Your SlideShare is downloading. ×
  • Like
Aidstar-One Case Study Georiga Harm Reduction Network_tagged
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Now you can save presentations on your phone or tablet

Available for both IPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Aidstar-One Case Study Georiga Harm Reduction Network_tagged

  • 631 views
Published

The Georgia Harm Reduction Network: http://aidstarone.com/focus_areas/prevention/resources/case_study_series/ghrn

The Georgia Harm Reduction Network: http://aidstarone.com/focus_areas/prevention/resources/case_study_series/ghrn

Published in Health & Medicine
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
631
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
2
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. AIDSTAR-One | CASE STUDY SERIES November 2012Uniting to Build HIV Preventionfor Drug UsersThe Georgian Harm Reduction Network T he patient at the private clinic in Gori, Georgia, looked Georgian Harm Reduction Network very tired. Committed to receiving treatment for his drug addiction, he sat in the office of the clinic director, asking for help. It had been difficult for him to get a job or integrate into society because of his addiction, and it had been impossible to find effective methadone treatment in the region where he lives. In Georgia, methadone must beThe Georgian Harm Reduction Network dispensed daily at a clinic—it cannot be taken at home—buthas over 20 member organizations across the closest methadone clinic was more than 60 kilometersthe country and administers service sitesin nince cities. away in Tbilisi. Because this clinic is a member organization of the Georgian Harm Reduction Network (GHRN), a solution was quickly found. The director— aware of treatment options offered by other network members—picked up the phone to refer the patient to a small clinical trial of buprenorphine, an alternative to methadone that can be prescribed and taken home. Enrolling in the trial would allow this patient to receive effective substitution therapy without traveling great distances every day. This The Georgian Harm Reduction Network coordinates the nongovernmental response to meeting the treatment and care needs of the country’s drug users. Its humanBy Patricia Case, MPH, rights-centered, evidence-based approach has successfullySc.D. supported effective treatment and prevention services and advocated for legal and policy change in Georgia.AIDSTAR-OneJohn Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was made possible through the support of the U.S. President’s Emergency PlanArlington, VA 22209 USA for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under contractTel.: +1 703-528-7474 number GHH-I-00-07-00059-00, AIDS Support and Technical Assistance Resources (AIDSTAR- One) Project, Sector I,Task Order 1.Fax: +1 703-528-7480www.aidstar-one.com Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
  • 2. AIDSTAR-One | CASE STUDY SERIES simple act could improve the likelihood that he will be able to reduce the WHAT IS HARM harms of drug use in his life and lower his risk for HIV. REDUCTION? One lesson of the global HIV epidemic has been that HIV prevention For decades, the term “harm among people who inject drugs (PWID) is built from numerous points reduction” has defined a of entry, lower thresholds and fewer requirements for engagement with combination approach that programs, and multiple levels of structural interventions and advocacy. flexibly uses multiple intervention Like drops of water, each combines with others to wear away the strategies, policy advocacy, and structural, legal, and individual barriers to treatment and care. At the legal change to both support heart of GHRN is a shared commitment to a harm reduction approach drug users at risk of HIV and based on human rights and evidence-based interventions to prevent HIV change the risk environment that transmission for drug users. surrounds them (Rhodes and Hedrich 2010). Founded in 2006, GHRN is a well-organized network of 21 organizations that operates both to reduce individual risk of HIV and to act on policy, Harm reduction interventions regulatory, legal, and other structural-environmental factors influencing seek to reduce the harms of the health of drug users. Almost all groups in Georgia that offer services drug use, prevent HIV and for drug users are members. other infectious diseases, and improve the health of drug users. Working toward cessation of drug use through treatment The Risk Environment for PWID is a major component of human reduction, as is the interruption To effectively lower vulnerability to HIV infection through sexual and of blood-borne HIV transmission injection risk behaviors, any intervention must take into account the risk by providing sterile injection environment as well as the behavior of the drug user, and then respond equipment, sexual risk reduction at multiple levels. Using its established advocacy and communications materials and education, capacity, GHRN organizations provide a wide range of strategic counseling, peer outreach, and approaches to risk reduction that engage drug users at different stages opioid substitution therapy. of change with simultaneous availability of outreach activities, HIV testing, harm reduction services, biomedical treatment, and structural interventions that respond to local realities. Injection drug use and associated HIV and infectious disease risk do not occur in a vacuum; risk is not merely a result of an individual behavior, and the reduction of risk behaviors on the part of individuals, while necessary, is insufficient. As conceptualized by Rhodes and colleagues (1999), vulnerability to HIV among drug users is firmly contextualized in the “risk environment” and is a product of the interaction between individual behaviors (such as using blood-contaminated syringes and injection equipment), the environment, and policy and legal structural elements. There are differing influences of micro- and macro-level factors in the risk environment in which individual risk behavior takes place. Micro-level environmental factors include issues that directly affect the drug user, such as targeted policing practices and restrictive2 AIDSTAR-One | November 2012
  • 3. AIDSTAR-One | CASE STUDY SERIESpolicies regarding access to drug treatment. Macro- kept or unavailable. Some researchers estimatelevel or overall structural factors include national that there were approximately 127,800 (range:drug possession enforcement policies, legal 14,400 to 241,266) adult PWID in Georgia in 2008,frameworks that enhance punishment and diminish with an estimated population prevalence of 4.1treatment, and national budgets that do not contain percent among 15- to 64-year-olds (Mathers et al.sufficient funding for their citizens affected by drug 2008). However, the most reliable estimate of thedependence or HIV (Rhodes et al. 1999). number of PWID in Georgia comes from a 2009 study conducted by the South Caucasus Anti-DrugWhat makes GHRN an effective model for others Programme using established statistical methods tois that the network acts at multiple levels of the risk estimate numbers. The study produced a nationalenvironment. Acting collaboratively in a strategic estimate of between 1.46 to 1.53 percent of theand organized way on both the micro and macro population and an estimated number of betweenlevels of the risk environment creates a combination 39,152 and 41,062 PWID (Sirbiladze et al. 2009).intervention with the potential to slow the emergenceof the HIV epidemic in Georgia (see Figure 1). Despite high prevalence of injection drug use in Georgia, HIV prevalence is relatively low—about 2 percent—among PWID (Chikovani et al. 2011a). But mounting evidence suggests a strong potential for an injection-related, blood-borne HIV outbreak, given the high rates of hepatitis C virus (HCV) infection—also blood-borne—among PWID in Georgia (Research Institute on Addiction 2007). Other countries in the region, such as Ukraine, have already experienced severe injection-related HIV outbreaks. HIV among PWID: Georgia is considered a low- prevalence country, with HIV prevalence of about 0.1 percent among adults aged 15 to 49 (United Nations General Assembly Special Session on HIV/AIDS 2010). Within the country, HIV is largely an injection-driven phenomenon, with 70 percent of HIV cases in 2009 attributable to injection, either directly through injected drug use or indirectly through sexual contact with PWID (European Centre for Disease Prevention and Control/ WHO Regional Office for Europe 2010). In a study ofInjection Drug Use in 1,108 PWID, 2 percent tested HIV-positive, and PWIDGeorgia in large urban areas, in prison, or in places of transition, such as conflict zones and ports, were found to be atBy any estimate, prevalence of injection drug use in higher risk of HIV infection. Thus, it is unsurprising thatGeorgia—1.5 to 4.1 percent of the adult population— in this study HIV prevalence among PWID is highest inis one of the highest in the region (Coffin, Sherman, Tbilisi (2.3 percent) and in the port city of Batumi (4.4and Curtis 2010; Sirbiladze et al. 2009). There are percent) (Chikovani et al. 2011a).few reliable data about the size of the population ofPWID in Georgia; official records are either poorly Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 3
  • 4. AIDSTAR-One | CASE STUDY SERIESGlobally, HIV infection among PWID is not static. A qualitative assessment conducted in 2008 amongBetween 2004 and 2009, the number of newly 39 women PWID found that women reported threediagnosed HIV infections among PWID increased by factors that put them at risk: 1) being the second in76 percent (European Centre for Disease Prevention line when sharing needles, 2) little direct access toand Control/WHO Regional Office for Europe 2010). services, and 3) gender-related barriers that impedeRates of HIV testing are quite low among PWID, which access to detoxification, rehabilitation, or OST servicesmay result in underestimates of HIV prevalence within (Burns 2009). Men were cited as being particularlythis population. In 2009, only 5.7 percent of PWID disapproving of women receiving help, and otherreported receiving an HIV test in the last 12 months and barriers were reported, such as lack of childcare. Inknowing the result (United Nations General Assembly Georgia, there are methadone programs in men’sSpecial Session on HIV/AIDS 2010). prisons, but there are none in women’s prisons (Burns 2009). In 2011, two GHRN member organizationsHCV among PWID: In contrast to HIV, HCV implemented programs specifically for women.infection among PWID in Georgia is the highest inthe region, with prevalence of 69 percent (Shapatava Legal and policy environment: Underet al. 2006). Among HIV-positive patients in Georgia, Georgian law, there is little distinction between selling,almost half (48.6 percent) are co-infected with HCV possession, and consumption of drugs, and status as(Badridze et al. 2008). HCV infection in Georgia a drug user. In addition, possession of a used syringehas been strongly associated with a high number (with drug traces) is illegal, regardless of whether oneof syringe-sharing partners (Kuniholm et al. 2008). is a drug user or a syringe exchange worker. PoliceFew HIV-positive women admit to injection drug use, may forcibly test citizens’ urine “on suspicion” of drugyet 17 percent are co-infected with HCV (Chikovani use. If the urine is found to be positive for illegal drugs,et al. 2011a). While official data are either limited or the police may impose high fines that can causeunreliable, studies of blood donors have shown that this considerable financial distress to citizens.is an injection-driven, blood-borne epidemic that hasresulted in very high HCV rates among blood donors, The legal environment emphasizes punishment rathera group similar to the general population. Two reported than the health or human rights—the right to privacy,HCV rates of 6.7 percent (Sharvadze et al. 2008) and self-determination, respect, and autonomy—of7.8 percent (Zaller et al. 2004) among blood donors are individuals affected by drug use. In 2008, GHRN wasmuch higher than rates in neighboring countries. instrumental in developing amendments to the drug law and relevant articles of the Criminal Code. WithinData on women and drug use: There are eight weeks, GHRN gathered 58,000 signatures in afew women drug users represented in surveillance petition of support for the bill. As of 2011, the initiativedata, reports, and programs. For example, one large remains stalled in the Georgian Parliament.opioid substitution therapy (OST) program has 250clients, but only 2.4 percent are women. All memberorganizations of GHRN report that women PWID are Implementation“out there” but are not accessing services, for reasonsthat include women’s felt stigma, discomfort with GHRN was founded by a dozen organizationsattending gender-mixed programs, or isolation. GHRN providing HIV services or involved in advocacymember organizations do not believe that women activities to promote programming for PWID. Oneavoid services because of institutional discrimination structural issue that drove these groups to unite as abut say that women drug users are more stigmatized network was the difficult legal environment in whichwithin Georgian culture and by male drug users. they struggled to do their work, according to Dr. David4 AIDSTAR-One | November 2012
  • 5. AIDSTAR-One | CASE STUDY SERIESOtiashvili, Director of the Addiction Research Center • Improve public health, reduce stigma, and protectat Alternative Georgia and a long-time GHRN leader. the rights of the marginalized“At that time, people who were working in the NGO • Facilitate drug users’ inclusion in social life.sector in the field of drugs and HIV realized that oneof the major barriers to delivering effective services GHRN accomplishes these goals as a networkwas that criminalization and punitive policies were by improving coordination between memberkeeping people from seeking help for their health and organizations and facilitating cross-referral.addiction,” he said. “We realized that there was an GHRN also conducts training for members andobvious need to work with decision makers and push supports sharing of experiences and informationfor change, and that we’d be more effective working through regular online and in-person meetings.together.” Members are engaged in debate and discussion in an effort to align goals and objectives and toToday, GHRN has grown to include 21 member flexibly develop new strategies. Perhaps the mostorganizations spread across nine Georgian cities: important function of the network is combining theTbilisi, Telavi, and Gori in the east, and in the west, individual organizations into a whole that is greaterBatumi, Kutaisi, Samtredia, Zugdidi, Poti, and than the sum of its parts for national advocacy andSukhumi. Two are at the borders of conflict zones change.within Georgia: Gori, near the South Ossetia conflictzone, and Sukhumi in west Georgia, which is the In the past, GHRN was supported by an all-volunteercapital of the disputed region of Abkhazia. In addition staff. Recently, the network obtained funding to hireto PWID from the immediate community, these core staff, such as an executive director, to supportorganizations also serve PWID internally displaced network activities, extend the advocacy efforts, offerdue to conflict. fundraising assistance to member organizations, provide technical assistance to increase quality ofIn 2011, GHRN member organizations reached services, and strengthen network-wide advocacy3,200 people, about 8 percent of the estimated efforts. GHRN is supported by the European Union;40,000 PWID in Georgia. The network has since the Global Fund for AIDS, Tuberculosis and Malariagrown, and there are now 10 service sites covering (GFATM); and the Open Society Foundations/Openmost of the country except for remote regions. By Society Georgia Foundation.the end of 2012, GHRN member organizationsexpect to reach a much greater percentage of GHRN holds meetings with representatives of allPWID in Georgia. member organizations on a monthly basis and uses social media, including a GHRN Google group, to further connect members, especiallyNetwork Operations those in more outlying areas. All decisions are posted online, which can lead to lively onlineThe stated purpose of the GHRN and the shared discussions on policy positions and advocacymission of its member organizations are to: strategies. GHRN also conducts training on topics of interest to the group.• Advance harm reduction strategies to prevent HIV GHRN is open to new member organizations,• Support reduction of drug use following an interview process to confirm that the applicant organization supports the network’s core• Facilitate prevention of HIV Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 5
  • 6. AIDSTAR-One | CASE STUDY SERIESprinciples. Member organizations pay dues of drug use, fewer injections, and stabilization ofabout U.S.$73.00 a year to support the network’s PWID (Corsi, Lehman, and Booth 2009; Schaubefforts. et al. 2010; Suntharasamai et al. 2009). For both HIV-positive and HIV-negative PWID, OST leads to reduced drug use, which reduces the number ofActivities of Member injections and leads to reduced sharing of needlesOrganizations and syringes. HIV-positive PWID on OST are also more likely to adhere to antiretroviral therapy,Member organizations provide services along a thus reducing their viral load and their likelihoodspectrum of prevention, from low-threshold harm of transmitting HIV to sexual partners in Georgia.reduction efforts to drug treatment programs Thanks to the advocacy efforts of GHRN, OST isusing methadone and buprenorphine. While now available in prisons.individual organizations provide specific services,organizations collaborate to refer drug users to other National advocacy: At the network level,appropriate services. GHRN conducts activities to address structural factors limiting effective public health responses toHIV counseling and testing: During HIV the drivers of the HIV epidemic in Georgia. In onecounseling and testing, drug users receive case, GHRN recently successfully advocated forinformation about their HIV status as well as one-time amnesty for incarcerated drug offenderscounseling about how to either remain HIV-negative with the objective of more successful socialor—for individuals who test positive—how to reintegration. Social reintegration of drug users intochange their behavior to avoid infecting others. their communities is an important element of drugMembers of the network conduct HIV counseling control strategies to reduce risky drug use, and itand testing with difficult-to-reach populations using also serves as an HIV prevention strategy. Twenty-outreach workers, mobile testing vans, or satellite one European countries have specific policiesoperations in prisons. regarding social reintegration as part of their national drug control policy (European MonitoringBehavioral HIV interventions: Strategies Centre for Drugs and Drug Addiction 2011).include targeted harm reduction initiatives for Advocating for measures that remove barriers toPWID, including supplying such materials as sterile social reintegration for drug users is one of GHRN’ssyringes and condoms, and offering brief counseling successes.techniques about HIV prevention and harm reductionfrom drug use. Research and surveillance: One memberBiomedical prevention activities: Medical organization, Union Alternative Georgia, leadscare, including traditional drug treatment and the efforts in conducting clinical and behavioral HIVstabilization of opiate users through the use of surveillance, designs and tests interventions,OST (methadone and buprenorphine) is available and collaborates with U.S.-based and Europeanwithin the network. OST has been shown to be researchers in intervention research. Theseeffective at preventing HIV among PWID, with activities provide a strong evidence base for thereduced HIV incidence rates as a result of less activities of the network. For example, Union Alternative Georgia is able to rapidly assess and6 AIDSTAR-One | November 2012
  • 7. AIDSTAR-One | CASE STUDY SERIESvalidate anecdotal reports from GHRN members the principles of harm reduction, GHRN membersabout potential emerging HIV risk patterns, new demonstrate through example. Other forms ofdrug trends, and associated HIV risks. GHRN engagement take place at the level of internationalmembers are then positioned to develop and test and regional drug policy developments, whereinterventions rapidly. GHRN forms close collaborative relationships with international agencies. Members of GHRN sit on steering committees for major international drugWhat Has Worked Well policy consortiums, such as the International Drug Policy Consortium and the Eurasian Harm ReductionNational and municipal advocacy for Network.legal change: In 2008, GHRN advanced a billto improve drug laws—a package of legislation Education and training: Within Georgia, GHRNthat includes revocation of criminal responsibility has disseminated information about state-of-the-artfor simple drug use—and to create an interagency harm reduction approaches throughout the networkgovernmental body to coordinate drug policy in and other health care systems in the country. Inthe country. The constitutional right of citizens to just one example, in 2010, an overdose preventioninitiate changes in legislation was used to lobby initiative started in Georgia, which included thefor this bill, when GHRN submitted 58,000 citizen training of drug users and distribution of naloxone—asignatures collected in 40 days to support the drug medication to counter opioid overdose—throughpolicy reform initiative—an impressive number, given member organizations of the GHRN (Coffin,that Georgia’s population is only 4.6 million people. Sherman, and Curtis 2010). All members of GHRNIn May 2012, the parliament adopted some minor were trained by Irma Kirtadze, a GHRN member,intermediate changes to drug policy that had little using a “training the trainers” model in the usepotential to improve the legal environment for drug of naloxone. The Georgian Red Cross Society, ausers. member organization of GHRN, is not funded to disseminate harm reduction information but on aDespite the slowness of the parliamentary response, volunteer basis conducted 94 seminars for 4,340organizing Georgian citizens in support of drug participants on overdose prevention harm reductionpolicy reform has changed both public opinion and and on safe injecting methods. The Georgian Redthe policy environment. GHRN has also successfully Cross Society also conducted a series of workshopsadvocated for increased governmental funding for on HIV and AIDS within the framework of harmdrug treatment and prevention services and for reduction for 9,586 young people (average age 23)the relaxation of some OST regulations, and has through 217 workshops conducted by 140 trainedmaintained a constant presence at the highest levels volunteers (Georgian Red Cross Society 2011).of national policy. GHRN is also conducting training and promotingEngaging gatekeepers: GHRN members its network model throughout the region. Forhave used engagement of gatekeepers and example, GHRN is providing harm reduction trainingpolicymakers as a network strategy for change. By to the Romanian Harm Reduction Network andconducting workshops and site visits for narcotics disseminating information about the network’sexperts, legislators, and others who may resist operations in the region. Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 7
  • 8. AIDSTAR-One | CASE STUDY SERIESChallenges argued that the law diverts attention and, even more important, economic resources away from evidence-Challenges to GHRN’s work are primarily structural, based and effective interventions that do work tomaking collaborative advocacy for policy change a prevent HIV, such as drug treatment.critical task for the network. Among these structural Furthermore, increased HIV risk may arise aschallenges are punitive law enforcement practices, a result of forced drug testing. Multiple studieslegal barriers to drug treatment, restrictions on globally have documented the negative effect of lawharm reduction program development, and funding enforcement and policing practices at the macrogaps. and micro levels in accelerating HIV outbreaks andLaw enforcement practices: These remain limiting the ability of PWID to reduce their drug-a significant obstacle to programs working to related risk (Rhodes et al. 2003). For example,improve the health of drug users and reduce forced urine testing leads to more incarceration,transmission of HIV. Policing practices have led to which is associated with increased HIV risk for PWIDcontinual harassment of PWID, who receive fines because drugs are widely available in prison butor imprisonment instead of treatment and care to sterile syringes are not (Gunchenko and Kozhanreduce HIV infection, HCV infection, overdose, 1999; Rhodes et al. 2006; Suntharasamai et al.and addiction. Unlike other countries, drug use in 2009).Georgia—in addition to possession or selling—is acriminal offense (Article 45 of the Georgia Criminal Legal barriers to drug treatment:Code). First offenders must pay an administrative Methadone treatment has been successfully rolledfine of approximately U.S.$304; a second offense out in Georgia, and with GFATM support, there iscan lead to a prison sentence of up to a year or a now free treatment available, as well as methadonefine of U.S.$1,219 or more. programs in prison. Program directors attribute this success to funding from the GFATM; to the influenceIn 2007, member organizations of the GHRN of Sandra Saakashvili-Roelofs, the Dutch-born Firstmobilized to educate the public about new changes Lady of Georgia, who has supported free methadonein the law allowing the police to forcibly conduct programs; and to the advocacy efforts of GHRN.urine tests on persons “in the case of reasonablesuspicion,” which led to a ten-fold increase in forcible Nevertheless, methadone is highly regulated intesting—with no increase in efficiency for identifying Georgia, as it is worldwide. Drug users must bedrug users. First, GHRN reported that the program 25 years old to join a methadone program, whichviolated the Georgian Constitution and explained contradicts the principle that early treatment, beforehow to legally refuse the test. The parliament then a PWID becomes infected with HCV or HIV, is goodpassed a new law stipulating that refusing a test clinical practice. Furthermore, patients cannot takemay be admitted as evidence of drug use. A GHRN methadone home; it must be dispensed at a clinic.organizational member, Union Alternative Georgia, Promoting the social integration of former drug usersconducted a survey of drug users in 2008 to assess into society is challenging because they spend sothe effectiveness of forced testing in persuading drug much time daily at the methadone clinic. GHRN asusers to stop using drugs. Union Alternative Georgia a network has advocated for change in methadoneconcluded that forced drug testing is ineffective regulations, and this remains an ongoing challenge.in deterring drug users, or in addressing drug useand associated HIV risks among drug users. They8 AIDSTAR-One | November 2012
  • 9. AIDSTAR-One | CASE STUDY SERIESRestrictions on harm reduction program frequently reported elevated rates of HIV-related riskdevelopment: These limit the expansion of behaviors (Shapatava et al. 2006).this critical element in HIV prevention work. Oneprimary benefit of needle exchange is the removal In addition to the risk of HIV and HCV infection, someof unsterile needles from the environment. While homemade drugs are severely toxic, with long-needle distribution is legal in Georgia, there is no term cognitive, mobility, and speech effects. Someexemption to Article 273 of the Georgian legal code homemade stimulants, principally methcathinonefor possession of a contaminated syringe for needle (jeff), have led to an outbreak of severe manganeseexchange program workers. Possession of drug- poisoning and Parkinsonism among users. In just onecontaminated syringes obtained from drug users clinic in Tbilisi, there were more than 70 patients withfor disposal has put workers in GHRN member manganese toxicity; a physician member of GHRNorganizations at risk of arrest. reported encountering 150 cases in the previous three years. There is little effective treatment available.Further inhibiting harm reduction efforts is theconfusing status of the drug naloxone, an opiate Other drugs and homemade opiates are a cause forantagonist that reverses respiratory failure great concern in Georgia, such as the use of divertedassociated with opiate overdose and is included Coaxil (tianeptine) reported in the South Caucasuson the World Health Organization 2011 Model List Anti-Drug Programme Assessment Mission Reportof Essential Medicines (World Health Organization in 2008 (Ives 2008) and the Georgia Medical News2011). Training drug users to act as “first responders” in 2009 (Vadachkoria et al. 2009). An emergingin the event of an opiate overdose and equipping drug, crocodile, is a homemade opiate made withthem with naloxone is a remarkably simple codeine-based medications, red phosphorous,intervention that can substantively reduce the and iodine. Early local knowledge about crocodilemortality of drug users (Doe-Simkins et al. 2009; was disseminated by GHRN to network membersLagu, Anderson, and Stein 2006; Saucier 2011; (Onlinenews.ge 2011; Shuster 2011). While GHRNStrang et al. 2008). Some program directors have members are seeking to address this transition toreported that naloxone can no longer be legally homemade drugs, the rapid increase in use hasimported into the country and is no longer available, outstripped the capacity of some organizations tobut others report that it is still a registered drug target jeff, crocodile, and Coaxil users.available at pharmacies. Funding gaps: Altogether, governmental andThe emergence of new drugs: Street drugs GFATM funding to support the health of drug users,are very expensive in Georgia, which has led to including drug treatment, is quite low, ranginga proliferation of homemade drugs. Some of the from only U.S.$30,000 in 2006 to U.S.$595,000 inemerging drugs have been linked to increased HIV 2009 (Javakhishvili et al. 2011). Despite marginalrisk behaviors among users. For example, in a increases in governmental funding for drug treatmentstudy of 1,127 PWID in Georgia, only 9.1 percent of and prevention, the contribution of the GeorgianPWID reported injecting ephedrine, and 81 percent government is so small relative to the need thatof ephedrine injectors reported unsafe injecting at GHRN members are dependent on nongovernmentallast injection (Chikovani et al. 2011b). Similarly, in funding sources. This has resulted in service gaps.a cohort of 583 PWID from three cities in Georgia, For example, some member organizations had tothose injecting homemade drugs and opium most close offices and prison HIV counseling and testing programs as they awaited the results of Round 10 Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 9
  • 10. AIDSTAR-One | CASE STUDY SERIESGFATM proposals in 2011. GHRN is engaged in organizations’ service provision and in GHRN’sadvocacy efforts to increase government funding and ability to strongly advocate for change at multipleto achieve sustainability for HIV prevention initiatives. levels of the risk environment. Use the reach of a network to advocateRecommendations for national legal and policy change: GHRN has had great success in mobilizing GeorgiansMaintain a consistent focus on human to advocate for national law and policy changesrights: Drug users are marginalized and to improve the risk environment at the micro andstigmatized as a population, and HIV prevention macro levels. Without alterations in policy and law,for them must go far beyond individual behavior HIV prevention efforts will stall at the individualchange. At its core, problematic drug use, in the level. Networks with a strong common vision canabsence of access to appropriate care, can be effectively address risks and barriers that impedeseen as a symptom of the abuse of human rights. the health and human rights of drug users. JoiningBy maintaining a focus on the right of drug users together in advocacy in large and diverse networks ofto health through ending stigma, discrimination, organizations sharing a common human rights-basedand structural barriers to health, this symptom can approach is far more effective in ensuring drug users’be treated. Intervening in micro- and macro-level right to health and preventing the rapid spread of HIV.structural risks for HIV through legal and policychange is very challenging for a single organization, Use the combined “local” knowledge ofas opposed to participating in a network with strong member organizations to respond withshared values and principles that promotes a united flexibility to emerging information: Withinrights-based approach to health. a network, timely and immediate information can be shared and a response crafted long beforeDo not compromise on core principles: the information shows up in a report, surveillanceGHRN is a membership organization. Potential data, or a publication. Within a national network,member organizations must apply, be interviewed, trends that emerge in one region can be addressedand agree to the core principles and theoretical before reaching another region. Creating venuesperspective of GHRN before they can be accepted. that facilitate dissemination of “on the ground” localUnlike other networks, in which agreements are knowledge, such as an online discussion group orbased on a minimal consensus and thus are diffuse through other forms of social media, is effective asin network-level initiatives, GHRN has established an early warning system.robust principles about advocacy and change.Thus, instead of diffusion of initiative, there is a Be sure that member organizations haveconcentration of shared efforts. Networks that share realistic expectations about what thea common vision are more effective in altering network can give them: Networking canstructural impediments to health. Elsewhere in the help groups face common external challenges andworld, networks based on the “lowest common generate effective joint problem solving, but somedenominator” have largely been ineffective in new GHRN members also expected financial andaltering the risk environment at the structural or administrative benefits that simply weren’t available.policy level simply because network members maynot be able to agree on policy approaches. The Expect differences of opinion: DifferentGHRN model facilitates successful evidence-based groups have different perspectives and differentHIV interventions both at the level of individual priorities, so some network decisions may not be10 AIDSTAR-One | November 2012
  • 11. AIDSTAR-One | CASE STUDY SERIESwell received by all network members. For GHRN, and its Associated Risk Factors. Georgian Medical Newsthis prompted the departure of one organization. 165:54–60.Dr. Otiashvili feels that this is a normal part of the Burns, Katya. 2009. Women, Harm Reduction and HIV:process and not necessarily a failure on the part of Key Findings from Azerbaijan, Georgia, Kyrgyzstan,the network overall. Russia and Ukraine. International Harm Reduction Development Programme, Open Society Institute.If possible, create paid administrative Available at www.idpc.net/sites/default/files/library/positions for the network: In the early wmhreng_20091001.pdf (accessed September 2011).years, GHRN depended on the volunteer efforts of Chikovani, Ivdity, Ketevan Goguadze, Sudit Ranade,network members to handle GHRN administrative Mollie Wertlieb, Natia Rukhadze, and George Gotsadze.work, which was extremely difficult, given their 2011a. Prevalence of HIV Among Injection Drug Users Inbusy schedules serving clients and running their Georgia. Journal of the International AIDS Society 14:9.own organizations. Designating funding for thesefunctions and creating a board has helped improve Chikovani, Ivdity, Ivana Bozicevic, Ketevan Goguadze,GHRN operations. Natia Rukhadze, and George Gotsadze. 2011b. Unsafe Injection and Sexual Risk Behavior Among Injecting Drug Users in Georgia. Journal of Urban Health 88:736–748.Future Programming Coffin, Phillip, Susan Sherman, and Matt Curtis. 2010. “Underestimated And Overlooked: A Global OverviewAs GHRN transitions to a paid staff and adds new Of Drug Overdose And Overdose Prevention.” In Global State of Harm Reduction 2010, ed. Catherine Cook,member organizations, it will continue to build on pp. 113-119. London: International Harm Reductionthe strong network collaboration it has pioneered in Association. Available at www.ihra.net/files/2010/06/29/the region. National advocacy for structural change GlobalState2010_Web.pdf (accessed September 2011).to support the prevention of HIV among drug userscontinues as the foundation of the network’s efforts. Corsi, Karen F., Wayne K. Lehman, and Robert E. Booth.As a network, GHRN plans to focus its efforts in 2009. The Effect of Methadone Maintenance on Positive Outcomes for Opiate Injection Drug Users. Journal oftwo directions: first, by participating in training and Substance Abuse and Treatment 37:120–126.sharing experiences with other countries in theregion to promote regional advocacy, and second, Doe-Simkins, Maya, Alexander Walley, Andy Epstein,by working on a national bill to decriminalize drug and Peter Moyer. 2009. Saved by the Nose: Bystander-use, to decrease imprisonment, and to increase Administered Intranasal Naloxone Hydrochloride fortreatment and care for drug users. In addition, Opioid Overdose. American Journal of Public Health 99:5.GHRN is planning new initiatives to prevent the use European Centre for Disease Prevention and Control/of homemade drugs, prevent HIV transmission in the WHO Regional Office for Europe. 2010. HIV/AIDScontext of drug use, and explore new and creative Surveillance in Europe 2009. Stockholm: Europeanideas for the clinical treatment of dependence and Centre for Disease Prevention and Control.toxicity associated with emergent drugs. n European Monitoring Centre for Drugs and Drug Addiction. 2011. Annual Report 2011: The State of the Drugs Problem in Europe, European Monitoring Centre for Drugs and DrugREFERENCES Addiction, Lisbon. Available at www.emcdda.europa.eu/ online/annual-report/2011 (accessed July 2012).Badridze, Nino, Nikoloz Chkhartishvili, Akaki Abutidze,Lana Gatserelia, and Lali Sharvadze. 2008. Prevalence ofHepatitis B and C Among HIV-Positive Patients in Georgia Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 11
  • 12. AIDSTAR-One | CASE STUDY SERIESGeorgian Red Cross Society. 2011. Annual Report. Economic Context Of Epidemics. Addiction 94:1323–Available at www.ifrc.org/docs/appeals/annual10/ 1336.MAAGE00210ar.pdf (accessed September 2011). Rhodes, Tim, Larissa Mikhailova, Anya Sarang, et al.Gunchenko, A., and Nataliya Kozhan. 1999. HIV 2003. Situational Factors Influencing Drug Injecting,Infection in the Penitentiaries of Ukraine [trans.] Zhurnal Risk Reduction and Syringe Exchange in Togliatti City,Mikrobiologii, Epidemiologii, I Immunobiologii 1:31–33. Russian Federation: A Qualitative Study of Micro Risk Environment. Social Science & Medicine 57:39–54.Ives, Richard. 2008. “Assessment Mission Report forthe SCAD V Programme, Component on Prevention and Rhodes, Tim, Lucy Platt, Svetlana Maximova, et al. 2006.on Media Work.” South Caucasus Anti-Drug (SCAD) Prevalence of HIV, Hepatitis C And Syphilis AmongProgramme (Phase V) United Nations Development Injecting Drug Users in Russia: A Multi-City Study.Programme. Available at http://www.un-az.org/undp/ Addiction 101:252–266.files/020007/mission%20report%20(Revised%20(4)%20Aug%2008%20.pdf (accessed September 2011). Rhodes, Tim, and Hedrich Dagmar. 2010. “Harm Reduction and the Mainstream.” In Harm Reduction:Javakhishvili, Darejan J., Lela Sturua, David Otiashvili, Evidence, Impacts and Challenges, Monograph Series 10,Irma Kirtadze, and Tomas Zabransky. 2011. Overview of Volume 1. Lisbon: European Monitoring Centre for Drugsthe Drug Situation in Georgia. Adictologie 11:42–51. and Drug Addiction.Kuniholm, Mark H., Malvina Aladashvili, Carlos Del Rio, et Saucier, Roxanne. 2011. “Stopping Overdose: Peer-al. 2008. Not All Injection Drug Users Are Created Equal: Based Distribution of Naloxone.” New York: Open SocietyHeterogeneity of HIV, Hepatitis C Virus, and Hepatitis B Foundation. Available at: http://www.soros.org/sites/Virus Infection in Georgia. Substance Use and Misuse default/files/overdose-naloxone-20110627.pdf (accessed43:1424–1437. September 2011).Lagu, Tara, Bradley J. Anderson, and Michael Stein. Schaub, Michael, Victor Chtenguelov, Emilis Subata,2006. Overdose Among Friends: Drug Users Are Willing Gundo Weiler, and Ambros Uchtenhagen. 2010.to Administer Naloxone to Others. Journal of Substance Feasibility of Buprenorphine and Methadone MaintenanceAbuse Treatment 30:129–133. Programmes Among Users of Homemade Opioids in Ukraine. International Journal of Drug Policy 21:229–233.Mathers, Bradley M., Louisa Degenhardt, BenjaminPhillips, et al., for the 2007 Reference Group to the UN on Shapatava, Ekaterine, Kenrad E. Nelson, TengizHIV and Injecting Drug Use. 2008. Global Epidemiology Tsertsvadze, and Carlos del Rio. 2006. Risk Behaviorsof Injecting Drug Use And HIV Among People Who Inject and HIV, Hepatitis B, and Hepatitis C SeroprevalenceDrugs: A Systematic Review. The Lancet 372(9651):1733– among Injection Drug Users in Georgia. Drug and Alcohol1745. Dependence 82(Suppl 1):S35–S38.Onlinenews.ge. February 10, 2011. “New Homemade Sharvadze, Lali, Kenrad E. Nelson, Paata Imnadze,Drug Appears in Georgia.” Available at www.onlinenews. Marika Karchava, and Tengiz Tsertsvadze. 2008.ge/index.php?id=7040&lang=eng (accessed September Prevalence of HCV and Genotypes Distribution in General2011). Population of Georgia. Georgian Medical News 165:71– 77.Research Institute on Addiction. 2007. Assessment ofDrug Dependence Treatment in Georgia. Tbilisi, Georgia: Shuster, Simon. June 20, 2011. The Curse of Crocodile:Research Institute on Addiction. Russia’s Deadly Designer Drug. Time. Available at www.time.com/time/world/article/0,8599,2078355,00.Rhodes, Tim, Andrew Ball, Gerry V. Stimson, et al. 1999. html?xid=rss-fullworld-yahoo (accessed SeptemberHIV Infection Associated With Drug Injecting in the Newly 2011).Independent States, Eastern Europe: The Social And12 AIDSTAR-One | November 2012
  • 13. AIDSTAR-One | CASE STUDY SERIESSirbiladze, Tamar, Lela Tavzarashvili, Tomas Zabransky, author extends her gratitude to all the members of theand Lela Sturua. 2009. Estimating the Prevalence of Georgian Harm Reduction Network for their generosity,Injection Drug Use in Five Cities of Georgia. South grace, and dedication during the case study process andCaucasus Anti-Drug (SCAD) Programme. Available at: writing. Special thanks go to Dr. David Otiashvili, Unionhttp://bemonidrug.org.ge/userfiles/files/Kvlevebi/EN/ Alternative Georgia, whose assistance was critical to thisEstimating%20the%20Prevalence%20of%20Injection%20 project; to the U.S. Agency for International DevelopmentDrug%20Use%20in%20Five%20Citi.pdf (accessed in Georgia and Washington, DC, for assistance andSeptember 2011). helpful feedback; and to Repsina Chintalova-Dallas of AIDSTAR-One for her nimble stewardship in moving theStrang, John, Victoria Manning, Soraya Mayet, et al. project through all the stages. The spirit and struggle of2008. Overdose Training and Take Home Naloxone for drug users and other people at risk of HIV in Georgia inOpiate Users: Prospective Cohort Study of Impact on making healthy changes in their lives and communitiesKnowledge and Attitudes and Subsequent Management and the members of the GHRN who maintain their focusof Overdoses. Addiction 103:1648–1657. on the health and human rights of drug users remain a constant inspiration.Suntharasamai, Pravan, Michael Martin, SuphakVanichseni, et al. 2009. Factors Associated withIncarceration and Incident Human Immunodeficiency RECOMMENDED CITATIONVirus (HIV) Infection Among Injection Drug UsersParticipating in an HIV Vaccine Trial In Bangkok, Thailand, Case, Patricia. 2012. Uniting to Build HIV Prevention for1999-2003. Addiction 104: 235–242. Drug Users: The Georgian Harm Reduction Network. Case Study Series. Arlington, VA. USAID’s AIDS SupportUnited Nations General Assembly Special Session and Technical Assistance Resources, AIDSTAR-One, Taskon HIV/AIDS. 2010. Monitoring the Declaration of Order 1.Commitment on HIV/AIDS: Georgia Country ProgressReport. Available at http://data.unaids.org/pub/Report/2010/georgia_2010_country_progress_report_en.pdf (accessed September 2011).Vadachkoria, Dmitri, L. Gabunia, Ketevan Gambashidze,N. Pkhaladze, and Nina Kuridze. 2009. Addictive Potentialof Tianeptine—The Threatening Reality. Georgian MedicalNews 174: 92–94.World Health Organization. 2011. WHO Model List ofEssential Medicines, 17th ed. Available at http://whqlibdoc.who.int/hq/2011/a95053_eng.pdf (accessed September2011).Zaller, Nickolas, Kenrad E. Nelson, Malvina Aladashvili,Nino Badridze, Carlos del Rio, and Tengiz Tsertsvadze.2004. Risk Factors for Hepatitis C Virus Infectionamong Blood Donors in Georgia. European Journal ofEpidemiology 19:547–553.ACKNOWLEDGMENTSThis case study was written with the support of AIDSTAR-ONE, the U.S. Agency for International Development’sglobal HIV/AIDS technical assistance program. The Uniting to Build HIV Prevention for Drug Users: The Georgian Harm Reduction Network 13
  • 14. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approaches around the world. These engaging case studies are designed for HIV program planners and implementers, documenting the steps from idea to intervention and from research to practice. Please sign up at www.AIDSTAR-One.com to receive notification of HIV-related resources, including additional case studies focused on emerging issues in HIV prevention, treatment, testing and counseling, care and support, gender integration and more.14 AIDSTAR-One | November 2012