Drug Use Patterns and HIV Risk
Behaviors of Russian Syringe
Exchange Participants
Jean-Paul C. Grund@, Denis Kobzev$, Vita...
Background
• Since the mid-1990s both injecting drug use and
HIV among IDUs have spread rapidly in Eastern
Europe.
• HIV a...
Background
• Whether such programs can bring the spread of
HIV among IDUs in Russia under control is a
question of great i...
Methodology
• Respondents were recruited from participants of
the exchanges.
• Structured questionnaires covering drug use...
Methodology
• Qualitative data were collected during site visits
about the drug scenes in the city where the
programs are ...
Table 1. Demographic Descriptors of Russian
Syringe Exchange Participants1 N= 1,076
N. N.
N = 236

Pskov
R-N-D St. Petersb...
Table 2. Drug Use Characteristics of Russian
Syringe Exchange Participants N = 1,076
N. N.
Pskov R-N-D St. Petersb. Volgog...
Table 3. Injection-Related HIV Risk Behaviors of
Russian Syringe Exchange Participants1 N = 1,076
N. N.
N = 236
Daily Inje...
Table 4. Injection-Related HIV Risk Behaviors of
Russian Syringe Exchange Participants1 N = 1,076
N. N.
N = 236
Bought Loa...
Table 5. Injection-Related HIV Risk Behaviors of
Russian Syringe Exchange Participants1 N = 1,076
N. N.
N = 236
Group Inje...
Table 6. Frequency of Group Injecting among
Russian Syringe Exchange Participants1 N = 1,097
N. N.
N = 236

Pskov
R-N-D
N ...
Table 7. Syringe-Mediated-Drug-Sharing among
Russian Syringe Exchange Participants1 N = 1,097
N. N.
N = 236

Pskov
R-N-D
N...
Table 8. Self-Production of Drugs among Russian
Syringe Exchange Participants1 N = 1,097
N. N.
N = 236

Pskov
R-N-D
N = 20...
Papaver Somniferum

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Cooking Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Cooking Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Cooking Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Cooking Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Cooking Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Frontloading Cheornaya in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Support with Injecting in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Support with Injecting in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Support with Injecting in Rostov Na Donu

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Frontloading Heroin in
Volgograd

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Support with Injecting in Volgograd

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Discussion (1)
• The data suggest a complex picture.
• On the one hand, they show substantial reductions
in previously ide...
Discussion (2)
• The percentages of respondents reporting
receptive syringe sharing--perhaps the most
widely used measurem...
Discussion (3)
• Region-specific risk behaviors, such as buying
Cheornaya loaded in syringes and using blood in
its prepar...
Discussion (4)
• On the other hand, these data show much less
impressive reductions in a number of—less
researched—behavio...
Discussion (5)
• This drug culture developed during the communist
era, when closed borders not only obstructed
transport o...
Discussion (6)
• More recently rapid and turbulent market
transformations characterize the Russian drug
culture, most mark...
Discussion (7)
• Therefore, syringe exchange programs and other
HIV education efforts in Russia need to address
the “Micro...
Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod

04/05/01, 12TH IHRC, New Delhi, India

J-P Grund, DV8-RTD
Discussion (8)
• Both our ethnographic and survey data suggest
that “Peer Support” strategies (including “Peer
Outreach” a...
Discussion (9)
• Programs should also address the “Macro Risk
Environment.”
• Data not presented here show that in particu...
Discussion (10)
“The relations with the police are tense. Police and
Program aims are opposite. The laws are not
satisfact...
Discussion (11)
• Agreements with one (of the several) police
department(s) do not preclude the negative
influence of Inte...
Peer Support?

Drug Use Patterns and HIV Risk
Behaviors of Russian Syringe
Exchange Participants

04/05/01, 12TH IHRC, New...
Drug Use Patterns and HIV Risk
Behaviors of Russian Syringe
Exchange Participants
Jean-Paul C. Grund@, Denis Kobzev$, Vita...
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  1. 1. Drug Use Patterns and HIV Risk Behaviors of Russian Syringe Exchange Participants Jean-Paul C. Grund@, Denis Kobzev$, 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)
  2. 2. 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 . 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  3. 3. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  4. 4. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  5. 5. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  6. 6. Table 1. Demographic Descriptors of Russian Syringe Exchange Participants1 N= 1,076 N. N. N = 236 Pskov R-N-D St. Petersb. N = 201 N = 199 N = 221 Volgograd N = 219 Total N = 1,076 Age (%) < 20 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 40 years > 40 years Gender (%) Male Female Marital Status (%) Married/Comm.Law Never Married/Single Divorced/Separated Widowed Living Arr. past 6 months2,3 (%) Own house/apartm. Someone else's H/A Homeless Prison 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 84 16 75 25 69 31 78 22 83 17 78 22 32 60 8 0 35 58 6 1 42 30 24 4 29 62 8 1 23 57 20 0 32 53 13 1 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  7. 7. Table 2. Drug Use Characteristics of Russian Syringe Exchange Participants N = 1,076 N. N. Pskov R-N-D St. Petersb. Volgograd N = 236 N = 201 N = 199 N = 221 N = 219 Age First IDU1 (Mean/SD) Total N = 1,076 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4) < 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 Years Injecting1 (%) 1 2 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. Percents may sum to > 100; more than one response may apply. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  8. 8. Table 3. Injection-Related HIV Risk Behaviors of Russian Syringe Exchange Participants1 N = 1,076 N. N. N = 236 Daily Injection of at least one drug (%) 30 Ds. Prior to SEP Last 30 Days P Receptive Sequential Syringe Use (%) 30 Ds. Prior to SEP Last 30 Days P Injected @ Anonym. Injecting Venue (%) 30 Ds. Prior to SEP Last 30 Days P 1 Pskov N = 201 R-N-D St. Petersb. N = 199 N = 221 Volgograd N = 219 Total N = 1,076 64 64 .7237 25 11 <.0001 52 36 <.0001 66 77 .0031 74 71 .2009 53 53 .0001 41 9 <.0001 26 4 <.0001 39 9 <.0001 48 29 <.0001 37 3 <.0001 38 11 <.0001 62 47 <.0001 25 9 <.0001 54 28 <.0001 37 19 <.0001 45 33 <.0001 45 28 <.0001 Totals may not equal 100% due to rounding or missing data. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  9. 9. Table 4. Injection-Related HIV Risk Behaviors of Russian Syringe Exchange Participants1 N = 1,076 N. N. N = 236 Bought Loaded Syringes (%) 30 Days Prior to SEP Last 30 Days P Used Blood in Preparation (%) 30 Days Prior to SEP Last 30 Days P Saw others use Blood in Preparation (%) 30 Days Prior to SEP Last 30 Days P 1 Pskov N = 201 R-N-D St. Petersb. Volgograd N = 199 N = 221 N = 219 Total N = 1,076 9 2 .0001 4 1 .0082 19 11 .0003 14 1 <.0001 13 1 <.0001 12 3 <.0001 5 0 -- 10 10 .8474 8 5 .1967 10 2 .0017 7 5 .3173 8 4 .0001 25 4 <.0001 33 14 <.0001 31 13 <.0001 21 2 <.0001 26 8 .0003 27 8 <.0001 Totals may not equal 100% due to rounding or missing data. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  10. 10. Table 5. Injection-Related HIV Risk Behaviors of Russian Syringe Exchange Participants1 N = 1,076 N. N. N = 236 Group Injecting (%) 30 Days Prior to SEP Last 30 Days P Shared Utensils (%) 30 Days Prior to SEP Last 30 Days P S-M-D-S (%) 30 Days Prior to SEP Last 30 Days P 1 04/05/01, 12TH IHRC, New Delhi, India Pskov R-N-D St. Petersb. Volgograd N = 201 N = 199 N = 221 N = 219 Total N = 1,076 91 86 .0093 96 89 .0016 87 80 .0006 96 93 .0707 85 81 .0114 91 86 <.0001 72 53 <.0001 93 86 .0011 85 73 <.0001 88 90 .2850 75 64 <.0001 82 73 <.0001 67 54 <.0001 47 36 .0020 50 30 <.0001 64 67 .4308 63 52 .0002 58 48 <.0001 Totals may not equal 100% due to rounding or missing data. J-P Grund, DV8-RTD
  11. 11. Table 6. Frequency of Group Injecting among Russian Syringe Exchange Participants1 N = 1,097 N. N. N = 236 Pskov R-N-D N = 205 N = 199 St. Petersb. N = 236 Volgograd N = 221 Total N = 1,097 30 Days Prior to SEP Use(%) Never 1-3 Times/Month-Less Once a Week 2-6 Times a Week Once a Day More than Once a Day / Almost Every Day 5 27 16 31 13 13 14 10 32 14 4 11 10 29 23 15 2 6 20 19 9 13 10 29 18 21 8 17 23 37 22 Last 30 Days During SEP Use (%) Never 1-3 Times/Month-Less Once a Week 2-6 Times a Week Once a Day More than Once a Day / Almost Every Day 1 9 12 10 31 18 14 11 10 26 20 11 36 13 31 4 20 15 17 28 10 7 8 6 26 32 20 5 7 19 16 14 14 10 26 17 19 5 12 22 33 18 Totals may not equal 100% due to rounding or missing data. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  12. 12. Table 7. Syringe-Mediated-Drug-Sharing among Russian Syringe Exchange Participants1 N = 1,097 N. N. N = 236 Pskov R-N-D N = 205 N = 199 St. Petersb. N = 236 Volgograd N = 221 Total N = 1,097 30 Days Prior to SEP Use(%) Never Less than half the time About half the time More than half the time Always 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 (%) Never Less than half the time About half the time More than half the time Always 1 26 10 10 12 41 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 Totals may not equal 100% due to rounding or missing data. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  13. 13. Table 8. Self-Production of Drugs among Russian Syringe Exchange Participants1 N = 1,097 N. N. N = 236 Pskov R-N-D N = 205 N = 199 St. Petersb. N = 236 Volgograd N = 221 Total N = 1,097 Tradition of SelfProduction in City? (%) No Yes Don’t Know 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 time About half the time More than 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 (%) Never Less than half the time About half the time More than half the time Always 1 14 86 0 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 Totals may not equal 100% due to rounding or missing data. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  14. 14. Papaver Somniferum 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  15. 15. Cooking Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  16. 16. Cooking Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  17. 17. Cooking Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  18. 18. Cooking Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  19. 19. Cooking Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  20. 20. Frontloading Cheornaya in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  21. 21. Support with Injecting in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  22. 22. Support with Injecting in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  23. 23. Support with Injecting in Rostov Na Donu 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  24. 24. Frontloading Heroin in Volgograd 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  25. 25. Support with Injecting in Volgograd 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  26. 26. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  27. 27. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  28. 28. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  29. 29. Discussion (4) • On the other hand, these data show much less impressive reductions in a number of—less researched—behaviors: using in groups, SyringeMediated-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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  30. 30. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  31. 31. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  32. 32. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  33. 33. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  34. 34. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  35. 35. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  36. 36. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  37. 37. 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 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  38. 38. 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. 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  39. 39. Peer Support? Drug Use Patterns and HIV Risk Behaviors of Russian Syringe Exchange Participants 04/05/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  40. 40. 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)

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