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

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)

Acknowledgement

• Funding: UNAIDS/UNICEF (PAF)

• Project Officer: Olena Sakovich, UNICEF, Kiev

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)

• 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

BACKGROUND:

A TWIN EPIDEMIC OF IDU AND HIV (ii)

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

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

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))

RDS Recruitment

Scheme

IDU 1

IDU 1.1 IDU 1.2 IDU 1.3 Non-IDU

IDU 1.1.1 IDU 1.1.2 IDU 1.1.3 Non-IDU

IDU 1 recruits 4 freinds: 3 IDUs and 1 non-IDU

The same scheme as for IDU-1

The same scheme as for IDU-1

Non-IDU respondents do not

recruit!

IDU 20

IDU 20.1 IDU 20.2 IDU 20.3 Non-IDU

The same scheme as for IDU-1

Seeds: IDU 1 ...... IDU20

The Resulting Sample

Injecting drug users

(IDUs), N=808

Non-injecting friends (non-IDUs),

N=802

Use drugs

non-injectingly

(NIDUs), N=476

Do not use any

illegal drugs (NU),

N=326

Kyiv

Od

esa

Pavlo

gra

d

Po

ltava

205 201 199 203

25% 25% 25% 25%

199 201 200 201

Kyiv

Od

esa

Pavlo

gra

d

Po

ltava

25% 25% 25% 25%

Demographics

IDUs Non-IDUs

Gender: M.

F.

78,5%

21,5%

63,3%

36,7%

Mean Age: 20 yrs. 19 yrs.

Employed: 35% 40%

Drugs of first injection by city of

residence (% )

59

68

77

35

60

9

11

11

10

1025

55

11

12

23

5

0

2

9

9

0% 20% 40% 60% 80% 100%

Kyiv

Odesa

Poltava

Pavlograd

Among all IDUs

Poppy straw extract Amphtamines Heroin Others

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.

Social Setting of the First Hit

“Who gave you the first injection?” by gender (%)

3

7

3

15

67

3

4

2

32

4

55

1

6

8

13

64

5

5

0 10 20 30 40 50 60 70 80

O ther persons

Running body

Drug dealer

Sexual partner

Self-made

Friend, acquantance

Men Women All

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

Behavioral risks associated with the first

injection (i)

• “At my initiation other people 80%

used the same drug.”

• Obtained first drug injected 75%

as liquid in syringe

• “Each in the group had 21%

his/her own syringe”

Behavioral risks associated with the first

injection (ii)

• didn’t know / unsure whether syringe 33%

was used by someone before or not

– Associated with Age: Younger at initiation increasing

incertainty;

– Associated with length of Non-IDU use:

2 Years 32%

4 Years 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).

Behavioral risks associated with the first

injection (iii)

“Did you use a sterile needle during the first injection?"

by other drug use (%)

494338

26

515662

73

010

2030

4050

6070

80

Had not used any stuff Non-injecting drugs Alcohol Alcohol and non-injecting

drugs

%

Do not know/unsure whether the syringe was new Sure, it was a new syringe

Syringe sharing at the first injection: Men: 29%

Women 51%

Behavioral risks associated with the first

injection (iv)

Other drug use during the first injection by gender (%)

5

25

14

55

6

38

11

44

0

10

20

30

40

50

60

Had not used any

stuff

Non-injecting drugs Alcohol Alcohol and non-

injecting drugs

%

Men Women

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: once 7

twice 6

tree or more 8

No, I didn’t 79

Initiation into IDU: Planned or Spontaneous?

Planning the first and the second injection, by gender (%)

4460

0

10

20

30

40

50

60

70

80

90

100

First injection Second

injection

%

28

45

0

10

20

30

40

50

60

70

80

90

100

First injection Second

injection

%

Women Men

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

Self-Assessment of the probability of

initiating IDU among NIDUs and NUs (%)

56

34

10

65

30

5

0 10 20 30 40 50 60 70 80 90 100

Sure they will never try injecting drugs

Not going to try injecting drugs so far, but don’t know

how the things will be going later on

Sure they will try one day

NIDUs NUs

Summary First injection:

• 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

Proposed

Strategy

• XXXXX IDUs

Non-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.

Abstinence-based drug education:

interventions targeting non-IDUs to prevent initiation

of injecting drug use.

Peer-based interventions targeting NIDUs & experimental IDUs, aiming at establishing sub-cultural norms favoring non-injecting modes of administration:

•Honest information on modes of administration; •Information on safer and effective non-IDU modes of administration

Peer-based interventions targeting (young) 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)

J-P Grund

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).