substitution Therapy NSP Needle and Syringe Program AIDS Acquired Immune Deficiency Syndrome VCT Voluntary Counselling and Testing WHO World Health Organization GHRN Georgian Harm Reduction Network RDSAT Respondent-Driven Sampling Analysis Tool NetDraw Network Graphic Image Instrument SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections CI Confidence Interval OR Odds ratio SD Standard Deviation

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Introduction

Peer-Driven Intervention in Georgia Peer-driven intervention (PDI) managed by peers themselves for HIV-AIDS prevention was established in the 90s of the 20th century by Robert Brodhead and Douglas Hackathorn in the University of Connecticut with the support of US National Institute on Drug Abuse (Broadhead et al., 1998). The purpose of the intervention is to increase the knowledge about the harm induced by drug use (among them combined psychoactive substances, alcohol and other preparations) via peer-to-peer education in the PWID population as well increase of awareness on overdose, injection and sexual risky behaviors, hepatitis B and C, syphilis, infection prevention and decrease of risks related to drug use.

Field and educational activities are effective means to reduce risky injection practice (Georgina J. MacArthur et al., 2014; Medley, Kennedy, O’Reilly, & Sweat, 2009) with the help of field work and educational programs based on peer-to-peer principle, during the six-month intervention, the rate for risky injection practice has decreased by 76% in the study environment (Garfein et al., 2007); such intervention makes an important contribution to reduce HIV transmission and supports reduction of hepatitis C transmission (Georgina J. MacArthur et al., 2014); filed work is an effective way to reach to undetected, hard to access population, who does not have any accessibility to the services.

Behavior interventions among them peer-driven one support safe behavior, reduce transmission risk of HIV and hepatitis C and increase accessibility to health-care services (Garfein et al., 2007; Latka et al., 2008); results of cost-benefit modelling confirm cost-effectiveness of field interventions (Ritter & Cameron, 2005).

Peer-driven methodology is based on an assumption that compared to paid outreach workers of HIV prevention programs, PWID have more access, communication and knowledge share ability to each other1: they provide education on issues for HIV prevention, carry out their attraction/recruitment in HIV prevention services offerin HIV counselling and testing, health and risk assessment, provision of sterile injection devices, condoms and educational materials. მიწოდებას.

In Georgia, peer-driven intervention was introduced by the Georgian Harm Reduction Network in 2010 and after that it has been carried out annually in an uninterrupted regimen in the harm reduction service centers. For this purpose, 8 educational modules were developed (information of key importance, which is necessary to be disseminated in PWID population; for example: ways of transmission for HIV and B/C hepatitis, harm caused by home-made stimulators, signs of overdose, first aid upon overdose induced by opioids and so on), which should be updated periodically based on need and importance. The main motivation of this

1 Extensions of Respondent-Driven Sampling: A New Approach to the Study of Injection Drug Users Aged 18–25, Douglas D. Hackathon, Salaam Semaan, Robert S. Broadhead, and James J. Hughes, AIDS and Behavior, Vol. 6, No. 1, March 2002 3

intervention was to attract hard to access sub-populations-women and young people (18-24) in harm reduction services, as well as involvement of those persons who had never been provided services of AIDS prevention programs. With the help of this intervention it became possible to achieve the purpose set and enlargement of quantitative coverage2 (table 1). This approach has been applied with success to cover large part of drug users of various groups (for example, stimulators)3. Peers, who are involved in PDI, support widespread of information related to HIV- AIDS prevention and safe drug use.

TABLE 1. NUMBER OF PWID COVERED BY PDI

years 2010 2011 2012 2013 2014 2015 2016 2017 2018-19

PDI 781 106 2,356 3,755 4,032 1,940 384 746 1990 coverage

Benefit of PDI besides fast dissemination of information in an effective way is to discover new unreachable population and offer and involve them in harm reduction services. Intervention and study of participants involved in intervention go underway in parallel and it is based on the appropriate protocol developed by the Harm Reduction Network in 2010 and its review and update takes place every year.

Study Purpose

Since 2010 PDI has been carried out year over year, this process is accompanied by data collection. The intervention itself is structured and within its frame it is easy to manage collection of data, moreover, collection of basic information on population, who is being recruited via peers in harm reduction services, is recommended. Consequently, current conditions are assessed and needs are revealed, which may be taken into account for future programs.

The purpose of this study is to review behavior related to injection drug use for beneficiaries within the frame of intervention provided for PWID, as well as to reveal level of education on HIV and hepatitis C in PWID and assess behaviors implying sexual and injection risks. Results of this study will give the opportunity to reveal needs and respond them

2 Lile Batselashvili, M Sinjikashvili, M Chelidze, I Kirtadze, N Topuria (2012). Results of piloting peer driven intervention – did we reach targeted population? Addiction Research Center, Alternative Georgia, Tbilisi, Georgia. http://hiveurope.eu/Portals/0/Conference%202012/HiEConf2012_Programme.pdf 3 Broadhead, R.S., Heckathorn, D.D., Weakliem, D.L., Anthony D.L., Madray, H., Mills, R.J., Hughes, J. (1998), Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention, Public Health Reports, 113 (Suppl. 1), pp. 42– 57. Page 21

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appropriately considering evidence-based data. Also, educational modules should be adapted and updated according to the needs detected as those modules are basic component for PDI.

Study Tasks

The tasks of the study are:

o to study injection and sexual risky/hazardous behaviors for beneficiaries included in PDI; o to study social-economic level of drug users; o to assess level of knowledge for HIV-AIDS and hepatitis C; o to study behaviors related to overdose; o to assess needs through various desirable services.

Methodology

Study Design

Within the frame of cross-sectional4 study, direct questioning of beneficiaries included in peer-driven intervention has been performed in 11 cities of Georgia (Tbilisi, Batumi, Akhaltsikhe, Rustavi, Kutaisi, Zugdidi, Telavi, Ozurgeti, Samtredia, Poti, and Borjomi); by 9 harm reduction service centers. This intervention and consequently, study was performed in Borjomi and Akhaltsikhe for the first time. A trained consultant of voluntary counselling and testing carried out questioning. The questioning was done within the period from October 2018 till June 2019 (9 months). Targeted population of the study was PWID involved in PDI, who was recruited (attracted) by a peer (recruiter) participating in this intervention. After participation in PDI was completed, a person was offered to participate in the study and in case of his/her consent, an interviewer carried out questioning in compliance with all rules envisaged for study and intervention procedure (picture 1). Financial incentives to reimburse time and transport costs were considered for the respondents for participation in the study and intervention, as well as recruiting other peers. According to the intervention, if recruiter/study participant managed and studied peers what he/she learned within the frame of this intervention, his/her work would be reimbursed. Compensation depended on how many questions would be answered correctly by a person recruited/educated peer. For each correct answer recruiter would receive 1 GEL, if 7 questions were answered properly- 8 (eight) and 8 questions -10 (ten) GEL. If a recruited person could not answer a question, recruiter would not receive any amount and coupons for further

4 Setia, M. S. (2016). Methodology Series Module 3: Cross-sectional Studies. Indian Journal of Dermatology, 61(3), 261–264. http://doi.org/10.4103/0019-5154.182410 5

recruitment, however, a consultant provides additional educational intervention, as a participant should not leave a service center without information intervention. Based on this, various clients pursuant to work done by them would take different amounts, each respondent, who brought potential peer in the intervention/study and transfer the knowledge obtained during the intervention, could potentially earn 30 GEL, as he/she was provided with 3 coupons with unique serial number. In this case, dissemination of the knowledge received via the intervention serves a motivation to have more compensation, which is the theoretic basis of this intervention-social control through group-mediators (Heckathorn & Douglas, 1990). Additional motivating (bonus) compensation was considered for recruiting women, who used drugs and young (18-25) PWID that also would be resulted in bringing more targeted sub-population.

PICTURE 1. STAGES OF PDI AND THE STUDY

search of in case of consent, 3 coupons are "seed", training given for recruitment and 3 for and enrollment enrollment of peer in in intervention intervention if he/she does not satisfy peer fetched if he/she satisfies peer fetched inclusion connects PDI inclusion criteria undergoes ciretira, center and continues discontinues agrre meeting screning participation in participation procedure intervention time in intervneiton in case of awarding informed consent is done in case of consent for recruiter and in questionng about consent, check recruitment, 3 recruited participation and of knowledge coupons with with recruitiment of other peers and survey is unique codes monetary in intervention made are provided insentives

Study Ethical Issues

Study protocol is mostly based on intervention protocol, and questionnaire (administrated by an interviewer) is used the same as in the study of behaviors for NSP participants. Two types of informed consent forms ( consent to participate in the study and recruit other peers), are provided within this intervention, consent forms were submitted to the commission of bioethical issues - Health Research Union (HRU, IRB 00009520), address: #47, Tashkenti street, Tbilisi) for consideration of study participants rights. The ethic commission of Health Research Union is 6

registered in the Registry of Human Rights Ethics Commission5. The Ethic Commission discussed the study application submitted and issued a right to conduct study pursuant to all rules (see annex 1).

Instrument

The structured questionnaire used by the Harm Reduction Network for data collection in the previous years has been applied as well as standardized risk assessment battery6, which is well-adapted in that population for performing study in Georgia7 and in addition, the questions on C hepatitis transmission were used. The final instrument was composed of the following sections: demographic data (17 questions), PWID practice (28 questions), risk assessment battery (29 questions), service assessment (3 questions), verifying knowledge for HIV infection transmission (5 questions), hepatitis C (19 questions). Most of the questions are simple with the possibility to select one answer, however, questions to select multiple answers and ranking sequence of answers were also provided (see annex 2).

Questioning of the respondents was carried out while participating in the PDI if they agreed to participate voluntarily in the study. Confidentiality of study participants was ensured (no name, surname or personal number was mentioned), fifteen-digit codes (they had been used upon administering harm reduction programs) and serial numbers of coupons (in order to control received and issued coupons) were only applied.

Sampling

Peer-driven intervention is based on respondent-driven sampling, which, by itself is a combined, non-probable snowball sampling in line with mathematic model that tries to balance non-probable factor of sampling via sampling-weighting, for that, it is required to collect the following data: variable of personal network size (degree, number of persons, who is familiar with a respondent from the targeted population), serial number of respondent (coupon number, by which a respondent is recruited in the study) and serial numbers for recruiting respondents (for respondents, numbers issued to recruiting others)8. each recruited person, who injects drugs in the harm reduction center is performed screening and in case of giving consent for study participation and recruitment (see appendix 3) is

5 http://ohrp.cit.nih.gov/search/irbsearch.aspx 6 Metzger DS, et al. The Risk Assessment Battery: Validity and Reliability; Paper presented at the 6th Annual Meeting of National Cooperative Vaccine Development Group for AIDS.Nov, 1993. 7 Otiashvili, D., Piralishvili, G., Sikharulidze, Z., Kamkamidze, G., Poole, S., & Woody, G. E. (2013). Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use, and reducing HIV risk behavior – Outcomes of a Randomized Trial. Drug and Alcohol Dependence, 133(2), 10.1016/j.drugalcdep.2013.06.024. http://doi.org/10.1016/j.drugalcdep.2013.06.024 8 Heckathorn, Douglas D. 1997." Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations." Social Problems. 7

given 3 coupons for further recruitment and 3 coupons for another recruited one and so on. As a result, recruiting process of PDI is increased through geometrical progression9. Intervnetion was carried out until monetary resources finished and as a result of this 2039 respondents were involves in PDI (diagram1). However, that number of sampling needed for the study giving the possibility to generalize results obtained for each city (taking into account the parameters: CI - 95%; margine of error – 2%, size of targeted population – in Georgia in 2016, by applying demographic indicator and prevalence coefficient (population density) arithmetical mean of number of injection drug users) was achieved only in Akhaltsikhe. However, in Borjomi and Tbilisi cases it was achieved within 4-5% error. Sampling in other cities significantly differs from minimum required for number of generalizing sampling. A participant of per-driven intervention was performed educational module and provided three coupons for recruitment with unique code to recruit further potential participants.

The following is considered inclusion criteria for the study:

 A participant must be adult (at the age of 18 and above);  Participation in the study is to be volunatary;  A potential participant has not participated in HIV prevention programs, among them needle and syringe programs and services of voluntary counselling and testing during the last 12 months  The mandatory requirement is participation in peer-driven intervention;  To have injection track;  A study participant should not have the problems related to mental health, thinking and speech which can impede him/her in participation in the study.

9 Sampling hard-to-reach populations with respondent driven sampling, Lisa G. Johnstona and Keith Sabinb, University of California, World Health Organisation, Methodological Innovations Online (2010) 5(2) 38-48 8

DIAGRAM 1. STUDY COURSE PROCESS

screening for receipt of PDI-2003

refusal to particcipate in intervention and study -0

not satisfying citeria-13

participant in peer-driven intervention- 1990

data for the end of July 2019 existing in study electroni base 1820

Data Collection and Analysis

Data collection was carried out through questionnaires and coupons, which were entered by an interviewer on JotForm® online platform. Through it probability of data entry by mistake is minimized and skip function irrelevant questions (so-called skip patterns) was applied. Online base was imported with CSV files in Exel, with following export in Statistical Package for the Social Science program (Statistical Package for the Social Science v.21)10, where whole base by applying data frequency and cross-tabulations.

Separate base for coupons was prepared in Excel, which identifies already given coupon or non-used coupon and recruitment chain, by applying relevant (what if) functions, doubling of coupons were prevented and the possibility to make errors for that reason was excluded. Accordingly, by analyzing coupon chain recruiting base, network picture of the respondents was received for each city. For this reason statistical program RDSAT v7.111 has been used and to receive visual image of recruiting chain (network) NETDraw12 was used. By applying SPSS on united base univariation analysis has been performed completely – central tendencies, bi and

10 Dembe, A. E., Partridge, J. S., & Geist, L. C. (2011). Statistical software applications used in health services research: analysis of published studies in the U.S. BMC Health Services Research, 11, 252. http://doi.org/10.1186/1472-6963-11-252 11 Volz, E.; Wejnert, C.; Cameron, C.; Spiller, M.; Barash, V.; Degani, I.; and Heckathorn, D.D. 2012. Respondent-Driven Sampling Analysis Tool (RDSAT) Version 7.1. Ithaca, NY: Cornell University 12 Ibd 9

muti-variaion analysis (cross tabulation of category variables, comparison of mean, t-test, ANOVA) and connections between variables (differences, associations and correlations) were revealed.

Study Limitations

The study is based on the collection of observations from the side of beneficiaries who are gaining benefit from peer-driven intervention. This study has created the general picture for risky injection and sexual behaviors of beneficiaries uncovered by AIDS prevention programs. Limitation of the study may be considered applied, non-probable approach and the method itself, in spite of the fact that is provided to work with undetected population, anyway, it is not the best, because Simic and his collogues (Simic et al., 2006) revealed that social network existed among sexual workers weak in Russian and other post-soviet countries. However, no other method offers better than this approach. According to Platt and his colleagues (Platt et al., 2006), this method is safe with wide access to obscured population, but it is quite expensive. Even in our case PDI stays a fast and effective approach for dissemination of information in obscured population, which is implemented within the AIDS program and for the study and data collection, additional resource were not spent. But due to restriction in financial resources, required sampling size could not be recruited. In consideration of those circumstances, we became somehow limited from the opportunity to generalize completely the findings; however, we are able to have a presentation on the tendencies for certain behaviors distributed in that population.

Study Results

Study Recruitment Chain

For the study 4 initial “seeds” (minimum 2 and maximum 9) were sought by each center, which amounted 54 initial seeds for the whole sampling (among them 2 women) based on which respondets’ recruitment started, but on average 2 “seeds’ continued active recruiting; from whom average values of the longest recruitment chain (wave) amounted to 12. Issuance of 5.998 coupons are seen in coupon pursuit in excel base and from them return of 1990 coupons (33%), which means the same number of participants in intervention, however, in online base 1820 respondents’ data are revealed in ah the end of 2019. This indicates that timely entry of the rest data could not be manages. Details of recruitment are provided in table 2 and appendix 4.

TABLE 2. PDI RECRUITMENT CHAIN

coupons number Number of attracted participants from initial seeds city seed# issuance return 1 2 3 4 5 6 7 8 9 Tbilisi-Akeso 4 411 133 68 40 9 16

Tbilisi-New Vector 6 459 147 32 39 34 17 13 12

Tbilisi-New Way 9 501 158 54 24 36 2 3 7 12 19 1 Batumi 4 276 137 17 13 22 85

Ozurgeti 3 558 183 62 5 116

Kutaisi 2 600 198 108 90

Samtredia 4 345 111 25 19 39 28

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Telavi 2 195 63 57 6

Poti 7 435 138 3 18 20 12 30 38 17

Zugdidi-Xenon 4 408 132 3 3 13 113

Akhaltsikhe 3 531 173 49 90 33

Borjomi 2 729 241 190 51

Rustavi 4 540 176 60 11 51 54

Demographic Data

The most number of the respondents is in Tbilisi, because data (25.2%; 459 respondents), were collected from three service centers, see diagram 2. Majority of the study participants are men (1,695 respondents; 93.1%), women are only small part (125 respondents; 6.9%). On the question “How would you describe yourself? 1 man mentions that he is bisexual, 4- gay, or homosexual, and the rest-heterosexual (1690 men questioned).

DIAGRAM 2. DISTRIBUTION OF STUDY PARTICIPANTS' NUMBER ACCORDING TO THE CITIES

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi akhaltsikhe

0 50 100 150 200 250 300 350 400 450 500

In Poti and Samtredia the women respondents were involved not in intervention and accordingly, nor in the study. In four cities the few women are presented, in Rustavi their number is 6 (5.3%), in Batumi-20 (16.5%), the most are in the Tbilisi recruitment (43 women; 11.5%), but in the Akhaltsikhe recruitment their share (41 women, 29.3%) compared to other shares of women for the rest cities is the highest (see diagram 3).

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diagram 3. gender distribution according to the cities

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

men women

The average age of the participants of the study is 35.3 years, median age is 34 (SD 10.95), minimum-18 and maximum 73. Number of the respondents up to 34 years old amounts to the most part, in Poti, Zugdidi and Akhaltsikhe 18-2r years old, as well as in Poti and Samtredia the young women up to 34 years old, compared to other cities, they have most share, the difference is statistically reliable χ2(40)=427.540, p=0.000 (diagram 4).

DIAGRAM 4. AGE DISTRIBUTION OF RESPONDENTS ACCORDING TO THE CITIES

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

18-24 25-34 35-44 45-54 55+

The average age of the women respondents is 34.90 years old. (CI 95% 32.93 – 36.87, SD 11.13) with minimum age of the respondents of 19 years old and maximum -60, and the average

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age of the men is 35.31 years old (CI 95% 34.79 – 35.83, SD 10.95) with minimum age-18 years old and maximum – 73; age difference in terms of gender is not statistically reliable.

Majority of the whole sampling has had comprehensive secondary education (46.1%), 10.2% -higher education, 16.6%-incomplete higher education, 9%-incomplete secondary education and 18%-professional education. It is noteworthy that the level of the education of the respondents in terms of gender does not differ, however, the level of education according to the cities is significantly different, in Telavi and Zugdidi respondents with higher education are more presented χ2 (50) =305.01, p=0.000 (diagram 5. level of education according to the cities).

In the whole sampling the level of employment is high (60.7%) significantly exceeding number of self-employed (21.8%), full-time employed (5.1%) and temporary employed (11.1%) in sum. Employment rate according to the cities is statistically different, unemployment share is relatively less in Rustavi, Satmredia and Borjomi (diagram 6) compared to other cities (χ2 (50) = 421.199, p=0.000). On a question-what was the basic source of your income in the last month- employment has taken more share in the answers (33.5%), however, number of those respondents is high (29.6%) indicating that they are receiving money from friends, relatives or partners. 14.8% of the respondents gets income through renting or buying things, 4.1% has social support, and 2%- illegal income and 7.8% has income obtained from casino, totalizator and 8.2% refrain from answering this question. For men the basic source of income is renting/buying and money won in casino compared to women, whose main source of income is money from various support (friend/relatives, borrowed money, social) (χ2 (5) = 25.735, p=0.000). difference according to the cities is statistically reliable, namely, in Samtredia income received from renting/buying takes more share and in Zugdidi –money from casino-totalizator compared to other cities χ2 (50) = 1031.203, p=0.000 (Error! Reference source not found.).

DIAGRAM 5. LEVEL OF EDUCATION ACCORDING TO THE CITIES

Kutaisi

Samtredia

Ozurgeti

Tbilisi

Borjomi

Akhaltsikhe 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

refrain from answer secondary (incomplete) secondary (complete) proessional higher (incomplete) higher (complete)

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DIAGRAM 6. EMPLOYMENT RATE BETWEEN RESPONDENTS

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

unemployed self-employed temporary work wotk full time pensioneer, diasable person refrain from answer

DIAGRAM 7. DISTRIBUTION OF MAIN SOURCE OF INCOME DURING THE LAST 30 DAYS

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kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

employment money received by renting or selling something money received from friends, relatives, partners, borrowed money social support or pension illegal income

Majority of the respondents live with their parents, relatives or friends (1043 respondents, 57%), however, more men have own home compared to women, more women live on rent than men and more women live in shelter χ2 (4) = 15.377, p=0.004). According to the cities significant differences are revealed, in particular, in Akhaltsikhe, Borjomi and Ozurgeti no one lives in rented home, all of them liver in their parents’, relatives’ or friends’ houses (χ2 (40) = 497.825, p=0.004), see (diagram 8. living conditions of respondents).

DIAGRAM 8. LIVING CONDITIONS OF RESPONDENTS

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Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

own flat parents'/relatives'/friends' flat rent, mortgage shelter homeless, not having permanent shelter

Injection Drug Use Practice

Based on the study participants’ statement, they started injection drug use at the age of 20. Regular drug use experience (minimum three times a week) is 9 years on average based on sum used years (minimum 0 year and maximum 40 years). For men is 9.18 years on average (SEM 0.187; CI 95% 8.81-9.55) and for women - 6.83 years (SEM 0.68; CI 95% 5.49-8.18; min 0 and max 30 years). This difference is statistically reliable F (1, 591.794) =10.201, p>0.001.

In the sampling, during the last 30 days, average value of number for injection drug use days amounted to 13.76 days (min. 1 and max.. 30; SD=8.67), in a day on average 1.27 times by injection (diagram 9). 57 respondents (3%) have not answered a question- how many times you have used injection drug during the last 30 days. But majority of respondents (1,357; 77%) answering this question indicate one injection a day, 370 (21%) respondents –twice a day, 36 respondents (2%) three or more times a day.

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DIAGRAM 9. NUMBER OF INJECTION DAYS DURING THE LAST 30 DAYS

11-15 days, 18.3%

16 and more days 6-10 days, 25.3% ago, 33.3%

1-5 days 23.1%

Number of the largest group of the group injecting drug once a day during the last 30 days for the whole sampling is 3.31 on average (SD=1.471; min=0, max=21), details are seen on diagram 10. Traditionally, men (on average 14 days) more frequently use drugs during a month compared to women (on average 10 days) (p=0.000), however, no difference is in number of injection use per day (p=0.282), also, men (3.34-member) mention injection use in larger groups compared to women (2.85-member) (p=0.000). Absolute majority of the respondents (n=1,605, 88.2%) have never been in methadone/suboxone replacement therapy (OST). The analysis according to the cities indicates that in all cities except Ozurgeti and Telavi, more than 90% of the respondents have never involved in OST. According to 52.5% respondents of Ozurgeti and 18.5% of Telavi they are in OST now (at the time of the study conduction) (χ2 (40) = 1038.981, p=0.000). Also, men (12%) have more experience in OST treatment compared to women (2%), which is statistically reliable (χ2 (4) = 12.541, p=0.014).

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DIAGRAM 10. DISTRIBUTION OF NUMBER OF MEMBERS WITHIN THE LARGEST GROUP FOR SINGLE INJECTION DURING THE LAST 30 DAYS

6 and more 4.6

3 - 5 68.8

2 19.6

1 7.1

DIAGRAM 11. TREATMENT EXPERIENCE IN OST PROGRAM

Kutaisi

Poti

Samtredia

Rustavi

Ozurgeti

Telavi

Tbilisi

Zugdidi

Borjomi

Batumi

Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

I never been involved currently I am involved I was involved in the past ( previous month or several months ago within period up to a year) I was involved one and more years ago refrain from answer

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During the last 30 days according to the picture of drugs used, majority of the respondents use heroin, siretz (1000, 55%) by injection, and cannabis, hashish (1076, 59%) in non-injection way. After it comes street subutex (664, 36%) and methadone (240, 13%). Use of suboxone (364, 20%) taken from the program exceeds methadone (129, 7%) of the program. Homemade vint (231, 13%) use by injection and ephedra vint (427, 23%) also takes significant position in drug use (diagram 12).

DIAGRAM 12. DISTRIBUTION OF PSYCHOACTIVE SUBSTANCES INJECTED DURING THE LAST 30 DAYS

alcohol

antihistamines in mixture

hallucinogens

bio-MDMA

synthetic cations

cannabis/hashish

ephedra vint

cocaine, crack

stree subotex

street methadone

phentalyn

desomorphine 0 200 400 600 800 1000 1200

non-injection injection

According to the cities, during the last 30 days, based on injection drugs used, the differences are seen with regard to all drugs, which is statistically reliable at p = 0.000 level (diagram 13). Namely, use of desomorphine is revealed in 6 cities- in Akhaltsikhe (2.1%) and Samterdia (2.7%), the value of use is much higher compared to Borjomi, Zugdidi and Kutaisi, where only few cases are revealed. Injection use of desomoprhine has not been mentioned at all. Rate of use of opiates, such as morphine, codeine, trammel, and opium, black during the last 30 days is the highest in Tbilisi-6.1% of the respondents, Telavi-10.8%, and in Akhaltsikhe, Batumi, Borjomi, Zugdidi and Ozurgeti it varies from 1.3% to 4.1%. Few cases of phentalyn use were revealed in Akhaltsikhe, Kutaisi and Tbilisi, however, in Borjomi 18.2% of the respondents mention its use; in other cities, no use is seen.

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DIAGRAM 13. DRUGS USED BY INJECTION ACCORDING TO THE CITIES DURING THE LAST 30 DAYS

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Akhal Batu Borjo Zugdi Ozurg Rusta Samtr Kutai Tbilisi Telavi Poti tsikhe mi mi di eti vi edia si synthetic cations 0.0% 3.3% 0.0% 0.0% 12.6% 0.0% 0.0% 0.0% 3.5% 0.0% 1.5% amphetamine/metamphetamine pills 0.0% 13.2% .6% .7% 3.5% 3.1% .6% 3.5% .9% 0.0% 0.0% ephedra vint 11.4% 13.2% 18.2% 1.5% 25.9% 18.5% 58.2% 30.1% 67.3% 0.0% 14.9% vint 12.1% 20.7% 17.6% 3.7% 13.1% 0.0% 2.5% 10.6% 6.2% 0.0% 35.6% cocaine, crack .7% .8% .6% 2.2% 3.7% 1.5% 0.0% 0.0% 0.0% 0.0% 1.0% program suboxone 0.0% 20.7% 46.1% 6.6% 20.0% 0.0% 15.8% 5.3% 64.6% 20.3% 13.9% street subotex 15.7% 42.1% 18.8% 62.5% 42.7% 44.6% .6% 15.0% 72.6% 75.7% 18.8% program methadone 0.0% 3.3% 2.4% 1.5% 13.7% 0.0% 10.1% 2.7% 11.5% 10.8% 4.0% ქstreet methadone .7% 10.7% .6% 30.9% 15.0% 1.5% 1.3% 8.0% 6.2% 52.0% 8.9% heroin, sirets 82.1% 41.3% 23.6% 44.9% 72.8% 58.5% 34.8% 92.0% 54.9% 16.2% 58.4% phentalyn .7% 1.7% 18.2% 0.0% .4% 0.0% 0.0% 0.0% 0.0% 0.0% .5% opiates 1.4% 4.1% 3.6% 2.2% 6.1% 10.8% 1.3% 0.0% 0.0% 0.0% 0.0% desomorphine 2.1% 0.0% .6% .7% .4% 0.0% 0.0% 0.0% 2.7% 0.0% .5%

Heroin is most frequently used drug for the last 30 days, the lowest rate of its use was seen in Samtredia (16.2%), in Akhaltsikhe, Tbilisi and Rustavi more than 70% mentioned its use. In other cities rate of heroin use varies from 23.6% to 58.5%. During the last 30 days, use of vint is mentioned by more respondents of Kutaisi (35.6%), Borjomi (17.6%) and Batumi (20.7%) compared to other cities, but the respondents of Poti and 20

Telavi have never mentioned its use. Rate of use of vint prepared homemade from ephedra bush is revealed in Samtredia (67.3%) and Ozurgeti (58.2%) as well as in Telavi (18.5%). The highest rate of use of synthetic cations (bath salts, bio-amphetamines, PVP, mephedrone and others) is seen in Tbilisi-12.6%; rate of use in Batumi, Samtredia and Kutaisi varies from 1.5% to 3.5%, no other cities were revealed. The respondents have indicated that a place for final injection was deep (702, 38.6%) and superficial (693, 38.1%) veins of upper and lower extremities; final injections in the inguinal area are mentioned by 14.3% of the respondents. Based on the analysis according to the cities, the respondents of three cities (Ozurgeti, Rustavi and Kutaisi) are seen, who compared to the respondents of other city apply risky places for injection, such as axillary, clavicular, inguinal areas and cervical veins (χ2 (90) = 1224.527, p = 0.000).

DIAGRAM 14. PLACE OF LAST INJECTION ACCORDING TO THE CITIES

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

deep veins in upper/lower extrimities superficial veins in upper/lower extrimities inguinal vein subclavian 9clavicular area)) veins of neck axillary area under tongue muscles refrain from answer

During the last 30 days, at least one case of overdose is mentioned by 6.3% of the respondents from the whole sampling (115 respondents). From them absolute majority indicated on case of overdose (98%). Majority of overdose cases (94; 76%) was developed after heroin use (χ2 (9) = 35.264, p = 0.000). Among the possible reasons of overdose heroin dosing problem ranks first place (59 cases), mixture with alcohol (18 cases) and other drugs (10 cases), which is statistically reliable (χ2 (32) = 85.530, p = 0.000).

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On a question related to withdrawal from overdose condition, from 115 respondents (they all have overdose) the half mentioned that naloxone was used, 42% called for emergency aid, very free (3 respondents) mentioned use of salty water or condition of artificial respiration (1 case), three respondents refrained from answering the question.

Risk Assessment Battery

To assess risky behavior, risk assessment battery has been applied, which is a standardized instrument and evaluates sexual and injection behaviors according to risk content by providing rating scores on relevant risky behavior. The final result of the instrument –risky behavior index (RAB index) from 0 to 1 and indicates at magnitude of HIV risk, closer is it to 1, higher is sexual and injection risky behaviors and accordingly, risk for blood transmission infections. 0.259 is average rate of RAB index in the whole sampling (min=o.5, max. =0.60; SD 0.100), however, risky behavior index for women (CI 95% 0.2478-0.2826, Mean 0.0087, SEM 0.00877) slightly exceeds the one for men (CI 95% 0.2540-0.2636, Mean 0.0024, SEM 0.00245), which is statistically reliable difference. While studying RAB index according to the cities, the cities with more or less indices have been revealed-Telavi, Akhaltsikhe and Rustavi (diagram 15). The lowest risky behavior index is seen in Samtredia.

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DIAGRAM 15. DISTRIBUTION OF RISKY BEHAVIOR INDEX ACCORDING TO THE CITIES

1

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

Association connection between the level of education and RAB index has been revealed, namely, more respondents with secondary and professional education is distinguished by relatively high risky behavior index from the respondents with higher education (diagram 16) in line with statistically reliable difference (χ2 (110) = 157.268, p = 0.002). It is noteworthy that risky behavior index up to 0.5 is characteristic for 99.2% of the whole sampling, the share of those respondents (0.8%, 14 respondents) is very little, risky behavior index of which is more than 0.5.

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DIAGRAM 2. RISKY BEHAVIOR INDEX IN TERMS OF EDUCATION.

higher (complete) higher (incomplete) professional secondary (complete) secondary (incomplete) refrain from answer

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0.05 0.08 0.1 0.13 0.15 0.18 0.2 0.23 0.25 0.28 0.3 0.33

Analysis of variables related to risky behavior that is component of risky assessment battery has showed that 34% of the whole sampling (611 respondents) mentioned share practice of syringes, needles or other injection instruments with various numbers of people during the last 6 months. It is important that the difference between the cities is statistically reliable (χ2 (30) = 818.401, p = 0.000) and the highest values of share practice have been revealed in the cities Telavi, Akhaltsikhe and Zugdidi (diagram 17).

DIAGRAM 17. DISTRIBUTION OF SYRINGE, NEEDLE OR OTHER INEJCTION INSTRUMENTS WITH OTHERS ACCORDING TO THE CITIES DURING THE PAST 6 MONTHS

100% with four or 90% more 80% persons 70% with two or three 60% persons 50% with one 40% person 30% no one 20% 10% 0%

On the question how often you share syringe with a person, who has AIDS or HIV- infected that was known for you or find out later, absolute majority of the respondents (1768; 24

97.1%) give negative answer, however, 52 (2.9%) respondents mentioned share practice with various frequency for mostly in Zugdidi, Akhaltsikhe and Tbilisi. Between the cities the difference is statistically reliable χ2 (30) =112.043, p = 0.000 (Error! Reference source not found.). It is noteworthy that from these 52 respondents no one is HIV-infected. The main source of syringes and needles for the respondents (80%, 1454 respondents) is a pharmacy (1454 respondents) and/or flats (places), where they gather for injections (33% 605 respondents). However, during the last 6 months, only 11 respondents mentioned practice of use of syringe dropped in a street, which is a very risky behavior. It should be mentioned the practice of syringe receipt (295 respondents, 16%), most part of them is the respondents of Ozurgeti (127 respondents) and the ones of Poti (13 respondents) and the respondents of Kutaisi (5 respondents). Gathering in various places (flats, specific places, boiling place) for drug use is mentioned by the most part of the respondents (1576, 86.6%), which was mentioned by more than 80% of the respondents of all cities except the ones of Kutaisi, where the same practice was mentioned by 58% of the respondents during the last 6 months. The difference is statistically reliable χ2 (30) = 682.529, at p = 0.000 level.

DIAGRAM 18. HOW OFTHEN HAVE YOU SHARED SYRINGE WITH A HIV-INFECTED PERSON THAT WAS KNOWN FOR YOU OR HAVE FOUND OUT LATER DURING THE LAST 6 MONTHS?

100%

95%

90% once or more times each week

85% several times each month totally several times or less 80% never

75%

On the question how you have cleaned syringes during the last 6 months, 70% of the respondents have mentioned that they always use new syringe, the rest (540, 30%) indicate at applying various rules of cleaning. Among them it should be mentioned use of boiled water (310, 57%) and water or soapy water (145, 27%), very few cases of chlorine, alcohol/spirit, soda and urine. Cleaning practice of syringe with boiled water is characteristic mostly for 95% of the respondents from Akhaltsikhe, 48% from Zugdidi and 21% from Poti, which gives statistically important difference (χ2(260) = 1572.384, p = 0.000) compared to other cities.

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During the last 6 months, share practice of syringe with various frequencies is significantly seen in Akhaltsikhe (99%) and Zugdidi (58%), which is statistically important difference (χ2 (30) = 905.544, p = 0.000), in other cities, this practice varies between 2%-25%. During the last 6 months, instruments share practice of instrument with various frequencies (boiling bowl, spoon and others) is sufficiently spread- 53.2% (969 respondents), however, the difference between the cities is statistically important (χ2(30) = 876.410, p = 0.000) and absolute majority of the respondents from Akhaltsikhe, Telavi and Rustavi (97%-99%) mentions this practice (diagram 19).

DIAGRAM 19. SHARE PRACTICE OF VARIOUS INSTRUMENTS (BOILING BOWL, SPOON AND OTHERS) DURING THE LAST 6 MONTHS

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

never totally several times or less several times each month once or more times each week

It is also important cotton share practice from non-injection instruments (489, 26.9%), which is less revealed in Batumi and Samtredia (2%-5%) and particularly high in Rustavi, where 92% of the respondents mentioned cotton share practice (diagram 20. cotton share practice during the last 6 months ). This difference between the cities is statistically important χ2 (30) = 707.696, p = 0.000.

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DIAGRAM 20. COTTON SHARE PRACTICE DURING THE LAST 6 MONTHS

Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Borjomi Batumi Akhaltsikhe

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

never totally several times or less several times each month once or more times each week

Transfer from syringe to syringe is a wide-spread practice mentioned by 61% (1117 respondents) of the whole sampling, the difference is seen between the cities and the highest rates are in Telavi (95%), Akhaltsikhe (99%) and Rustavi (100%). In other cities this rate is detected in 43%-82% of the respondents, exception is Borjomi (16%) and Poti (18%); χ2(30) = 1180.339, p = 0.000. During the last 6 months establishment of sexual relations in order to obtain drugs is low in the whole sampling and does not exceed 1.6% (30 respondents). Also, establishment of sexual relations (0.9%; 17) for providing drugs (1.6%; 32) and/or receiving money is low. However, from these values, practice of sexual relations for making payment is high (6.9%; 125), which is mostly revealed in Rustavi compared to other cities χ2 (30) = 331.286, p =0.000. During the last 6 months, value of use of condom regularly and in most cases amounted 30% in the whole sampling, in other cases use of condom with various frequencies is revealed. With this regard, the least respondents mentioned non-use of condom in Batumi, Poti, Zugdidi and Samtredia compared to other cities. Rate of use (means regular use) is seen in Akhaltsikhe and Tbilisi (diagram 22). In case of sexual relations with more than 2 partners, 24.7% have indicated that they never used condom or used sometimes. The difference between the cities is statistically reliable χ2 (40) = 802.126, p =0.000.

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DIAGRAM 21. CONDOM USE PRACTICE ACCORDING TO THE CITIES DURING THE LAST 6 MONTHS

100% never used 90%

80% simetimes 70%

60% in most cases 50%

40% always 30%

20% I have not had any 10% sexual relations during the last 6 0% months

For a question-how many times do you have sexual relations with a person with HIV that was known to you or found out later during the last 6 months, totally, 11 positive answers (5- Tbilisi, 2- Kutaisi and few cases in Akhaltsikhe, Telavi and Rustavi) are revealed, from which 10 involves several times or less contacts and one case regular one (once or twice each week). However, the difference between the cities is not statistically reliable, which means that no city characterized with such type of behavior.

On a question to- what extent you are worried with threat of HIV/AIDS disease: 8.6% (157 respondents) is not worried at all, and also, not worried about the fact that he/she may be infected 17.5% (319 respondents). However, threat related to be infected with HIV is significantly and much revealed in the respondents from Batumi, Zugdidi and Samtredia (diagram 22). With this regard, the difference between the cities is statistically significant χ2 (40) = 1510.516, p =0.000.

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DIAGRAM 22. TO WHAT EXTENT YOU ARE WORRIED ABOUT THREAT OF HIV INFECTION

100% too much 90% 80% significantly 70% 60% moderately 50% 40% 30% a bit 20% 10% not worried at all 0%

In the whole sampling, 1,220 (67%) respondents have never been tested for HIV. The share of those respondents tested during the last month (51; 2.8%) or during the last 6 months (175; 9.6%) is low. According to the fifth of the respondents (374; 20.5%), they were tested a year and more times ago. It is important, that the part of the respondents, who have ever been tested, all of them are informed about their status. Testing is more or less performed for the respondents from Ozurgeti and Telavi, but absolute majority of the respondents from Akhaltsikhe, Samtredia and Kutaisi has never been tested. The difference between the cities (table 3, diagram 23), which is statistically reliable (p = 0.000) is low.

TABLE 3. HOW OFTEN IS YOUR BLOOD SAMPLE TAKEN FOR DETECTION OF HIV INFECTION

95% confidence interval city N average SEM Minimum maximum Lower limit Upper limit

Akhaltsike 140 0.2 0.012 0.00 0.05 0 1 Batumi 121 0.79 0.082 0.62 0.95 0 4 Borjomi 165 0.22 0.045 0.13 0.31 0 5 Zugdidi 136 0.17 0.042 0.09 0.25 0 4 Tbilisi 459 0.83 0.071 0.69 0.97 0 10 Telavi 65 2.45 0.350 1.75 3.15 0 10 Ozurgeti 158 1.89 0.056 1.78 2.0 0 4 Rustavi 113 0.35 0.066 0.22 0.49 0 3 Samtredia 113 0.04 0.019 0.01 0.08 0 1 Poti 148 0.20 0.037 0.13 0.28 0 2 Kutaisi 202 0.07 0.022 0.03 0.12 0 3

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DIAGRAM 23. DISTRIBUTION OF HIV TESTING PERFORMED ANY PERIOD OF TIME ACCORDING TO CITIES

100%

80% 10 times

60% 8 times 7 times 40% 6 times 20% 5 times 0% 4 times 3 times

Assessment of Knowledge for Transmission of HIV Infection

Majority of the respondents (1474, 81%) answers correctly all questions (totally 5 questions) on HIV transmission, detailed questions and answers see at diagram 24.

DIAGRAM 24. DISTRIBUTION OF ANSWERS ABOUT TRANSMISSION OF HIV INFECTION

is it possible transmission of HIV infection to a person via mosquito bite

can a person be infected by sharing food/water with HIV-infected person

do you think that HIV-infected person can have healthy person's appearance

can a person reduce HIV infection risk by using condom regularly

risk of HIV infection decreases, if you have one devoted sexual partner

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

I do not know no yes

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Assessment of knowledge and Practice on Hepatitis C

The level of information capacity on transmission of hepatitis C is very high, more than half of the respondents (1,228, 67.5%) answers all questions correctly (diagram 25). The fourth of the respondents (452; 25%) does not know or answers incorrectly a question whether hepatitis C is transmitted by sexual way or not. Questions related to infecting by hepatitis C are answered more and less correctly by majority of the respondents (diagram 26).

DIAGRAM 25. DISTRIBUTION OF ANSWERS ON TRANSMISSION OF HEPATITIS C

trnsmitted by holding things in public areas transmitted by share of used needle or syringe transmitted by share of domestic things transmitted by share of personal hygiene things transmitted through cough, sneezing-drops transmitted by shaking hands transmitted by sexual contact transmitted by food

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

q do not know no yes

DIAGRAM 26. DISTRIBUTION OF ANSWERS ABOUT HEPATITIS C INFECTION RISKS

I do not know

I was affected in the past and wiil not be infected

non-use of non-sterile or used medical devices

non-share of injection device

non-share of needle and syringe used with others

use of condom

vaccination

0 200 400 600 800 1000 1200 1400 1600 1800

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21.5% (391) of the respondents answered that it is impossible that a person has hepatitis C and not revealed in symptoms or do not know whether symptoms can have or not. Also, 11.1% (201) respondents do know where he/she was tested for hepatitis C. However, 483 (16.5%) respondents mentioned performance of testing within 1 year period, few respondents indicated at performing hepatitis C testing within 2-5 years (90, 4/9%), majority of them (1194 respondents, 65.5%) indicated that they have never been tested. From those respondents, who have never been tested, most part is in Ozurgeti (123; 77.8%) and Batumi (71; 58.7%), in other cities, this value varies between 1.4%-41.5%. The difference between the cities is statistically reliable (p=0.000). With regard to the reasons for non-performing hepatitis C testing, 7.3% (133 respondents), who have never been tested mentioned that they have fears of positive answer or do not want that a result become known, as people guess that she/he is a drug user and prefers not to be tested. The rate of those respondents assuming that they do not need testing is quite high (359; 19.7%). Only 7 respondents from the whole sampling indicate that currently, they are on hepatitis C treatment, 3 respondents mentioned stopping treatment earlier and 116 respondents completed treatment course. For 3 respondents, who stopped treatment, the reason was side-effects of preparations. Majority of the treated patients 9103 respondents) indicated at successful treatment and no case of virus returns seen. During the treatment 93 respondents continued injection drug use, 35 stopped, but only 2 respondents have not resumed drug use after completion of hepatitis C treatment.

DIAGRAM 27. FAVORABLE PLACE FOR HEPATITIS C TREATMENT

hepatitis C treatment facility, in my city 1%1%

methadone substitution 35% therapy center/departmnet in my city harm reduction (syringe 63% and needle program) 0% service center in my city

with other service provider in my city other

On a question where is mostly desirable to perform hepatitis C testing, confirmation, treatment service, majority of the respondents (1,152; 63.3%) named harm reduction center and hepatitis C treatment facility (632; 34.7) (diagram 27. favorable place for hepatitis C treatment ). 32

Screening results of the respondents for HIV and hepatitis C testing have been entered into questionnaires’. No respondent from Samtredia has Anti-HCH positive, the high value was revealed in Telavi (47% of the respondents-HCV positive), the difference between the cities is statistically reliable (p=0.000). While screening for HIV infection, 7 positive cases were revealed, from which two cases were co-infection with hepatitis C, and hepatitis mono-infection is equally seen both in women and men, without difference. Infection distribution according to gender is provided in table 4, statistically reliable difference between gender and hepatitis C or HIV infection is not revealed.

TABLE 4. DISTRIBUTION OF RESULTS FOR HIV AND HEPATITIS C TESTING

Result women (%) men (%) HIV(+) 0 7 (0.4%) HIV(-) 125 (100%) 1,688 (99.6%) HCV(+) 280 (16.5%) 1,351 (79.7%) HCV(-) 25 (20%) 98 (78.4%)

REMARK: AT THIS STUDY PHASE, 3.6% (66 RESPONDENTS) OF THE SAMPLING HAVE NOT BEEN PERFORMED HCV TESTING.

Basic Findings and Recommendations

Irrespective of the existing methodology restrictions, according to the study results, peer- driven intervention gives the opportunity to attract that part of injection drug users (most share of it), who have never had any connections with HIV prevention services during the last 12 months. In some cities participating in the study, women respondents were not enrolled, which is, to some extent, is conditioned by lack of women in initial seeds rows. But in some cities women were enrolled in the study with the support of men and it is possible that monetary stimulations determined for man to attract women for the study have become a reason, however, low enrollment of women in the study may be conditioned by high degree of stigmatization in women (D. Otiashvili, Kirtadze, Vardanashvili, Tabatadze, & Ober, 2019) (Kirtadze et al., 2013) Average age of the study participants is 35.3 years, median is 34 (SD 10.95), the young respondents up to 34 years old are mostly seen in the following cities: Poti, Zugddi, Akhaltsikhe and Samtredia. In the whole sampling, the level of unemployment is very high significantly exceeding self-employed, full time employed and temporary employed persons in sum. The rate of employment according to the cities is statistically different and the most unemployed participants are in Kutaisi. For the third of the whole sampling, the basic source of income was

33

friends, relatives, parents or partners last month. The basic source of income for men is renting/buying things and money won in casino, compared to women, for them, the basic source of income is money obtained in various ways (friends/relatives, borrowed money, social support). Casino and totalizator is mostly seen in Zugdidi and Poti compared to other cities. More man have own flats compared to women, more women live in rented houses compared to men and more women have mentioned living in shelter than men. This proves and indicates at support for injection women drug users’ needs and their economic dependence on relatives and partners. Accordingly, while managing harm reduction services for women, their needs are to be taken into account, which ensures offering appropriate services or referring them to relevant facilities. The tendency is clearly outlined that men start drug use in earlier age compared to women and use drugs much more years than women. Also, men (14 days on average) more frequently use drugs per month than women (10 days on average), however, there is no difference in number of injections used per day between men and women. Men have mentioned that they inject drugs in larger groups compared to women. This should be considered during education activity in order to clearly explain what possible risks are related to injections in larger groups. Absolute majority of the respondents has never been involved in OST. According to the cities the analysis shows that in all cities except Ozurgeti and Telavi, more than 90% of the respondents mention non-involvement in OST. But the information related to Ozurgeti may be considered as restriction because more than half of the sampling at the time of the study is involved in OST that violates the study inclusion criteria (during the last 12 months, they have not had any connections with HIV prevention programs). In terms of gender difference in OST treatment inclusion is harsh; men have more experience in OST treatment compared to women. It is possibly conditioned by stigmatization problem; women not frequently go to treatment facilities (D Otiashvili et al., 2015; David Otiashvili et al., 2013). During the last 30 days according to the picture of drugs used via injection, most respondents use heroine, sirets followed by street subutex and methadone. However, it is noteworthy use of homemade vint, especially ephedra vint. Use of desomorphine is very low and in the cities participating in the study it use does not exceed 2%. The same values are revealed with regard to injection use of synthetic cations (wash salts, bio-amphetamine, PVP, ephedrine and other similar drugs) In the inguinal vein last injections are seen in 14.3% of the respondents. According to the cities, during analysis, the respondents of three cities are seen (Ozurgeti, Rustavi and Kutaisi), who compared to the respondents from other cities apply to injection of significantly risky places, such as axillary,clavicular, inguinal areas and cervical veins. During the last 30 days, among the reasons for overdose cases, heroin dosing problem, mixture drug with alcohol and other drugs take leading positions. The half of the respondents indicated at use of naloxone or calling for emergency aid, very few (3 respondents) mentioned use of salty injection or artificial respiration (1 case). Average value of risky behavior index in sampling is not high, however, risky behavior index of women slightly exceeds the value of index for men; during assessment according to the

34

cities, high index of risky behavior is revealed in Telavi, Akhaltsikhe and Rustavi. The lowest risky behavior index is seen in Samtredia. However, upon analysis of variables of risky behavior, it has been determined that:  The highest rates of syringe and needle share practice is revealed in Telavi, Akhaltsikhe and Zugdidi, this information is to be used while planning educational works with injection drug users.  At the same time, more respondents with secondary and professional education are distinguished by high risky behavior index compared to the respondents with higher education.  It is noteworthy cleaning practice of used syringe, the third of the respondents use such practice, from which the half uses boiled water for cleaning that is not right technique for syringe cleaning. This practice is mostly characteristic for the respondents of Akhaltsikhe, Zugdidi and Poti compared to the respondents from other cities.  Share of syringe washing water are frequently used by the respondents from Akhaktsikhe and Zugdidi.  Few cases of use of chlorine, alcohol/spirit, soda and urine for syringe washing with various frequencies are revealed.  From non-injection instruments it should be mentioned cotton share practice, applied by the fourth of the respondents and it is especially high in Rustavi, where 92% of the respondents mentioned cotton share practice  From sexual risky behaviors, use of condom is low during the last 6 months and only third of the respondents mentioned regular use or use in most cases. In case of sexual relations with two or more partners, the fourth of the respondents mentioned that they use condoms sometimes or did not use it.  The respondents from Samtredia, Zugdidi and Batumi are much worried/concerned with threat of HIV infection  Testing was more or less performed by the respondents of Ozurgeti and Telavi, but in Akhaltsikhe, Samtredia and Kutaisi, absolute majority of the respondents has never been tested for HIV.  The level of education on transmission of HIV infection was satisfactory, more than 80% of the respondents answered all questions (totally 5 ones) correctly. The level of information capacity on transmission of hepatitis C is also satisfactory, more than two/third of the respondents answered all questions correctly. The problematic question whether hepatitis C is transmitted in sexual way or not, the fifth of the respondents did not know or answered incorrectly. Also, the fifth of the respondents did not know if symptoms are revealed if a person is infected by hepatitis C.  Number of tested persons for hepatitis C is low, more than two third mentioned that had never been tested, the most respondents are from Batumi and Ozurgeti. Among the reasons for not performing testing on hepatitis c is fear of positive

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answer or they do not want that a result become known, because people guess that she/he is a drug user and prefers not to be tested.

Significantly low rate of testing on HIV infection, all types of hepatitis as well as low value of use of OST treatment services may be conditioned by deficit of specific information in this population. Namely, this population is not informed why testing should be done for HIV infection or viral hepatitis, how they are benefited from testing results, despite the fact that they well know ways of transmission and associated risks, however, certain part of the population does not know where testing on hepatitis C is performed and does not have the information on advantage of treatment for drug- dependency. It is recommended to perform risk reduction counseling if prepared information materials are understandable for persons with any levels. Attention should be paid to practice of sterile injection instrument use and discussion negative sides of wide-spread washing practice. Performance of educational talks, consultations or demonstration of risky practice of washing water share explaining why it is threatful is recommended. It is important to teach negative results of washing practice by alcohol or boiled water and show rule of correct cleaning. It would be good to have higher rate of correct answers on some questions related to transmission of hepatitis C and risky behaviors than it has been revealed in reality. For example, it is important for this population to distribute information on hepatitis C immunity that after completion of treatment, possibility of reinfection is high if risky injection behavior is maintained even while sharing non-sterile injection or syringe and needle and having unprotected sexual relations, which takes important role in distribution of infection hepatitis 13 14 . Half of the respondents prefers to be tested, diagnosed and treated for hepatitis C in a specialized medical facility, 47.6% (355 respondents), the second half mentioned that this service is acceptable to receive in harm reduction service centers.

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Appendices

Appendix N1. Report of ethic Commission Appendix N2. Study Questionaries’ Appendix N3. Informed Consent Appendix N4. PDI recruiting chain according to the Cities

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