delhi sep in russia

Drug Use Patterns and HIV Risk

Behaviors of Russian Syringe

Exchange Participants

Jean-Paul C. Grund@, Denis Kobzev$, Vitalic Melnikov%,

Catherine Zadoretsky*, Elena Zemlianova&,

Stephen Titus*, Theresa Perlis#, Denise Paone*,

Valentina Bodrova& & Don C. Des Jarlais*#

@ DV8 Research Training & Development (Frankfurt) $ Medecins Sans Frontieres-Holland (Moscow) % Kolodets (Moscow)

* Beth Israel Medical Center (New York) & Center for Public Opinion and Market Research (WCIOM) (Moscow)

# National Development and Research Institutes (New York)

04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD

Background

• Since the mid-1990s both injecting drug use and

HIV among IDUs have spread rapidly in Eastern

Europe.

• HIV among IDUs has become a particular

problem in Russia and other Newly Independent

States (NIS).

• Effective programs to prevent HIV infection

among IDUs have been developed, including

syringe exchange programs, community outreach,

and “low threshold” drug treatment .


Background

• Whether such programs can bring the spread of

HIV among IDUs in Russia under control is a

question of great importance for the future of the

HIV/AIDS epidemic in that country.

• We report here on drug use patterns and HIV risk

behavior among participants in syringe exchange

programs in five Russian cities: Nizhniy

Novgorod, Pskov, Rostov-Na-Donu, St.

Petersburg, and Volgograd.


Methodology

• Respondents were recruited from participants of

the exchanges.

• Structured questionnaires covering drug use and

HIV risk behavior were administered by trained

independent interviewers.

• Drug use patterns and HIV risk behaviors were

assessed for two periods: the last 30 days before,

and during program participation.


Methodology

• Qualitative data were collected during site visits

about the drug scenes in the city where the

programs are located

• Different ethnographic techniques were used,

including participant observation of group drug

preparation and use settings, focus groups and

informal interviews with program participants,

peer workers and non-participants.


Table 1. Demographic Descriptors of Russian

Syringe Exchange Participants1 N= 1,076 N. N.

N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Age (%)

< 20 years

20 – 24 years

25 – 29 years30 – 34 years

35 – 40 years

> 40 years

15

48

28

6

1

1

17

47

19

8

5

5

9

16

25

23

14

14

22

46

22

6

3

1

20

51

21

5

3

1

17

42

23

9

5

4

Gender (%)

Male

Female

84

16

75

25

69

31

78

22

83

17

78

22

Marital Status (%)

Married/Comm.Law

Never Married/Single

Divorced/Separated

Widowed

32

60

8

0

35

58

6

1

42

30

24

4

29

62

8

1

23

57

20

0

32

53

13

1

Living Arr. past 6

months2,3

(%)

Own house/apartm.Someone else's H/A

Homeless

Prison

22

79

0

0

37

69

1

2

27

63

0

5

20

70

0

4

19

77

1

1

25

72

0

2

1. Totals may not equal 100% due to rounding or missing data; 2. Percents may add up to more than 100 since more than one

response may apply; 3. N differs because results are derived from intake questionnaires that linked with R.A. questionnaires.


Table 2. Drug Use Characteristics of Russian

Syringe Exchange Participants N = 1,076 N. N.

N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Age First IDU1 (Mean/SD) 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4)

Years Injecting1 (%)

< 3 years

3+ – 6 years

6+ – 10 years

>10 years

22

33

33

12

47

31

10

12

18

22

25

35

43

27

16

14

26

41

26

6

30

32

23

15

Drug Injected1,2

(%)

Homemade opiates

Powder Heroin

Amphetamine

83

47

9

15

53

61

84

5

24

6

96

9

21

90

4

42

59

20

Reported Secondary Exchange (%) 40 46 40 43 48 44

1 N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N

for

Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160;

and the total N for the five programs = 643.

2 Percents may sum to > 100; more than one response may apply.


Table 3. Injection-Related HIV Risk Behaviors of

Russian Syringe Exchange Participants1 N = 1,076 N. N.

N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Daily Injection of at

least one drug (%)

30 Ds. Prior to SEP

Last 30 DaysP

64

64

.7237

25

11

<.0001

52

36

<.0001

66

77

.0031

74

71

.2009

53

53

.0001

Receptive Sequential

Syringe Use (%)

30 Ds. Prior to SEPLast 30 Days

P

41

9

<.0001

26

4

<.0001

39

9

<.0001

48

29

<.0001

37

3

<.0001

38

11

<.0001

Injected @ Anonym.

Injecting Venue (%)

30 Ds. Prior to SEP

Last 30 Days

P

62

47

<.0001

25

9

<.0001

54

28

<.0001

37

19

<.0001

45

33

<.0001

45

28

<.0001

1 Totals may not equal 100% due to rounding or missing data.




N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Bought Loaded

Syringes (%)

30 Days Prior to SEP

Last 30 DaysP

9

2

.0001

4

1

.0082

19

11

.0003

14

1

<.0001

13

1

<.0001

12

3

<.0001

Used Blood in

Preparation (%)

30 Days Prior to SEPLast 30 Days

P

5

0

--

10

10

.8474

8

5

.1967

10

2

.0017

7

5

.3173

8

4

.0001

Saw others use Blood

in Preparation (%)


Last 30 Days

P

25

4

<.0001

33

14

<.0001

31

13

<.0001

21

2

<.0001

26

8

.0003

27

8

<.0001





N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Group Injecting (%)


Last 30 Days

P

91

86

.0093

96

89

.0016

87

80

.0006

96

93

.0707

85

81

.0114

91

86

<.0001

Shared Utensils (%)


Last 30 Days

P

72

53

<.0001

93

86

.0011

85

73

<.0001

88

90

.2850

75

64

<.0001

82

73

<.0001

S-M-D-S (%)


Last 30 DaysP

67

54

<.0001

47

36

.0020

50

30

<.0001

64

67

.4308

63

52

.0002

58

48

<.0001



Table 6. Frequency of Group Injecting among


N = 236

Pskov

N = 205

R-N-D

N = 199

St. Petersb.

N = 236

Volgograd

N = 221

Total

N = 1,097


Use(%)

Never

1-3 Times/Month-LessOnce a Week

2-6 Times a Week

Once a Day

More than Once a Day/ Almost Every Day

9

12

10

31

18

21

5

27

16

31

13

8

13

14

10

32

14

17

4

11

10

29

23

23

15

2

6

20

19

37

9

13

10

29

18

22

Last 30 Days During

SEP Use (%)

Never

1-3 Times/Month-Less

Once a Week2-6 Times a Week

Once a Day

More than Once a Day/ Almost Every Day

14

11

10

26

20

19

11

36

13

31

4

5

20

15

17

28

10

12

7

8

6

26

32

22

20

5

7

19

16

33

14

14

10

26

17

18



Table 7. Syringe-Mediated-Drug-Sharing among


N = 236

Pskov

N = 205

R-N-D

N = 199

St. Petersb.

N = 236

Volgograd

N = 221

Total

N = 1,097


Use(%)

Never

Less than half the timeAbout half the time

More than half the time

Always

26

10

10

12

41

52

26

5

2

16

44

16

11

5

25

30

21

8

9

29

23

14

6

8

46

35

17

8

7

31

Last 30 Days During

SEP Use (%)

NeverLess than half the time

About half the time


Always

40

11

8

7

32

60

20

4

3

12

63

9

4

3

22

28

17

5

10

35

43

18

6

4

25

45

15

6

6

26



Table 8. Self-Production of Drugs among Russian

Syringe Exchange Participants1 N = 1,097 N. N.

N = 236

Pskov

N = 205

R-N-D

N = 199

St. Petersb.

N = 236

Volgograd

N = 221

Total

N = 1,097

Tradition of Self-

Production in City? (%)

No

YesDon’t Know

14

86

0

5

87

8

1

98

1

34

46

19

17

24

53

15

68

16

Prevalence:

30 Days Prior to

SEP Use(%)

Never

Less than half the timeAbout half the time


Always

6

11

15

11

58

5

2

5

3

84

>1

3

5

6

86

32

26

6

11

25

46

12

2

14

25

11

9

8

8

65

Last 30 Days

During SEP Use (%)

NeverLess than half the time

About half the time


Always

15

12

4

12

53

8

6

0

2

82

3

>1

4

6

87

86

10

1

1

1

69

4

2

2

15

24

7

3

6

59



Papaver Somniferum


Cooking Cheornaya in Nizhniy Novgorod


Frontloading Cheornaya in Nizhniy Novgorod


Support with Injecting in Nizhniy Novgorod


Support with Injecting in Rostov Na Donu


Frontloading Heroin in

Volgograd


Support with Injecting in Volgograd


Discussion (1)

• The data suggest a complex picture.

• On the one hand, they show substantial reductions

in previously identified injection risk behaviors,

such as needle sharing, from the time prior to

using the exchanges and generally low rates of the

same behavior while using the exchanges.


Discussion (2)

• The percentages of respondents reporting

receptive syringe sharing--perhaps the most

widely used measurement in judging the

effectivity of SEPs-- are comparable to those in

effective syringe exchange programs in other

countries.

• Based on these data we recommend that syringe

exchange and other HIV prevention programs in

Russia should be expanded.


Discussion (3)

• Region-specific risk behaviors, such as buying

Cheornaya loaded in syringes and using blood in

its preparation decreased substantially as well. At

present, it is not clear whether this is a result of

program participation, or of changes in the

Russian drug markets.


Discussion (4)

• On the other hand, these data show much less

impressive reductions in a number of—less

researched—behaviors: using in groups, Syringe-

Mediated-Drug-Sharing and collective use of drug

preparation paraphernalia.

• The latter behaviors are generally all situated

within the context of preparing and injecting drugs

in (friendship) groups, which is a typical, and

perhaps rather ubiquitous feature of the drug

culture in Russia.


Discussion (5)

• This drug culture developed during the communist

era, when closed borders not only obstructed

transport of legal commodities.

• Historically grounded in instrumental rationales,

over the years a robust culture of interdependency

developed around collective drug use, which not

only facilitated getting high, but also provides

support and protection against (outside) threats.

• Within this context, the mutual sharing of drugs

has become a strong social norm.


Discussion (6)

• More recently rapid and turbulent market

transformations characterize the Russian drug

culture, most markedly the rapid diffusion of

imported powder heroin.

• It remains a question whether the progressive

diffusion of heroin will significantly erode the

practice of communal acquisition, preparation and

use.


Discussion (7)

• Therefore, syringe exchange programs and other

HIV education efforts in Russia need to address

the “Micro Risk Environment” of group

preparation and use, in which behaviors, such as

frontloading and collective use of drug preparation

equipment flourish.

• The question is whether pragmatism will prevail

in implementing these approaches in Russia.


Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod


Discussion (8)

• Both our ethnographic and survey data suggest

that “Peer Support” strategies (including “Peer

Outreach” and “Secondary Exchange”) may be

crucial tools for reaching sufficient numbers of

IDUs, and facilitating the subcultural change

required to control the HIV epidemic among drug

injectors.

• Between 40 and 48 percent of the respondents

engaged in secondary exchange, whether the

program encouraged this or not.


Discussion (9)

• Programs should also address the “Macro Risk

Environment.”

• Data not presented here show that in particular the

activities of law enforcement agencies present a

serious impediment to pragmatic HIV prevention

efforts, such as needle exchange.


Discussion (10)

“The relations with the police are tense. Police and

Program aims are opposite. The laws are not

satisfactory. They negatively influence drug abuse

morbidity. Drug users in Nizhniy Novgorod are

educated enough in questions of safe drug use,

disinfecting rules. But the situation itself forces

them to infringe on safety rules.”

Interview with SEP Staff Member, Nizhniy Novgorod


Discussion (11)

• Agreements with one (of the several) police

department(s) do not preclude the negative

influence of Internal Affairs on IDUs’

participation in needle exchange and other HIV

prevention programs.

• Therefore, Internal Affairs should be targeted by

intense advocacy and education efforts.


Peer Support?







Jean-Paul C. Grund@, Denis Kobzev$, Vitalic Melnikov%,

Catherine Zadoretsky*, Elena Zemlianova&,

Stephen Titus*, Theresa Perlis#, Denise Paone*,

Valentina Bodrova& & Don C. Des Jarlais*#

@ DV8 Research Training & Development (Frankfurt) $ Medecins Sans Frontieres-Holland (Moscow) % Kolodets (Moscow)

* Beth Israel Medical Center (New York) & Center for Public Opinion and Market Research (WCIOM) (Moscow)

# National Development and Research Institutes (New York)

delhi sep in russia

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