Analysis Results of Quantitavive Study Conducted Among Beneficiaries of Needle and Syringe Program
Study Report
Georgian Harm Reduction Network Tbilisi 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 (Kutaisi), Nestor Maisadze (samtredia) Union “New Vector” –Manana Khikhadze, Dimitri Tsiklauri (Tbilisi), Elene Qajaia (Rustavi) Union “Imedi” -Tamuna Esebua (Batumi) Union “Step To The Future”-Nino Beruashvili (Borjomi), Mariam Baindurashvili, Nino Tabuashvili (Gori), Zeinab Kobiashvili (Telavi) Association of National Development of Education, Social Rehabilitation and Historic Values Protection “Ordu”-Liana Topuria, Lela Kurashvili (Poti) Association of Young Psychologists and Doctors “Xenon” –Tsira Egutia, Medea Chichalava (Zugdidi). Hepa Plus-Maka Revishvili, Tamuna Kiladze (Tbilisi), Lia Tsikarishvili (Akhaltsikhe) International Organization for Women “Akeso”-Irina Fatsatsia, Gela Lashkhia (Tbilisi) Fenix-2009-Enri Maminashvili (Ozurgeti)
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 managebale.
The stury report has been preparated by the professor of addiction studies of Ilia State University, Irma Kirtadze (doctor).
2
Table of Contents
ABBREVIATIONS 2
INTRODUCTION ERROR! BOOKMARK NOT DEFINED. Harm Reduction Programs conditioned by Injection Drus Use in Georgia ...... ERROR! BOOKMARK NOT DEFINED.
STUDY OBJECTIVES AND TASKS ERROR! BOOKMARK NOT DEFINED.
METHODOLOGY ERROR! BOOKMARK NOT DEFINED.
STUDY DESIGN ...... ERROR! BOOKMARK NOT DEFINED. ETHICAL ISSUE OF THE STUDY ...... ERROR! BOOKMARK NOT DEFINED. INSTUMENT ...... ERROR! BOOKMARK NOT DEFINED. RECRUITMENT ...... ERROR! BOOKMARK NOT DEFINED. SCREENING AND INCLUSION CRITERIA FOR STUDY PARTICIPANT ...... ERROR! BOOKMARK NOT DEFINED. DATA COLLECTION AND ANALYSIS ...... ERROR! BOOKMARK NOT DEFINED. STUDY LIMITATIONS ...... ERROR! BOOKMARK NOT DEFINED.
STUDY RESULTS ERROR! BOOKMARK NOT DEFINED.
DEMOGRAPHIC DATA ...... ERROR! BOOKMARK NOT DEFINED. DRUG SUE PRACTICE ...... 12 RISK ASSESSMENT BATTERY ...... ERROR! BOOKMARK NOT DEFINED. SERVICE ASSESSMENT ...... 24 KNOWLEDGE ASSESSMENT FOR HIV INFECTION TRANSMISSION ...... ERROR! BOOKMARK NOT DEFINED. ASSESSMENT OF KNOWLEDGE AND PRACTICE FOR HEPATITIS C TRANSMISSION ERROR! BOOKMARK NOT DEFINED.
BASIC FINDINGS ERROR! BOOKMARK NOT DEFINED.
RECOMMENDAITONS ERROR! BOOKMARK NOT DEFINED.
BIBLIOGRAPHY ERROR! BOOKMARK NOT DEFINED.
APPENDICES 36
APPENDIX N1. ETHICAL COMMISSION REPORT ...... 36 APPENDIX N2.STUDY QUESTIONARRIE ...... 36 APPENDIX N3. INFORMED CONSENT ...... 36
Abbreviations
NSP Needle and Syringe Program PWID Persons who injects drugs (injection drug users) HIV Human immunodeficiency virus OST Opioids Substitution Therapy AIDS Acquired Immune Deficiency Syndrome VCT Voluntary Counselling and Testing WHO World Health Organization GHRN Georgian Harm Reduction Network SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections IIMAI for Injections Instruments Mechanical Apparatus Global
Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
NCDSPH National Center for Diasese Control and Public Health
2 Introduction
Harm Reduction Programs conditioned by Injection Drus Use in Georgia
According to the joint, consolidated recommendations of the World Health Organization, Joint United Nations Program on HIV-AIDS and United Nations Office on Drugs and Crime (WHO, World Health Organization, 2015), in order to have effective response to HIV infection epidemic, it is necessary to use comprehensive package of harm reduction in persons who inject drugs (PWID), which is available in Georgia with the support of the Global Fund and implemented by the National Center of Disease Control and Public Health. In Georgia, universal package stipulated for consolidated guideline is available for PWID population and it contains: 1. Needle and Syringe Program; 2. Opioids Substitution Therapy 3. HIV testing service; 4. Antiretroviral therapy; 5. Prevention and treatment of sexually transmitted infections 6. Condom program for PWID and their sexual partners; 7. Targeted information, education and communication; 8. Viral B/C hepatitis prevention, vaccination, diagnostics and treatment; 9. Tuberculosis prevention, diagnostics and treatment; 10. Naloxone distribution in community.
Harm reduction, as the response approach on a drug abuse problem represents an important component for public health and state drug policy and it is based on the principles of human rights protection. Injection drug use-driven harm reduction involves strategies, programs and practices that are directed to diminish health, social and economic harm caused by use of legal or illegal psycho-active substances and it is not required to be targeted at decreasing drug use. Harm reduction approach admits that from those people, who inject drugs, not all of them can manage or has the desire to stop drug use. At the same time, resulting from the threat related to HIV infections, B/C hepatitis and blood-borne infections and overdose, it is essential to provide bio-psychological-social and legal support suited on those people. In Georgia, over the last 15 years, number of problematic users using psychoactive substances has increased1 and it amounts to approximately 2.02% within 18-64 aged group of the Georgian population. Consequently, health and social harm caused by use of psychoactive substances has also enlarged. With this regard, it is noteworthy growth of cases related to blood- borne infection diseases (HIV/AIDS, C/B hepatitis). According to data provided by the Research Center for the Infection Pathology, AIDS and Clinical Immunology and taking into account the
1 Bemoni Public Union & Curatio International Foundation. (2017). Population Size Estimation of People who Inject Drugs in Georgia 2016 (p. 54). Tbilisi.
3 situation as of July 2019, 293 cases of HIV-infection have been registered and transfer of infection in 39% cases was caused by drug use (Research Center for AIDS and Clinical Immunology, 2019). In Georgia, harm reduction program has been actively implemented since 2005 with the support of the Global Fund and geographical availability has been steadily increasing ever since. Currently, provision of harm reduction services are carried out by all known modes: inpatient, outpatient, field access (so-called outreach work) and special apparatus. By the situation as of 2019, in Georgia, 16 inpatient and 8 outpatient harm reduction service centers have operated. All service centers have field-access service and piloting of injection instruments mechanical apparatus is being carried out, which means installation of 8 apparatus in Tbilisi and 2 ones in Rustavi at the end of 2020. The harm reduction program operating in Georgia offers PWID complex, diverse services suited on their needs and provides questioning among the program beneficiaries applying quantitative method of the study. Based on this fact, functioning of harm reduction programs, growth of geographical area of the service, improvement of service quality and increase of accessibility, consideration of PWID population’s needs and management of services suited on them are crucial for harm reduction programs. For this purpose, the Georgian Harm reduction Network routinely gets feedback from the service beneficiaries on an annual basis, this feedback is related to service assessment, injection and sexual risky behaviors, the current situation is being evaluated and needs are revealed that may be taken into account for future programs.
4 Study Objectives and Tasks
The purpose of the study is to review PWID beneficiaries’ behavior connected with drug use, level of the knowledge of HIV-AIDS and hepatitis C in injection drug users and to estimate sexual and injection behaviors implying risks. The results of the mentioned study will give the opportunity to reveal needs and consequently, to develop response to them taking into consideration evidence-based data, namely; to plan and make relevant amendments in HIV- infection/AIDS prevention program for injection drug users.
o To study beneficiaries’ risky injection and sexual behaviors, who participate in the Needle and Syringe Program; o To study the social-economic level of the drug users; o to study the level of the knowledge for HIV-AIDS and hepatitis C; o to study behaviors related to overdose; o to study frequently applied harm reduction services, o to study needs to presented in various favorable services
Methodology
Study Design
Within the frame of cross sectional2 study face-to-face questioning administrated by an interviewer for beneficiaries using harm reduction services has been performed. Interviewing was carried out by the consultants for voluntary counselling and testing of the harm reduction services. Reporting of results for each interviewing was done on the paper questionnaire by pen. Questioning was continued for 4 months-from January 2019 till April of the same year in 11 harm reduction inpatient service centers. Each interview needed approximately 20-30 minutes. The targeted population of the study was beneficiaries, who has used the services of the above-mentioned centers during the last 6 months, and agreed to participate into the study. On JotForm® online platform electronic base of the questionnaire was placed, where each service center transfer data obtained from interviewing from paper into electronic platform. Ethical Issue of the Study
The study protocol, the questionnaire (administrated by an interviewer) and informed consent form was prepared for submission to the Commission for Bioethics Issues -Health Research Union (HRU IRB#2018-08, IRB 00009520; address: #47 Tashkenti street, Tbilisi) to discuss study participants rights. The Ethic Commission of the Health Research Union is
2 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 registered in the US registry of Ethic Commissions for Protection of Study Participants Rights3. The Ethic Commission has discussed the application for the presented study and has given a right to conduct the study pursuant to all rules (see appendix 1).
Instrument
Structured questionnaire has been applied as a study instrument, which was used by the Georgian Harm Reduction Network in the previous years, among them risk assessment battery4, which is well-adapted in this population for conduction of studies in Georgia5 and in addition to it, questions related to hepatitis C was applied (see appendix 2). The instrument is composed of the following sections: demographic data (17 questions) injection drug use practice (28 questions) risk assessment battery (29 questions) service assessment (3 questions) verification of HIV-infection transmission knowledge (5 questions) Information on hepatitis C (19 questions)
Majority of the questions is simple with possibilities to choose only one from given answers, however, questions are provided for choosing multiple answers and answers with possibilities to choose by ranking sequence. The main thing to participate in the study was expressed voluntary desire for participation. Confidentiality of respondents was preserved (name, surname, personal number were not mentioned) via seven and fifteen-figured codes within the frame of the service (they are used during administering harm reduction programs) Recruitment
Non-probable, easily available recruitment design6, was used, which means questioning of those beneficiaries, who were accessible for the service center during four-month period of the study conduction and agreed to participate in the study. Number of the study participants accounted for 987 (diagram 1).
3 http://ohrp.cit.nih.gov/search/irbsearch.aspx 4 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. 5 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 6 Tyrer, S., & Heyman, B. (2016). Sampling in epidemiological research: issues, hazards and pitfalls. BJPsych Bulletin, 40(2), 57–60. http://doi.org/10.1192/pb.bp.114.050203
6 DIAGRAM 1. PROCESS OF STUDY RECRUITMENT
participation in the study was offered to 1092
refusal for participation -105
criteria are not satisfied by 0
final recruitment -987
Screening and Inclusion Criteria for Study Participant
Information on the study was placed on the walls of all service centers as well as field workers have offered the beneficiaries to participate in the study. A person expressing willingness to participate in the study has been performed screening (evaluation of correspondence with study inclusion criteria) and the procedure obtaining consent for study participation. For this purpose, an interviewer has explained each potential participant the study goal and introduced informed consent for study participation (appendix 3). No cash indemnity was considered for study participation. The following has been defined as study inclusion criteria: A participant is to be major (18 years old and more): study participation is to be voluntary; a mandatory condition for study involvement is minimum six-month service period of benefit with Needle and Syringe Program a study participant does not have to mental problems as well as ones with thinking and speech that would impede his/hercomplete participation in the study;
Data Collection and Analysis
Data collection has been done by applying questionnaire, data was enetered by an interviewer on JotForm® online platform. With the help of this platform, the probability to enter data mistakenly has been minimized and skip patterns of irrelevant questions have been used. Online base was exported into so-called CSV files and combined in Excel for later export
7 into Statistical Package for the Social Science7, where whole base has been checked by applying data frequencies and cross-tabulations.
Uni-variation analysis has been performed- frequencies, medium and median rates were calculated and through bi-variation analysis (cross tabulation of category variables, comparison of averages, t-test, ANOVA), interrelations (differences) between variables were revealed.
Study Limitations
This study as well as all other studies is accompanied by certain limitations. The study is based on collection of considerations of beneficiaries using the service and non-probable, easily available selection is applied that in certain cases restricts us from data generalization. Restriction is also assumed mobilization of study participants with the help of social workers, which in certain cases can cause potential calling for those beneficiaries, who provide positive answers acceptable to a social worker and the circumstances that the service provider itself was conducting beneficiaries questioning (in this case a consultant of voluntary counseling and testing). Consequently, taking into account the above-described circumstances, the possibility to completely generalize implications are restricted to some extent, but it provide some opinions about certain behaviors distributed in this population.
Study Results
Demographic Data
The beneficiaries using harm reduction services provided in 11 cities of Georgia (Batumi, Borjomi, Gori, Zugdidi, Tbilisi, Telavi, Ozurgeti, Rustavi, Samtredia, Poti and Kutaisi) have participated in the study. Totally, 1092 screenings were performed, 105 beneficiaries refused to participate and data of 987 respondents were entered into the final data-base. Diagram 1. Majority of the respondents questioned was in Tbilisi, because 4 service centers have been operating in this city (27.8%, 274 respondents) see diagram 2. Majority of the study participants is man (967 respondents, 98%), and the other little part- women (20 respondents, 25) (see diagram 3). On a question, how can you describe yourself- heterosexual, gay, bi or homosexual-the absolute majority has indicated heterosexual and only one mentioned that he/she is bisexual. As number of the women in total selection is too low, it becomes aimless to consider the rates into the network perspective.
7 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
8 DIAGRAM 2. DISTRIBUTION OF STUDY PARTICIPANTS' NUMBER ACCORDING TO THE CITIES
350 295 300 250 200 150 96 100 74 81 71 76 100 70 63 55 50 6 0
DIAGRAM 3. GENDER DISTRIBUTION ACCORDING TO THE CITIES
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
woman man
The age distribution in the study approaches to normal rate (diagram 4); average age of the participants is 41.48, median age-41 (minimum -20 and maximum-66).
9 DIAGRAM 4. AGE DISTRIBUTION HISTOGRAM BY NORMAL DISTRIBUTION CURVE
Majority of the respondents (467; 47.3%) has had comprehensive secondary education (see diagram 5).
DIAGRAM 5. EDUCATION LEVEL OF RESPONDENTS
refrain from highest answer, (complete) 0.4% average , 16.3% (incomplet e), 7.5%
highest (incomplet ed) , 13.4% average (complete) , 47.3% profession al, 15.1%
In the total recruitment, unemployment rate is high (563; 57%), which exceeds significantly the rates in sum of self-employment (24%), temporary employment (12%) and employers in fulltime (63; 6.4%).
10 DIAGRAM 6. EMPLOYMENT RATE BETWEEN RESPONDENTS
refrain from answer 0.5
pensioneer, diasable person 0.1
wotk full time 6.4
temporary work 12.1
self-employed 23.9
unemployed 57
0 10 20 30 40 50 60
In the last month, incomes received from employment (366; 37.1%) and friends, relatives or partners (295; 29.9%) between the basic sources of earnings are dominated (see diagram 7). It is noteworthy that the main income of participants employed in various ways is employment itself, compared to unemployed participants, whose basic source of income is relatives/friends/partners or selling/renting, money obtained, or illegal activity that is revealed by statistically reliable difference (χ2 (30) = 771.837, p = 0.000.)
DIAGRAM 7. DISTIBURION OF MAIN SOURCE FOR PERSONAL INCOME IN LAST MONTH
employment
6% money received by renting or selling something 6% 2% 5% money received from friends, relatives, partners, 37% borrowed money social support or pension
illegal income 30% 14% money won (casino, totalizator, other)
refrain from answer
Half of the respondents (486; 49.2%) lives with parents, relatives, partners, friends and 38.9% of the respondents have own flats, see diagram 8. Statistically reliable difference was seen
11 between living conditions and employment, namely, more employed participants have own flats than unemployed ones, who mostly live together with parents, friends, partners or relatives χ2 (25) = 95.656, p = 0.000.
DIAGRAM 8. LIVING CONDITIONS OF RESPONDENTS
refrain from answer 0.3
homeless, not having permanent shelter 0.6
shelter 1
rent, mortgage 9.9
parents'/relatives'/friends' flat 49.2
own flat 38.9
0 10 20 30 40 50 60
Drug Use Practice
Based on the study participants’ statement, they started injection drug use at the age of 20 on average (SEM=0.097; median of age -20 years), minimum 14 and maximum 40 (diagram 9). Twenty-seven respondents have refrained from answering that question. Regular drug use experience (minimum three times a week) is 14.27 years on average (SEM=0.241, median 15 years, minimum 1 year and maximum 42 years). 13% of the respondents (126 respondents) have had 5-year experience of regular injection drug use, most of them (60%) –more than 10 years (diagram 10). No difference is if the respondents are employed or unemployed, have income or not, in all categories regular injection drug use is equally revealed, which is relatively high in respondents aged 30 or more (χ2 (92) = 532.998, p = 0.000)
12 DIAGRAM 9. AGE DISTRIBUTION FOR DRUGS, FIRST INJECTION
DIAGRAM 10. DISTRIBUTION OF INJECTION DRUG USE EXPERIENCE
up to 5 years 6-10 years 11 and more
More than half of the respondents (n=683, 69.2%) mentioned that they have never involved in opioids (methadone/suboxone) substitution therapy (OST), however, at the study moment 11.8% of the respondents has been in OST and 19% has had treatment experience (187 respondents).
13 DIAGRAM 11. TREATMENT EXPERIENCE IN OST PROGRAM
14.20.1 4.8 11.8
69.2
never been
currently being in program
been in the past (last month or several months ago, no less than a year ago)
During the last 30 days, average value of number of injection days amounted to 17.72 days (median -17.5 days, minimum -1 and maximum -30 days, SD=8.77), 1.36 times per day on average (minimum-once, maximum-9 times a day, median and mode 1) by number of injections done, detailed information on distribution of number of injection days during the last 30 days is available on diagram 12. 68% of the total recruitment (673 respondents) applies injection once a day, 26.3% (260 respondents) -injection twice a day, only little part applies 3 or more times a day (41; 4.1%).
DIAGRAM 12. INJECTION FREQUENCIES CARRIED OUT WITHIN THE LAST 30 DAYS
up to 5 injections , 10.9, 11%
6-10 injections 16.5%
16 and more injections 56.9% 11-15 injections 15.7%
14 In the last month while injection drug use just in one turn, the biggest number of the group members varies from 0-to 15, on average it amounts to 3.85 (SD=2.175). Very little is number of those members, who apply injection lonely (37; 4%), mostly group use consisting of 3- 5 members is seen (diagram 13).
DIAGRAM 13. DUSTRIBUTION OF NUMBER FOR MEMBERS WITHIN THE LARGEST GROUP UPON INJECTION MORE THAN ONCE
4% inject lonely 16% 18% together with 1 or 2 persons together with 3-5 persons with 6 or more 62% persons
During the last 30 days majority of the respondents has mentioned use of kenaf/hashish (618; 62.6%), psychotropic medications (293; 29.7%) and sedative preparations (107; 10.8%) among psycho-active substances used via non-injection way. Most respondents have indicated at use of heroin (575; 58.3%) among injection drugs followed by injection use of buprenorphine of OST program (338; 34.2%), so-called ephedra vint (319; 32.3%), street buprenorphine (296; 30%) and traditional vint (153; 15.5%). Diagram 14 shows completely psycho-active substances used for the last 30 days. Also, it has been revealed that non-injection use of new psycho-active substances (MDMA, ketamine, hallucinogens, synthesis cations, so-called bio-hash, bio-MDMA) exceeds injection substances (3 cases). During the last 30 days through analysis of illegal drugs used according to cities, it has been revealed that only 9 respondents have mentioned use of desomorphine in the total recruitment: Samtredia (4 respondents), Rustavi (2), Zugdidi (2), and Poti (1), in other cities use of desomorphine has never been seen, this difference in terms of cities is statistically reliable (χ2 (30) = 614.605, p = 0.000). Injection use of opioids has been mentioned by only 18 respondents, most of them in Kutaisi (10 respondents), Zugdidi (4) and equally 1-1 respondent in Borjomi (1), Tbilisi (1), Rustavi (1) and Poti (1) (χ2 (30) = 680.831, p = 0.000). Use of fentanyl was mentioned by only 12 respondents, most of them in Poti (8 respondents), then in Tbilisi (2), Zugdidi (1) and Rustavi (1) with statistically reliable difference (χ2 (30) = 583.271, p = 0.000).
15 Use of heroin has been revealed in all cities, mostly in Rustavi (100%) and Tbilisi (78.08%), in Borjomi this rate was 66.7% (4 respondents), Samtredia -60.6% (43), Kutaisi-59.2% (45), Telavi -45.7% (32), Gori-41.7% (40), Ozurgeti-28.6% (18), Zugdidi-25.9% (21) and the least value in Batumi-24.3% (18), (χ2 (30) = 682.704, p = 0.000). Injection use of methadone (street) is mostly seen in the respondents of Poti with relatively high rates (54.5%; 30) and Zugdidi (37%; 30). The respondents of Borjomi, Telavi, Ozurgeti, Rustavi and Samtredia have never mentioned use of methadone in (χ2 (30) = 516.396, p = 0.000). Injection use of Buprenorphine like heroin is revealed in all cities: Batumi (31.1%; 23), Borjomi (50%; 3), Gori (34.3%; 33), Zugdidi (56.8%; 46), Tbilisi (16.3%; 48), Telavi (54.3%; 38), Ozurgeti (1.6%; 1), Rustavi (22%, 22), Samtredia (28.2%, 20), Poti (76.4%; 42), Kutaisi (26.3%; 20) (χ2 (30) = 275.652, p = 0.000). Injection use of program suboxone in all cities, except Telavi, the highest rate is in Samtredia (95.8%; 68), Gori (80.2%; 77), Batumi (56.8%; 42) and Tbilisi (37.6%; 111), and in other cities it varies from 1% to 16.48% (χ2 (30) = 851.862, p = 0.000). Use of vint prepared by ephedra bush is revealed in all cities except Poti. Namely, injection use of vint for the last 30 days is mentioned by the respondents of Ozurgeti -55.6% (35 respondents), Samtredia -54.9% (39), Rustavi - 52% (52), Tbilisi- 39% (115), Telavi - 32.9% (23), Gori- 21.9% (21), Zugdidi - 19.8% (16), Borjomi- 16.7% (1), Kutaisi - 15.8% (12) and Batumi - 6.8% (5) with statistically reliable values (χ2 (30) = 722.012, p = 0.000), while use of vint is significantly low in Ozurgeti (1.6%; 1) and Samtredia (7%; 5) (χ2 (30) = 845.557, p = 0.000). Injection use of antihistamines is characteristic for the respondents of Poti (49.1%; 27) andOzurgeti (22.2%; 14). The respondents of Telavi, Samtredia and Kutaisi have never mentioned injection use of antihistamines (diagram 15) with statistically reliable difference among cities (χ2 (30) = 412.982, p = 0.000).
16 DIAGRAM 14. DISTRIBUTION OF PSYCHOACTIVE SUBSTANCES INJECTED DURING THE LAST 30 DAYS
cocktail other bio-MDMA bio-hash synthetic cathions antihistamines sedative preparations psychotropic preparations hallucinogens cetamine/calipso MDMA cannabis/hashish amphetamine/metamphetamine ephedra-vint vint cocaine buprenorphine buprenorphine (street) methadone (program) methadone (street) heroin phentalyn opiods desomorphine
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
not used refrain from asnwer non-injection use injection use
Few cases of injection use of synthetic cations are seen only in two cities; Kutaisi (2 respondents and Gori (1 respondent) (χ2 (30) = 884.857, p = 0.000). Majority of the respondents has indicated that a place of final injection was deep (460; 46.6%) and superficial (319; 32.3%) veins of upper and lower extremities, however, the fifth part of the respondents (200; 20.3%) –in the risky areas (inguinal, axillary, cervical, subclavian areas) (table 1)
17
DIAGRAM 15. DISTRIBUTION OF PSYCHOACTIVE SUBSTANCES INJECTED DURING THE LAST 30 DAYS
100% amphetamine/metamph etamine 90% epherda vint
80% vint
70% buprenorphine (street)
60% buprenorphine (program) 50% methadone (street)
40% methadone (program) heroin 30% phentalyn 20% opioids 10% desomoprhine 0%
TABLE 1. PLACE OF FINAL INJECTION
PLACE OF INJECTION N/%
DEEP VEINS OF UPPER AND LOWER EXTRIMITIES 460/46.6% SUPERFICIAL VEINS OF UPPER AND LOWER 319/32.3% EXTRIMITIES INGUINAL VEIN 103/10.4% SUBCLAVIAN AREA 20/2% CERVICAL VEINS 49/5% AXILLARY AREA 28/2.8% IN MUSCLES 3/0.3% ABSTAIN 5/0.5%
Differences in terms of cities, for example, for Borjomi, injections of superficial veins of upper and lower extremities are characteristic (100%), while the respondents of Poti (60%) and Samtredia (53.3%) are distinguished by injections mostly in deep veins of upper and lower extremities, subclavian area, injections in clavicular area are characteristic for the respondents of
18 Tbilisi (2%), Rustavi (6%) and Kutaisi (10.5%). In the cervical veins injections are seen in 4 cities: Kutaisi (14.5%), Rustavi (10%), Tbilisi (7.8%) and Zugdidi (6.2%). In the inguinal area injections are seen in all cities except Poti and Borjomi, the highest rates are in Kutaisi (26.3%), Ozurgeti (19%) and Tbilisi (16.6%). Difference described between cities are statistically reliable (χ2 (90) = 501.647, p = 0.000). During the last 30 days minimum one case of overdose has been mentioned by 35 respondents (3.5%), according to the opinion of their majority, the reason for overdose was use of drug in high doses 925 cases), also mixture with alcohol or other drug (8 cases). Cases of overdose were revealed in all cities except Borjomi, Batumi, and Telavi. High rate of overdose is in Rustavi (9%; 9 respondents), and in other cities: Gori - 2 cases (2.1%), Zugdidi - 3 (3.7%), Tbilisi – 7 cases (2.4%), Ozurgeti - 3 (4.8%), Samtredia - 3 (4.2%), Poti - 4 (7.3%), Kutaisi-4 cases (5.3%). In the last month rate of two-times overdose was seen only in two cities: Rustavi and Zugdidi. Difference described between cities is statistically reliable (χ2 (30) = 180.998, p = 0.000). It is noteworthy that in most cases of overdose Naloxone was used (26 cases), ambulance was called in 6 cases and only in one case salt solution was applied.
Risk Assessment Battery
Risky injection and sexual behavior was assessed by standardized instrument (Risk Assessment Battery). The final score of the instrument –risky behavior index (RAB index) varies from 0-to 1 and indicates at expected HIV-infection risk, closer is to 1, higher is HIV-infection risk conditioned by sexual and injection risky behaviors. In recruitment average rate of RAB index is 0.16 (minimum=0.03; maximum=0.60; SD 0.114), median -0.125; taking into account that study of difference of risky behavior index according to cities has showed difference of minimum one city rate from other cities, during studying t test of difference between average rates has revealed that Telavi RAB index significantly differ from average rates of all other cities (table 2), however, Telavi index itself is an indicator for low risk (0.33). Distribution of risk index frequency according to cities clearly indicates that majority of indexes sums up to 0.4 (diagram 16) and difference of index between cities is statistically reliable (χ2 (10) = 4.382, p = 0.000). While studying associations by One Way Anova, statistically reliable association is revealed between high rate if risk index and during the last 30 days, number of collected group members (F12, 934 =
4.468, p=0.000), years of regular use (F38, 927 =1.449, p=0.040), more than one injection a day (F6, 967
=3.631, p = 0.001) and number of injection days (F28, 927 = 8.750, p=0.000).
TABLE 2. AVERAGE OF RISK ASSESSMENT INDEX ACCORDING TO CITIES
RAB 95% CI City N SEM average Upper limit Lower limit Batumi 0.07 74 0.003 0.06 0.08 Borjomi 0.20 6 0.049 0.07 0.32 Gori 0.09 96 0.005 0.08 0.1 Zugdidi 0.13 81 0.004 0.12 0.14
19 Tbilisi 0.18 295 0.007 0.18 0.21 Telavi 0.34 70 0.012 0.31 0.36 Ozurgeti 0.19 63 0.011 0.16 0.21 Rustavi 0.18 100 0.008 0.16 0.2 Samtredia 0.08 71 0.003 0.07 0.08 Poti 0.11 55 0.011 0.09 0.13 Kutaisi 0.12 76 0.013 0.1 0.15
Diagram 16. distribution of risk index in cities
Upon frequency analysis of risk assessment battery variables, it has been revealed that 15.2% of the whole recruitment has mentioned share practice of syringe, needle or other injection instruments with different number of people. Share practice has not been mentioned by the respondents of Batumi, Borjomi, Zugdidi and Samtredia. Telavi is distinguished by the highest rate (100%) of share practice compared to other cities-all respondents shares with minimum one person syringe, needle or other injection instrument (share with two or more persons 98.6%; 69 respondents). diagram 17. distribution of share of needles, syringes or other injection instruments according to the cities during the last 6 months
20 clearly shows different practice of share between the cities, which is statistically reliable (χ2 (30) = 528.595, p = 0.000).
DIAGRAM 17. DISTRIBUTION OF SHARE OF NEEDLES, SYRINGES OR OTHER INJECTION INSTRUMENTS ACCORDING TO THE CITIES DURING THE LAST 6 MONTHS
Kutaisi
Satmredia
Ozurgeti
Tbilisi
Gori
Batumi 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0 noone 1 with one person 2 witj two or more persons 3 four or more persons
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 (99.5%) give negative answer, share practice with various frequency for only 5 respondents are revealed in the cities: Batumi 91 respondents-several times each month), Kutaisi (3 respondents-several times or less) and Tbilisi (1 respondents-several times or less). It is noteworthy that from these 5 respondents no one is HIV-infected. The given difference between the cities is statistically reliable χ2 (20) = 38.505, p = 0.000. The main source of syringes and needles for the most part of the respondents (96%) is the Needle and Syringe Program, however, as well as they consider a pharmacy (26.45), places, where they gather. In such places there are always syringes and needles (14.2%), only 1 respondent from Tbilisi stated about syringe use dropped in a street and the respondents from Samtredia and Kutaisi indicated that they asked for syringes to patients with diabetes. The differences described between the cities are statistically reliable χ2 (110) = 422.866, p = 0.000. The large amount of the respondents stated about gatherings in various places for drug use (flats, specific places, boiling) (85.1%), relatively less amount mentioned that gathering practice for injection has not carried out during the last 6 months (14.9%). This practice with the most share (80% and more stated that they had been minimum several times) is revealed in all cities, except: Zugdidi and Kutaisi. This difference is statistically reliable χ2 (30) = 481.51, p = 0.000. On the question how you have cleaned syringes during the last 6 months, 92.3% (911 persons) of the respondents have mentioned that they always use new syringe, which is revealed by 100% in the cities: Batumi, Samtredia, Borjomi and Gori. The city respondents has mentioned clean practice by various ways and among them it is noteworthy syringe cleaning cases with boiled water and soapy water, most of them was seen in Telavi (21.5%) and Poti (20%); few cases were seen in other cities except Tbilisi (9.2%), it should be mentioned use of one case of chloride
21 (Ozurgeti) and distillated water (Zugdidi). The difference between the cities is statistically reliable (χ2 (110) = 395.456, p = 0.000). During the last 6 months, 35.2% of the respondents has mentioned instruments share practice (boiling bowl, spoon and others), which has taken place systematically (share once or more time each week) in Telavi respondents (25.7%) , the difference described between the cities is statistically reliable (χ2(30) = 642.817, p = 0.000). also, share practice of syringe from mouth- mouth (so-called frontloading) or from the end of syringe pump (so-called back loading) is high (53.5%) for the last 6 months, half of these cases takes place several times or less (diagram 18).
DIAGRAM 18. SHARE PRACTICE FROM SYRI NGE WITH PREPARED DRUG TO ANOTHER SYRINGE (MOUTH-MOUTH OR FROM EDND OF SYRINGE)
Kutaisi Poti Samtredia Rustavi Ozurgeti Telavi Tbilisi Zugdidi Gori Borjomi Batumi
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
no times several times or less in total several times each month once or more each week
The mentioned practice several times each month or once or more time each week is mostly characteristic the respondents of Telavi (62.9%), Rustavi (53%) and Tbilisi (40.7%). The difference described between the cities is statistically significant (χ2 (30) = 526.598, p = 0.000). Absolute majority of the respondents indicates that they are heterosexual (99.9%), except one considering himself bisexual. Sexual relation practice to get money is very low and does not exceed 0.7% in the whole recruitment (p =0.000); in opposite, payment for establishment of sexual relation is revealed in 6.4% of the respondents (p =0.000). During the last 6 months, establishment of sexual relations to get drugs has been revealed in the small part of the respondents (1.9%), the opposite – use of drugs to establish sexual relations is seen in 3.1% of the respondents (p = 0.000). 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, no poisitve responde was obtained. 8.2% of the respondents have not had sexual relations for the last 6 months, 22.1% indicated that they always used condoms, 21.4% used it in most cases, 20% - sometimes and 28.4% -never used it. Diagram 19 has
22 showed distribution of condom use frequency between the cities, from which, it is clearly seen that the most unprotected relations are in Tbilisi and Kutaisi. (χ2(40) = 623.688, p = 0.000).
DIAGRAM 19. DISTRIBUTION OF SEXUAL RELATIONS ACCORDING TO THE CITIES DURING THE LAST 6 MONTHS
100%
90%
80%
70%
60% have never used 50% sometimes 40% in most cases
30% always
20% never been in sexualr elations
10%
0%
It should be mentioned that those ones who mentioned sexual contact with two or more partners for the last 6 months (315, 32% of the whole recruitment), majority of them (200 respondents, 63.5%) have mentioned not regular use of condoms (χ2 (12) = 410.654, p = 0.000). The third of the respondents have been too much or significantly worried threat for HIV infection, in this regard statistically important difference is revealed between the cities, the most worried respondents questioned are in Samterdia (100%), Zugdidi (83.9%), Batumi (74.3%) and Borjomi (83.9%) (χ2(50) = 763.327, p = 0.000). In the whole recruitment, only 6 respondents have mentioned that that have never been tested for HIV infection (diagram 20. testing rate of HIV-infection ). Testing rate of absolute majority per one respondent equals 3 on average (minimum -1 and maximum -10, SD-1.791), however this rate does not significantly differ from recently provided testing time and between the cities (diagram 21. distribution of HIV infection testing done recently according to the cities ), namely, 45.5% of the respondents states about testing one and more years ago and the most part of such beneficiaries are in Rustavi, Samtredia, Poti, Telavi, Ozurgeri and Tbilisi (χ2 (30) = 647.795, p = 0.000).
23 DIAGRAM 20. TESTING RATE OF HIV-INFECTION
DIAGRAM 21. DISTRIBUTION OF HIV INFECTION TESTING DONE RECENTLY ACCORDING TO THE CITIES
Kutaisi Poti Samtredia Rustavi have never been performed Ozurgeti during last one month telavi Tbilisi during the last 6 months Zugdidi a year and more ago Gori Borjomi Batumi
0% 20% 40% 60% 80% 100%
Service Assessment
A list of services devoted attention from the side of the beneficiaries has been studied via three questions selecting three of them from the list involving what would beneficiaries like to have as an additional service and what are those services most frequently applied by the beneficiaries.
24 According to the most part of the beneficiaries (diagram 22. service attracting beneficiaries’ attention and making a decision to enroll in needle and syringe program ), beneficiaries’ attention has mostly devoted to the Syringe and Needle Program (856, 87%), C hepatitis testing (613, 62%), HIV testing service (497, 50%), naloxone (276, 28%) and doctor’s consultations (237, 24%).
DIAGRAM 22. SERVICE ATTRACTING BENEFICIARIES’ ATTENTION AND MAKING A DECISION TO ENROLL IN NEEDLE AND SYRINGE PROGRAM
syringes and needles
Hepatitis C testing
HIV-testing
naloxone
doctor's consultations
vein-care preparations
condoms
psychologist's consultation
trainings, risk consultations
peer-driven intervention
confirmatory RNA test on hepatatis C
lawyer's consultations
information materials
0 100 200 300 400 500 600 700 800 900
In response to a question related to a desirable additional service, 471 (48%) respondents think that all services are not offered and do not know what an additional service might be. From the rest 516 respondents, the third (168, 32.6%) consider dental service as a desirable additional service, relatively small part (79, 15.3%) –need of adding a bowl –so-called “balloon”, a spoon, a filter, 34 respondents (6.6%) –liver elastography service and so on (
25 DIAGRAM 23. DESIRABLE SERVICE
).
DIAGRAM 23. DESIRABLE SERVICE
dental service
bowl (ballon),spoon, filter
other
fribroscanning
various studies
accompany and service of a lawyer
OST and Suboxone free programs
neurologist's consultation
dermatologist-venerologist' consultation
psychologist
1ml Brown's syringes
injection room
diagnostics, treatment of hepatitis C-all services through one window
0 20 40 60 80 100 120 140 160 180
Majority of the respondents are benefited with the Syringe and Needle Program (948, 96%), naloxone (435, 44.1%), vein care preparations (334, 33.8%), doctor’s consultation (272, 27.6%), HIV testing (252, 25.53%)condoms (250, 25.33%) and others (
26
DIAGRAM 24. MOST FREQUENTLY APPLIED SERVICE
).
DIAGRAM 24. MOST FREQUENTLY APPLIED SERVICE
27 syringes and needles
naloxone
vain-care preparations
doctor's consultation
HIV testing
condoms
hepatitis C testing
trainings, risk consultations
psychologist's consultation
information materials
not answered
lawyer's consultation
peer-driven intervention
0 100 200 300 400 500 600 700 800 900 1000
Knowledge Assessment for HIV-Infection Transmission
Knowledge about HIV-infection transmission has been assessed via 5 questions. The vast majority of the respondents (847, 85.8) has answered five questions correctly, 4 questions have been correctly answered by 104 (10.5%) respondents, 3 questions - 28 (2.8%), 2 questions - 5 (0.5%) respondents, 1 question –one respondent (0.1%) and only two respondents (0.2%) have not answered any questions correctly. Detailed questions and answers see on diagram 25. In total, the respondents’ knowledge about HIV-infection transmission is good, 96% of the answers are correct. The respondents of Batumi, Gori, Zugdidi, Telavi, Kutaisi and Poti have been distinguished with best rate of knowledge, 90% and more correct answers (diagram 26). The difference between the cities is statistically significant (χ2 (55) = 106.664, p = 0.000).
28 DIAGRAM 25. DISTRIBUTION OF ANSWERS FOR HIV INFECTION TRANSMISSION
Might a person be infected with mosquito bite 6 919 62
might a person be infected by sharing food/water with 5 969 13 HIV infected person
do you think that HIV infected person can have healthy 900 3849 appearance
Can a person reduce HIV infection risk if he uses 982 32 condom each time
HIV infection risk is reduced if you have devoted sexual 976 74 partner
yes no not know
DIAGRAM 26. DISTRIBUTION OF CORRECT ANSWERS FOR HIV INFECTION ACCORDING TO THE CITIES
Kutaisi
Samtredia
Ozurgeti
Tbilisi
Gori
Batumi 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
none 1 answer 2 answers 3 answers 4 answers 5 answers
Assessemnt of Knowledge and Practice for Hepatitis C
Knowledge of C hepatitis tranmission has been assessed by 8 questions. In total, majority of the respondents has answered correctly questions (94% correct answers are revealed). 64.7% (639) respondents answered eight questions correctly, 300 (30.4%) respondents answered correctly seven questions, 22 (2.2%)-6 questions, 11 (1.1%)- 5 questions, 6 (0.6%)-4 questions, 6 (0.6%)-3 questions, 2 (0.2%) -2 questions, and only one respondent (0.1%) has not answered any questions. Good knowledge are particularly revealed in Borjomi and Gori χ2 (70) = 568.065, p = 0.00). Distribution of correct answers according to the cities is provided on diagram 28. Knowledge of C hepatitis transmission according to the cities .
29
DIAGRAM 27. DISTRIBUTION OF ANSWER FOR C HEPATITIS TRANSMISSION
transmitted by holding things in hands in public areas 7 947 33
transmitted bu sharing needles or syringes 977 91
transmitted by sharing domestic things 6 961 20
transmitted by sharing personal hygiene things 973 113
transmitted by coughing, sneezing-drops 9 950 28
transmitted by shaking hand 3 963 21
transmitted by sexual contact 697 256 34
transmitted by food 1 977 9
yes no not know
DIAGRAM 28. KNOWLEDGE OF C HEPATITIS TRANSMISSION ACCORDING TO THE CITIES
Kutaisi Samtredia Ozurgeti Tbilisi Gori Batumi 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
none 2 answers 3 answers 4 answers 5 answers 6 answers 7 answers 8 answers
On questions related to risk reduction of C hepatitis infecting, majority of the respondents has answered correctly except 7 respondents, who answered incorrectly questions related to hepatitis vaccination and past hepatitis ( in case of vaccination and past hepatitis, infection risk reduces). 65% (642 respondents) of the respondents questioned is informed that by applying condom, infection risk with hepatitis C diminishes, 83.3% (822 respondents) of the respondents know that by sharing non-sterile or used medical devices transmission of hepatitis C is carried out, as well as by sharing injection devices (851, 86.2%) and used needles or syringes (980, 99.3%). Absolute majority of the respondents (except two ones) is informed where hepatitis C testis is performed and also, absolute majority (983, 99.6%) has been performed this test. 4 respondents, who are not tested, consider that there is no need to perform such testing.
30 Majority of the respondents have been performed hepatitis C testing (877, 88.9%) during the last 2 years. More than 80% of the respondents of all cities, except Telavi (61.4%) have been tested for the last 2 years (χ2 (40) = 154.500, p = 0.00). 325 (32.9%) respondents have been treated for hepatitis C for the last 2 years, 47 (4.8%) respondents stated that they have been treated during 2-5 years, 3 respondents stated that they go treatment 5 years ago. Most patients involved in treatment have been treated for the last 2 years (χ2 (16) = 1389.451, p = 0.00) diagram 29. distribution of persons tested for hepatitis C and enrolled in treatment .
DIAGRAM 29. DISTRIBUTION OF PERSONS TESTED FOR HEPATITIS C AND ENROLLED IN TREATMENT
not know no answer
HCV testing has never been performed
HCV treatment has HCV testing was performed 5 years ago been performed during the period of up to 2 years HCV testing has been performed during the period of 2-5 years HCV treatment has been performed HCV testing has been performed during the during the period of last 2 years 2-5 years
0 200 400 600 800 1000
From tested respondents on hepatitis C, who were not treated (606 respondents) 71.5% (434 respondents) have stated that they are not infected or self-treated, the others indicate at various reasons for not performing treatment; no need for treatment (58 respondents), being in the waiting list of treatment (36 respondents), covering long-distance to see a physician or medications (10 respondents), side effects of treatment medications (16 respondents), refraining from answer (12) respondents or no desire to be treated.
Respondents (375), who mentioned that they had undergone went treatment, involve those ones ceasing treatment (2 respondents) due to side effect or other undefined reasons, according to majority of the respondents, they completed treatment (339; 90%), some part is under treatment (30; 8%), the rest refrained from answering. 87.2% (327) mentioned successful completion of treatment, from which 192 indicated at repeated testing on hepatitis C and only 5 stated return of virus. 66.4% (249 respondents) of the respondents did not stop drug use being on hepatitis C treatment and 111 (30%) respondents resumed drug use after treatment. (p = 0.00). While hepatitis C treatment period certain association is revealed between injection drug use and HCV return (χ2 (9) = 422.509, p = 0.00).
31 DIAGRAM 30. STATUS FOR INJECTION USE AND VIRUS RETURN DURING TREATMENT
160
140
120
100
80
60
40
20
0 not used drug by injection used drug by injection refuse to answer
not know no return of virus return of virus
Vast majority of the respondents (825, 83.6%) have desire to be tested on hepatitis C, get confirmation, treatment service in harm reduction center of his/her own city, however respondents of Rustavi, Poti, Samtredia and Kutaisi think differently, they wish to get treatment services in special treatment facilities (χ2 (40) = 644.280, p = 0.00).
32 DIAGRAM 31. DESIRABLE SERVICE FOR HEPATITIS C TREATMENT
100% other 90%
80% with other service 70% provide in my city
60% harm reduction 50% (needle and Syringe Program) service center in my city 40% methadone 30% substitution therapy center/department in my city 20% hepatitis C treatment 10% facility, in my city
0%
DAIAGRAM 32. DISTRIBUTION OF HIV TESTING RESULTS
100% 90% 80% 70% 60% 5 50% 74 96 81 292 70 63 99 70 54 75 40% 30% 20% 10% 1 0% 0 0 0 3 0 0 1 1 1 1
HIV+ HIV-
In the whole recruitment, 8 HIV positive cases were revealed (0.81%). Share of HIV cases is high in Borjomi (daiagram 32. distribution of HIV testing results ), (χ2 (10) = 23.354, p = 0.01). Number of positive results for hepatitis C antibodies is 346 (35%) and Tbilisi is distinguished with high rates (χ2 (20) = 611.874, p = 0.00)
33 DIAGRAM 33. DISTRIBUTION OF C HEPATITIS TESTING RESULTS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
HCV+ no testing performed in the study period HCV-
Basic Findings
The beneficiaries of the harm reduction services of 11 cities, who got offered and agreed, have participated in the study (105 beneficiaries refused to participate). From 987 respondents participating in the study, most of them were men (98%) with average age of 41.48. The level of unemployment is high in the whole recruitment, the share of the respondents with complete secondary education exceeds to others. The main source of revenue for the respondents employed in various ways (temporary work, full time, self-employed) is employment compared to the unemployed ones, whose main source of living is relatives, friends or partners and renting/selling things, money won and illegal activity. The half of the respondents lives with their parents, relatives, partners, friends. The employed respondents have own flat more than the unemployed ones, who mostly live with their parents, friends, partners or relatives. Injection use of drugs in the whole recruitment usually stars at the age of 20, but the age for regular drug use experience (minimum three times a week) is 14.27. No difference is if the respondents are employed or unemployed have income or not, in all categories regular injection drug use is equally revealed, which is relatively high in respondents aged 30 or more. During the last 30 days, average value of number of injection days amounted to 17.72 days, 1.36 times per day on average. 68% of the total recruitment applies injection once a day, 59% more than fifth times a month and 62% -injection within 3-5 member groups. More than half of the respondents have never involved in opioids (methadone/suboxone) substitution therapy (OST), however, 58% of the whole recruitment mentioned use of opioids during the last month. At the study moment 12% of the respondents have been in OST.
34 From non-injection psychoactive substances, mostly cannabis and psychotropic medications are used. From drugs of opioid group, mostly heroin and buprenorphine is used, and from handicraft stimulators, frequently ephedra vint and vint is applied. During the last 30 days minimum one case of overdose has been mentioned by 35 respondents (3.5%), according to the opinion of their majority, the reason for overdose was use of drug in high doses, also mixture with alcohol or other drug. Most share of overdose is in Tbilisi and Rustavi. The sixth of the respondents indicated that during the last 6 months they have shared needle or other injection instrument with various people. In this regard Telavi is distinguished compared to other cities with share practice within a group of more than two persons. Rate of unprotected sexual contacts is high. Among those respondents, who mentioned sexual relations with two or more persons during the last 6 months, their majority stated about irregular use of condoms. In most cases protected sexual relations are revealed in Batumi and Borjomi. The main source of syringes and needles for the respondents is the Needle and Syringe Program, however, in 20% of cases, it is a pharmacy, and majority of the respondents has mentioned places, where they gather for injection, share practice of boiling bowl, spoon and other injection materials is high. Share practice for syringe to syringe (from mouth-to mouth or from end of syringe) is also high, half of the respondents indicated that event takes place minimum once a week systematically. Such types of gatherings are characterized as usual with high probability of share practice. Average rate of risky behavior index in the whole recruitment is very low, however, according to the cities, Telavi is distinguished, and whose average risky behavior index differs from average ones of all other cities. The respondents indicated that their attention has been mainly devoted to needles and syringes, hepatitis C testing, HIV testing service, naloxone and doctor’s consultations. Majority of the respondents considered dental service as a desirable additional service, relatively small part – need to add bowl, so-called “balloon”, spoon, filter, liver ealstography and other services. It is noteworthy vast majority of the respondents most frequently are benefited from the Needle and Syringe Program, naloxone, vein-care preparations, doctor’s consultations, HIV-testing and condoms. The knowledge of the respondents about HIV infection transmission is very good, 96% of answers on questions for assessment of HIV infection knowledge are correct. The respondents are informed that they can be tested for hepatitis C. Rates for HIV and hepatitis C are high, namely, in the whole recruitment, only 6 respondents have mentioned that they have never been tested for HIV tests and 4 ones –hepatitis C testing. However, according to testing time recently done between the cities, half of the respondents have mentioned that they were tested for HIV one and more years ago and number of such beneficiaries are in Rustavi, Samtredia, Poti, Telavi, Ozurgeti and Tbilisi-the cities, where certain types of risky behaviors are seen. In case of hepatitis C, majority of the respondents have been tested during the last 2 years. The third of the whole recruitment has mentioned that hepatitis C treatment has been performed during the last 2 years and very few (2 respondents) ceased treatment. 87.2% of the treated
35 respondents for Hepatitis C indicated at successful completion of treatment (8% in under treatment). 192 respondents have mentioned repeated testing for hepatitis C and only 5 respondents stated about return of virus. While being under treatment of hepatitis C, two third of the respondents did not cease drug use, and one third resumed after completion of treatment. Certain association is revealed between virus return and injection drug use during treatment. In the whole recruitment * HIV positive case were detected and share of HIV cases is high in Borjomi. Presumable it is conditioned by testing service of the harm reduction center recently opened in this city, through this service new HIV-infection cases have been detected in non- tested population.
Recommendations
Despite the fact that average value of risky behavior index is low in the whole recruitment, it is noteworthy to mention those qualitative findings of risky behavior that are related to share practice of each city (for example: Telavi, Rustavi). Special focus is to be done for studying safe injection practice: o threats related to share of syringes, needles and non-injection instruments and ways of their prevention; o expected risks upon injection within groups of many persons and ways of their prevention; o risks related to injection in deep veins, inguinal area and other unsafe places and their prevention possibilities; o prevention of expected overdose as a result of mixture of drugs and incorrectly counted dose According to revealed unprotected sexual practice, it is recommended to provide educational counselling on sexually transmitted infections more actively and support distribution of condoms maximally. It is revealed that use of naloxone has been introduced in the beneficiaries’ practice and significant support is required for disappearing salty water injection practice and naloxone should be available for everybody. It is recommended OST treatment, awareness of such treatment and its expected benefit should be increased to encourage involvement in OST therapy.
Bibliography
WHO. (2016). Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations. Retrieved from http://apps.who.int/iris/bitstream/10665/128049/1/WHO_HIV_2014.8_eng.pdf World Health Organization. (2015). Consolidated Guidelines on HIV Testing Services 5Cs: Consent, Confidentiality, Counselling, Correct Results and Connection. https://doi.org/ISBN 978 92 4
36 150892 6 Sceintific-Practice Center for AIDS and Clinical Immunology (2019). HIV/AIDS transmission in Georgia . Retrieved from https://aidscenter.ge/epidsituation_geo.html Bemoni Public Union & Curatio International Foundation. (2017). Population Size Estimation of People who Inject Drugs in Georgia 2016 (p. 54). Tbilisi. 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 Metzger DS, et al. The Risk Assessment Battery: Validity and Reliability; Paper presented at the 6th Annual Meeting of National Cooperative Vaccine Development Group for AIDS.Nov, 1993. Otiashvili, D., Piralishvili, G., Sikharulidze, Z., Kamkamidze, G., Poole, S., & Woody, G. E. (2013). Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use, and reducing HIV risk behavior – Outcomes of a Randomized Trial. Drug and Alcohol Dependence, 133(2), 10.1016/j.drugalcdep.2013.06.024. http://doi.org/10.1016/j.drugalcdep.2013.06.024 Tyrer, S., & Heyman, B. (2016). Sampling in epidemiological research: issues, hazards and pitfalls. BJPsych Bulletin, 40(2), 57–60. http://doi.org/10.1192/pb.bp.114.050203 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
Appendices
Appendix N1. Ethic Commission Report Appendix N2. Study Questionnaire Appendix N3. Informed Consent
37