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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
25. Support with Injecting in Volgograd
04/05/01, 12TH IHRC, New Delhi, India
J-P Grund, DV8-RTD
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. 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. 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. 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. 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. 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. 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. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
04/05/01, 12TH IHRC, New Delhi, India
J-P Grund, DV8-RTD
34. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
04/05/01, 12TH IHRC, New Delhi, India
J-P Grund, DV8-RTD
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. 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. 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. 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. 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. 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)
