The document summarizes the results of a respondent driven sampling study on initiation into injecting drug use among young IDUs and their non-IDU peers in Ukraine. The study found that most participants' first injection involved a home-produced opiate taken in a group of friends at the apartment of a friend. The injection was usually administered by a close friend or, for women, a sexual partner, and obtained from a close friend for free. Initiation was generally unplanned. The study proposed peer-based interventions targeting both IDUs and non-IDUs to establish norms discouraging initiation and promoting safer drug use.

1. Initiation Into Injecting Drug Use In Ukraine:
Results From a Respondent Driven Sampling
Study Among Young IDUs and Non-IDU Peers
Jean-Paul Grund, Olga Balakireva, Olena Sakovich,
Yuliya Rubanets, Marina Ryabova, Cas Barendregt,
Nataliya Levchuk, Tatyana Bondar

2. Project Data
• Project Title: Preventing Initiation of Injecting Drug Use
amongst Vulnerable Adolescents and Youth in Ukraine
• Implemented by:
- Ukrainian Institute for Social Research
(Olga Balakireva (PI), Yuliya Rubanets, Marina
Ryabova, Nataliya Levchuk, Tatyana Bondar);
- DV8 Research, Training & Development, Rotterdam,
the Netherlands (Jean-Paul Grund (co-PI));
- Addiction Research Institute (IVO) Rotterdam, the
Netherlands (Cas Barendregt)

3. Acknowledgement
• Funding: UNAIDS/UNICEF (PAF)
• Project Officer: Olena Sakovich, UNICEF, Kiev

4. BACKGROUND:
A TWIN EPIDEMIC OF IDU AND HIV (i)
• Registered drug users in Ukraine:
– 1990
43.2 per 100K pop.
– 2005
179.2 per 100K pop. (Ministry
of Health of Ukraine. 2006)
• Number of IDUs in Ukraine:
– 560.000 (Social Monitoring Center, 2002)
– 424.700 (consensus estimate of national
HIV/AIDS specialists, 2005)

5. BACKGROUND:
A TWIN EPIDEMIC OF IDU AND HIV (ii)
• Injecting drug use remains main mode of HIV
transmission:
– 2005: 45.5% of PLWHA infected through IDU
(Ukrainian AIDS Center, 2006)
BUT…
– Existing HIV testing and HIV case registration
system seriously underestimates actual
number of HIV-positive IDUs (UAC /UNAIDS, 2002)
– Local Sentinel Surveillance studies suggest HIV
prevalence among IDUs between 10% and 59%,
with IDUs aged 15 to 19 at highest risk.
– IDU population keeps growing in number

6. STUDY OBJECTIVES
• Present prevention approaches either tend to emphasize targeted
interventions aimed at established drug injectors or public
information campaigns, aiming at informing the general public in
a ‘broadcast’ fashion.
• Importance of needle exchange, Substitution treatment and other
harm reduction interventions, but…
• Is it possible to “Break the Cycle” of initiation into IDU?
– Little scientific information is available on the determinants of initiation
into injecting drug use among youth. From Ukraine and other post Soviet
countries none whatsoever.
Study aims:
• Provide data on the process of initiation into injecting drug use
• Serve as foundation for prevention activities seeking to reduce the
incidence & prevalence of IDU

7. Study Design
• Literature review on (prevention of) initiation of
injecting drug use among youth and support
services for young/novice injecting drug users
(IDUs);
• In-depth interviews with young/recent IDUs;
• Quantitative survey of young/recent IDUs
and their non-injecting friends in four cities
(Kyiv, Odesa, Poltava and Pavlograd);
• Each phase informed the following

8. Survey Methodology
• Respondent Driven Sampling (Heckathorn,
1997, 2002) in four cities:
Kyiv, Odesa, Poltava and Pavlohrad;
• Target Populations:
1. Injecting drug users (IDUs) up to 23 years of age,
having injected at least once in the last 3 months);
not in treatment for drug addiction and not involved
in rehabilitation programs at the time of interview.
2. IDUs’ friends who do not inject drugs (non-IDUs)
up to 23 years of age (thus including non-users
(NUs) and users of non-injected drugs (NIDUs))

9. IDU 1 recruits 4 freinds: 3 IDUs and 1 non-IDU
IDU 1
IDU 1.1
IDU 1.2
IDU 1.3
The same scheme as for IDU-1
IDU 1.1.1
IDU 1.1.2
Non-IDU
Non-IDU respondents do not
recruit!
Non-IDU
IDU 1.1.3
The same scheme as for IDU-1
IDU 20
IDU 20.1
IDU 20.2
IDU 20.3
Non-IDU
The same scheme as for IDU-1
Seeds: IDU 1 ...... IDU20
RDS
Recruitment
Scheme

10. The Resulting Sample
Non-injecting friends (non-IDUs),
N=802
Kyiv
Odesa
Pavlograd
Poltava
Kyiv
Odesa
Pavlograd
Poltava
Injecting drug users
(IDUs), N=808
25%
25%
25%
25%
25%
25%
25%
25%
205
201
199
203
199
201
Use drugs
non-injectingly
(NIDUs), N=476
200
201
Do not use any
illegal drugs (NU),
N=326

11. Demographics
IDUs
Non-IDUs
Gender: M.
F.
78,5%
21,5%
63,3%
36,7%
Mean Age:
20 yrs.
19 yrs.
Employed:
35%
40%

13. Drugs of first injection by city of
residence (% )
Among all IDUs
25
60
Pavlograd
5
55
35
0
Poltava
11
77
Odesa
2
12
68
Kyiv
9
23
59
0%
10
20%
Poppy straw extract
9
40%
60%
Amphtamines
80%
Heroin
10
11
11
9
100%
Others

14. Social Setting of the First Hit
“Who was present at your first injection?”*
Company
%
Friends or good acquaintances
80
Person I did not know very well
20
Sexual partner
17
Stranger
7
Alone
5
* More than one answer was possible.

15. Social Setting of the First Hit
“Who gave you the first injection?” by gender (%)
64
Friend, acquantance
55
67
13
Self-made
4
15
8
Sexual partner
32
3
6
Drug dealer
2
7
5
Running body
4
5
1
O ther persons
3
3
0
10
20
Men
30
40
Women
50
60
All
70
80

16. Social Setting of the First Hit
Average age of first injection:
17.7 years
Average age of “Initiator”:
22.8 years
Initiator is usually an IDU friend
First drug of injection is usually obtained from a close
friend, free of charge
Most common location of IDU initiation:
A friend‘s apartment

17. Behavioral risks associated with the first
injection (i)
• “At my initiation other people
used the same drug.”
• Obtained first drug injected
as liquid in syringe
• “Each in the group had
his/her own syringe”
80%
75%
21%

18. Behavioral risks associated with the first
injection (ii)
• didn’t know / unsure whether syringe
was used by someone before or not
33%
– Associated with Age: Younger at initiation  increasing
incertainty;
– Associated with length of Non-IDU use:
2 Years
4 Years
32%
21%
• 50% was high on AOD
“At the time of my first injection I was under the influence of alcohol
and marijuana.” (Poltava, female, 19 years).

19. Behavioral risks associated with the first
injection (iii)
“Did you use a sterile needle during the first injection?"
by other drug use (%)
% 80
70
60
50
40
30
20
10
0
73
62
38
56
49
43
51
26
Had not used any stuff
Non-injecting drugs
Do not know/unsure whether the syringe was new
Alcohol
Alcohol and non-injecting
drugs
Sure, it was a new syringe

20. Behavioral risks associated with the first
injection (iv)
Other drug use during the first injection by gender (%)
% 60
50
55
44
38
Men
Women
40
25
30
14
20
11
5
10
6
0
Had not used any
stuff
Non-injecting drugs
Alcohol
Syringe sharing at the first injection: Men:
Women
Alcohol and noninjecting drugs
29%
51%

21. The reproduction of injecting drug use
• 167 IDUs (21%) initiated 605 Novice IDUs
 Reproduction Rate: 3.6 per initiator or 0.7 for
whole sample
– Males:
22%, RR 3.83
– Females: 16%, RR 2.61
“Did you ever initiate a novice?”
%
Yes, I did
21
No. of times:
7
twice
6
tree or more
No, I didn’t
once
8
79

22. Initiation into IDU: Planned or Spontaneous?
Planning the first and the second injection, by gender (%)
100
% 90
80
70
60
50
40
30
20
10
0
100
%
90
80
70
60
50
60
44
40
30
20
10
First injection
Men
Second
injection
45
28
0
First injection
Women
Second
injection

23. Did you ever want to try an injecting drug?
(%) of the NIDUs and NUs
NIDUs
NUs
No, never
56
80
Yes, a couple of times
37
17
Yes, quite often
5
1
Yes, I really would like to try an injecting
drug
2
2

24. Self-Assessment of the probability of
initiating IDU among NIDUs and NUs (%)
5
Sure they will try one day
10
Not going to try injecting drugs so far, but don’t know
how the things will be going later on
30
34
65
Sure they will never try injecting drugs
56
0
NIDUs
10
20
30
40
50
60
70
NUs
80
90 100

25. First injection:
Summary
•
•
•
•
Mostly home-produced opiate;
Taken in a group of friends;
At the apartment of a friend;
Administered by a close friend or, in the case of
women, a sexual partner;
• Obtained from a close friend, free of charge;
• Generally an unplanned event.
Additional data on:
– Motivations for & Barriers to initiation of drug
injecting
– Risk & Protective Factors

26. Peer-based interventions targeting (young) IDUs,
Interventions targeting IDUs to prevent initiation of
other, that is:
- to not inject in the presence of non-injectors;
- to not give other people their first injection;
- inform non-injectors on the negative effects of
injecting drug use.
• XXXXX
IDUs
Non-IDUs
aiming at changes in sub-cultural norms towards
rejecting initiation of non-IDUs:
•Do not give other people (e.g. non-IDUs friends)
their first injection
•Do not inject in the presence of non-IDUs
•Honestly inform non-IDUs on the consequences of
injecting drug use (health, habit)
•Example: Break the Cycle (Hunt 1998)
Proposed
Strategy
Peer-based interventions targeting NIDUs & experimental IDUs, aiming at
Abstinence-based drug education:
establishing sub-cultural norms favoring non-injecting modes of administration:
interventions targeting non-IDUs to prevent initiation
of injecting drug use.
•Honest information on modes of administration;
•Information on safer and effective non-IDU modes of administration

27. Reference:
• Jean-Paul Grund, Olga Balakireva, Olena Sakovich, Yuliya
Rubanets, Marina Ryabova, Cas Barendregt, Nataliya Levchuk,
Tatyana Bondar. Initiation into Injecting Drug Use In Ukraine:
Results From a Respondent Driven Sampling Study Among Young
IDUs and Their Non-IDU Peers. Presented at the Seventeenth
International Conference on the Reduction of Drug Related Harm,
Vancouver, Canada, May 3, 2002 (Abs.No. We.07.1).
J-P Grund