SOCIAL MARKETING RESEARCH. The PSI Dashboard

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1 SOCIAL MARKETING RESEARCH Central Asia (2006): HIV/AIDS TRaC Study Evaluating Condom Use, Needle Sharing, Overdose, and Initiation of Others into Injecting Drugs among Injecting Drug Users in Tashkent and Bishkek First Round The PSI Dashboard Uzbekistan and Kyrgyzstan September 2006 PSI s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation, and Entrepreneurship * Long-term Commitment to the People We Serve

2 Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C Central Asia (2006): HIV/AIDS TRaC Study Evaluating Condom Use, Needle Sharing, Overdose, and Initiation of Others into Injecting Drugs among Injecting Drug Users in Tashkent and Bishkek First Round PSI Research & Metrics September 2006 Suggested citation of this work: Population Services International. (2006). Central Asia (2006): HIV/AIDS TRaC Study Evaluating Condom Use, Needle Sharing, Overdose, and Initiation of Others into Injecting Drugs among Injecting Drug Users in Tashkent and Bishkek. First Round (Social Marketing Research Series). Retrieved date from Population Services International, 2006 Contact Information: Shahnoza Tashkhodjaeva, M&E Coordinator 33a M. Yakubova St. Tashkent, Uzbekistan Phone: +7 (998-71) Fax: +7 (998-71) Leah Hoffman, Acting M&E Manager 33a M. Yakubova St. Tashkent, Uzbekistan Phone: +7 (998-71) Fax: +7 (998-71)

3 SUMMARY Acknowledgements This research project was supported by the United States Agency for International Development (USAID) as part of the Drug Demand Reduction Program (DDRP) in Uzbekistan, Tajikistan and the Ferghana Valley Region of Kyrgyzstan. This report represents the work of many individuals. The study design was developed by Arman Dairov (Regional Research Manager) and Aziz Karimov (Research Assistant) with help from Kim Longfield (PSI/DC Senior Researcher), Marty Bell (PSI C. Asia Regional Representative), Robert Gray (PSI C. Asia Deputy Regional Representative), Leah Hoffman (PSI C. Asia Regional Program Manager) and Varja Lipovsek (Senior Researcher for Eastern Europe and Central Asia). Data collection was conducted by Expert-Fikri Research Group Ltd. based in Tashkent, Uzbekistan. Data cleaning and analysis were completed by consultant Joel Joseph. The report was written by Shakhnoza Tashkhodjaeva, Leah Hoffman, Varja Lipovsek, Haneefa Saleem, and Kim Longfield. Justin Buszin and Amara Robinson provided additional assistance. Background and Research Objectives PSI/Central Asia is implementing a 5-year USAID-funded Drug Demand Reduction Program (DDRP) among injecting drug users, opiate drug-using sex workers, sex workers and at-risk youth in select sites in Kyrgyzstan, Tajikistan, Uzbekistan. In Uzbekistan, PSI also implements a grants program with vulnerable women, migrants, and opiate drug users. As part of the Break the Cycle component of DDRP, PSI works with injecting drug users to reduce their involvement in the initiation of young people to injecting drug use and to prevent their own overdose and overdose death and that of their peers. This program funds the Break the Cycle intervention in Khujand, Tajikistan; Osh, Kyrgyzstan; and Tashkent, Uzbekistan. Another USAID-funded project implemented by PSI in Central Asia is Project EBB Tide. EBB Tide supports the Break the Cycle intervention in Bishkek, Kyrgyzstan. The current study serves as the baseline to measure the impact of these activities at the Tashkent and Bishkek sites. 1. To obtain and provide both comprehensive and detailed data to support PSI s interventions with injecting drug users (IDUs); 2. To segment the target population in terms of: 1

4 - Initiating injecting drug users during last 6 months; - Overdose experienced in last 12 months; 3. To obtain baseline information regarding IDUs; 4. To reduce injecting initiation through the Break the Cycle intervention; 5. To identify key determinants (OAM Opportunity, Ability and Motivation) associated with initiation assistance behavior; and 6. To obtain information for monitoring the key indicators, behavior change, and OAM determinants. Methodology PSI/Central Asia conducted the field work for this baseline tracking survey in Bishkek, Kyrgyzstan and Tashkent, Uzbekistan in In total, data was collected from 440 eligible IDUs in both sites. Eligibility guidelines required that the IDU be aged 15-45, have injected heroin/opiates in the previous 6 months, had been an IDU for at least one month, living in the target cities, and had been recruited for interview either as a seed or through a voucher from an IDU peer. Both screening and main questionnaires served as survey tools. The survey in Tashkent city was conducted from September 4-12, 2006 using eight governmental Counseling Service Centers working with IDUs as main interview sites. The Bishkek study was conducted between September 8-10, 2006 in two governmental Counseling Service Centers and one NGO working with IDUs. This study used Respondent-Driven Sampling (RDS) for data collection from this population. Respondents were interviewed at these IDU Centers and were given vouchers to refer other IDUs. IDUs were given small incentives to answer the questions and for each person they successfully referred. Other than the seed IDUs, IDUs without vouchers were ineligible for interviews. IDUs who did not feel comfortable in these Centers were interviewed in alternate sites, such as cafes. The questionnaire collected information on background characteristics, opinions on needlesharing practices, personal drug use and sharing practices, assisting others to initiate injecting, beliefs and knowledge about HIV infection, sexual practices and condom use, and exposure to HIV prevention intervention. For segmentation tables, correlation matrices were examined first; then logistic regression for survey data was used to obtain final models, and the proportions 2

5 presented in the tables were calculated using the adjusted proportions command, (adjusting for all other variables in the model). Multivariate analyses were performed to identify significant factors associated with assisting non-users initiate injecting drug use. Simple frequencies were run on descriptive data to permit monitoring of project indicators. The data were analyzed using SPSS (version 15.0). Main Findings The rate of growth in IDU populations is between 5 and 10% in Target Sites. 5.9% of surveyed IDUs in Tashkent and 9.5% of surveyed IDUs in Bishkek were new injectors, i.e. those who had initiated into injecting drug use within the last 12 months, (Graf 1) % Tashkent, (N=220) City 9.5 % Bishkek, (N=220) Graph #1: Percentage of surveyed IDUs who have been initiated into injecting drugs during the last 12 months (new injectors) The Majority of IDU Respondents Reported Initiating Injecting with the Assistance of another IDU. Very high proportions of surveyed IDUs reported that they had help from someone else when they first injected drugs (85.9% in Tashkent and 85.5% in Bishkek), (Graf 2). 3

6 % 85.5% Tashkent, (N=220) City Bishkek, (N=220) Graph #2: Percentage of surveyed IDUs who had received help from IDUs when they first injected drugs. Relationship Trends between IDUs and those who Helped them Initiate Injecting Drugs 44.1% in Tashkent and 46.8% in Bishkek of surveyed IDUs reported that they were helped to inject by a peer relative (brother, sister, or cousin). 27.3% in Tashkent and 29.5% in Bishkek were helped to initiate by friends. Contrary to commonly held beliefs by members of the public, drug dealers represented a small percentage of those who helped others initiate. The close relationship between the initiated and the initiator is consistent with the finding from PSI s earlier qualitative study that it is most often the non-user that pressures the user to help him/her to initiate and not the other way around 1, (Graf 3). 1 Arman Dairov, Robert Gray, Kim Longfield Injecting Drug Users in Bishkek, Kyrgyzstan and Tashkent, Uzbekistan: Injecting Histories, Risk Practices, and Barriers to Adopting Behaviors Less Likely to Transmit HIV January

7 Relationship with Person IDUs Report Helped Them Initiate Injecting Bishkek 2006 Other 23.7% Brother, Sister, or Cousin 46.8% Friends 29.5% Graph #3: The Relationship between IDUs and the people who helped the IDU initiate injecting drugs, (N=188) IDUs who Report Helping Non-Users to initiate in the past 6 months 23.2% in Tashkent and 17.3% in Bishkek of the surveyed IDUs reported that they had in-turn helped someone else make their first injection in the last 6 months. 30.5% of Tashkent respondents and 27.7% of Bishkek respondents had injected in the presence of non-users in the last 6 months, showing that modeling of injecting to non-injectors is a significant issue in the region. Also, quite a high proportion of respondents have talked about the benefits of injecting (i.e. the more intense high, etc.) with non-injectors in the last 6 months in both cities (34.5% in Tashkent and 26.8% in Bishkek), (Graf 4). 5

8 40.00% 35.00% 30.00% 25.00% 20.00% Tashkent, N=220 Bishkek, N= % 10.00% 5.00% 0.00% Helped Others to Initiate Injected in front of Non-Users Talked about the perceived benefits of injecting drugs with non-users Graph #4: Prevalence of IDU behavior that contributes to the initiation of injecting drugs. The Average Number of those Initiated to Injecting Drugs in the Last Six Months per Helper IDU Of the IDUs who reported that they assisted someone in the past six months with their first injection, the mean number of non-users that each IDU respondent helped to initiate during this period was 2.9 non-users in Tashkent and 2.71 non-users in Bishkek, (Graf 5) Tashkent, N=51 Bishkek, N=38 City Graph #5: Mean number of non-users who had been helped to make their first injection in the last six months per helper IDU 6

9 Prevalence of Overdose among IDUs in Target Sites Overall, overdose is another crucial issue among the surveyed IDUs. A high proportion of respondents from both cities have personally suffered from overdose in the last 12 months; 24.5% in Tashkent and 38.2% in Bishkek, (Graf 6) % 38.2 % 0 Tashkent, N=220 Bishkek, N=220 City Graph #6: Percentage of surveyed IDUs who personally suffered from overdose within the last 12 months. Overdose is a visible, tangible part of an IDU s life % of Tashkent IDUs and 81.8% of Bishkek IDUs reported witnessing someone else overdose in the last 12 months, (Graf 7) % % Tashkent, N=220 City Bishkek, N=220 Graph #7: Percentage of surveyed IDUs who reported having witnessed someone else suffered from an overdose within the last 12 months. 7

10 More than one-third of IDUs reported having witnessed someone die from an overdose; 30.5% in Tashkent and 42.3% in Bishkek % 42.3% 0 Tashkent, N=220 City Bishkek, N=220 Graph #8: Percent of surveyed IDUs who reported having witnessed someone die from an overdose within the last 12 months. Knowledge of HIV and Overdose Risk Behaviors There were very interesting findings of the knowledge of overdose risk among IDUs who believe, correctly, that the following is true: After an IDU has quit for some time, restarting heroin/opiate use at the same dosage can increase the risk of overdose (88.6% in Bishkek and 92.7% in Tashkent). However, knowledge of HIV transmission was much lower. Only 24.5% of IDUs in Bishkek and 10% in Tashkent were able to spontaneously cite three correct methods of HIV prevention % 24.5% 0 Tashkent, N=220 Bishkek, N=220 City Graph #9: Percentage of surveyed IDUs able to cite three HIV prevention methods. 8

11 IDU knowledge about misconceptions of HIV transmission was better. 75.5% of IDUs in Tashkent and 54.1% in Bishkek had no misconceptions about the modes by which HIV is and is not transmitted, (Graf 10) % 54.1 % Tashkent, N=220 Bishkek, N=220 City Graph #10: Percentage of surveyed IDUs who had no misconception on how HIV is transmitted. Sharing needle/syringes and other injecting equipment When asked if they shared needles or syringes (N/S) at last injection, sharing was reported among only 10.9% of IDUs in Bishkek and 10.5% of IDUs in Tashkent (Graph 11) % 10.9 % 0 Tashkent, N=220 Bishkek, N=220 City Graph #11: Percentage of surveyed IDUs who reported sharing N/S at last injection. A high percentage of the surveyed IDUs reported sharing water (or other solution), for mixing drugs in the last 6 months in both cities (50% in Tashkent and 46.4% in Bishkek), (Graph 9

12 12). Nearly 33% of IDUs in Tashkent reported that they have ever shared needles/syringes with their sexual partner % 46.4 % 20 0 Tashkent, N=220 Bishkek, N=220 City Graph #12: Percentage of surveyed IDUs who reported sharing water or solution for mixing drugs in the last 6 months Social norms regarding the sharing of injecting equipment Social norms among IDUs generally confirm that sharing other injecting equipment (i.e. spoon, cup, cotton, and rinse water) is considered the norm and is common: 51.4% of respondents in Tashkent and 47.7% in Bishkek stated that when injecting, It is common in my group to share spoon, cup, cotton, and rinse water. Consistency of Condom Use Condom use amongst the surveyed IDUs differs according to partner type. Amongst the IDUs who reported having sex with commercial partners, quite a high proportion used condoms during their last sexual intercourse (87.9% in Tashkent and 79.3% in Bishkek), although fewer were likely to consistently use condoms with commercial partners in the last 6 months: 76.0% in Tashkent and 74.8% in Bishkek. (Graph 13) 10

13 % 74.8 % Tashkent, N=58 City Bishkek, N=58 Graph #13: Percentage of surveyed IDUs who reported consistent condom use with a commercial partner in the last 6 months IDUs were less likely to consistently use condoms with regular partners (33.8% in Tashkent and 20.4% in Bishkek). Even though reported condom use at the last sexual intercourse with regular partners was higher (43.6% in Tashkent and 31.6% in Bishkek), there is a great deal of improvement to be made, (Graph 14) % 31.6 % 20 0 Tashkent, N=172 Bishkek, N=152 City Graph #14: Percentage of surveyed IDUs who reported condom use at last sexual intercourse with their regular partner Knowledge of HIV Risk Behaviors and Transmission Knowledge of the HIV risk associated with letting someone else use one s injecting equipment was quite high: 88.6% in Bishkek and 81.4% in Tashkent. Nearly 97% of respondents in 11

14 Tashkent and 99.5% in Bishkek knew that consistent condom use reduces the risk of HIV transmission. Yet only 24.5% of IDUs in Bishkek and 10% in Tashkent were able to spontaneously cite three correct methods of HIV prevention through sexual transmission, which were to abstain, be faithful to one sexual partner, and use condoms. (Graph 15) % 24.5% 0 Tashkent, N=220 Bishkek, N=220 City Graph #15: Percentage of surveyed IDUs able to cite three methods to prevent the sexual transmission of HIV 75.5% of IDUs in Tashkent and 54.1% in Bishkek had no misconceptions about reducing the risk of HIV. Misconceptions included 1) HIV being transmitted by sharing the same dishes with people living with HIV; 2) HIV transmitted through mosquito bites; and 3) the idea that people living with HIV can be recognized by how they look, (Graph 16) % 54.1 % 20 0 Tashkent, N=220 Bishkek, N=220 City Graph #16: Percentage of surveyed IDUs who had no misconceptions on HIV transmission 12

15 Norms and Attitudes regarding Condom Use While most respondents recognized the need to use condoms, they remain reluctant to use them. A relatively high proportion of agree that condoms are necessary with regular partners (57.7% in Tashkent and 55% in Bishkek), but quite a high proportion of those surveyed reported they do not like to use condoms (70% in Tashkent and 72.2% in Bishkek) (Graph 17). Most respondents believe that using condoms feels unnatural (72.7% in Tashkent and 70% in Bishkek), and that using condoms decreases sexual pleasure (66.8% in Tashkent and 73.6% in Bishkek) % 70% Tashkent, N=220 Bishkek, N=220 City Graph #17: Percentage of surveyed IDUs who report they do not like to use condoms Coverage of IDUs with HIV Prevention Programs: Surveyed IDUs who reported exposure to HIV prevention services was higher than expected. 87% of IDUs in both Tashkent and Bishkek report being tested for HIV and more than half reported receiving condoms from outreach workers (56.4% in Tashkent and 60% in Bishkek) and IEC materials (58.6% in Tashkent and 70.9% in Bishkek) during the last 6 months (graph 18). Attending peer education sessions was less common, but still higher than expected (28.2% in Tashkent and 52.3% in Bishkek). Comparing these exposure levels to the reports of the programs working with IDUs, these exposure levels seem high and may suggest a possible bias in the sampling. In the following rounds of this survey, the methodology will be amended to address this possibility. In the comparison of this and other rounds, the effectiveness of programs may be harder to measure. At the same time, IDUs are aware that police have been instructed to interfere less with IDUs who report being linked to HIV services and IDUs may overestimate their linkage with these services as a result. 13

16 % 60% Tashkent, N=130 Bishkek, N=140 City Graph # 18: Percentage of surveyed IDUs who received condoms from outreach workers in the last six months 14

17 Summary Recommendations A significant percentage of IDUs reported that they have exposed non-injectors to injecting drug use by injecting in front of them or talking with them about the perceived benefits of injecting. Many IDUs also report that they have helped a non-user to initiate injecting drugs. More than 80% of IDUs themselves report having initiated with the help of an IDU. This data confirms the need for the Break the Cycle intervention to work with IDUs to resist the request of non-users to help them inject and to change behavior such as talking about injecting or injecting in front of non-users which builds the curiosity of non-injectors on injecting. This is especially important because of the key role IDU siblings and cousins play in the initiation of non-injectors. Programs working with youth co-dependents of IDUs and linked to programs targeting IDUs should be linked through a referral system. Overdose and overdose death prevention was identified not only as an urgent intervention among IDUs, but also as a way to build IDU demand for services that provide overdose prevention education as part of a larger menu of HIV prevention services. IDUs continue to have low awareness on HIV and programs working with IDUs need to build the educational and communications components to address this gap. We should educate IDUs about which actions constitute sharing and put them at risk of HIV, Hepatitis B and C, and Syphilis. There is a high prevalence of sharing injecting equipment other than needles and syringes and HIV prevention programs targeting IDUs should strengthen this educational component of their work. Condom use, especially with regular partners, is quite low. Even if IDUs are faithful to their regular sexual partners, if they share needles, syringes, or other injecting equipment, they put their sexual partners at risk. Increasing consistency of condom use should be prioritized within IDU programs. Communications should increase the attractiveness of condoms to IDUs and help IDUs introduce condom use with regular and occasional partners. 15

18 Monitoring Table (1 of 2) Monitoring Trends in behavior: Opportunity, Ability, and Motivational determinants of behavior and exposure among IDUs in Tashkent, Risk Group: Injecting Drug Users aged Behavior: (1) Has injected in the presence of non-users, has talked about benefits of injecting with non-users, has received drug treatment, was initiated into injecting for the first time in the last six months, new injectors during last 12 months and received help from an IDU when first injected drugs. (2) Needle/syringe and other injecting equipment sharing (3) Consistent condom use with regular partner, with occasional partner, Condom use at last sexual intercourse with commercial partner in the last six months 2006 N=220 INDICATORS % Behavior Has injected in the presence of non-users in the last 6 months 30.5 Has talked about benefits of injecting with non-users in the last 6 months 34.5 Has helped to make injection for the first time in the last 6 months 23.2 Has ever received drug addiction treatment (detoxification, rehabilitation, 46.4 substitution therapy)? Has been initiated to injecting drugs during last 12 months ( new 5.9 injectors ) Injected within the last 7 days 70.0 Received help from IDU when first injected drugs 85.9 Has overdosed in the last 12 months 24.5 Has witnessed someone else overdose in the last 12 months 47.7 Has witnessed someone die from an overdose 20.9 Increased consumption of drugs in the last six months 36.8 Has shared other sharing equipment 30.5 Has shared water or solution for mixing drugs in the last 6 months 50.0 Has shared needle/syringe at last injection 10.5 Condom use at last sexual intercourse with regular partner 43.6 Consistent condom use with regular partner in the last 6 months 33.7 Consistent condom use with occasional partner in the last 6 months 63.5 Condom at last sexual intercourse with commercial partner 87.9 Consistent condom use with commercial partner in the last 6 months 76.0 Beliefs Agrees with the statement: When I am dope sick, I will do anything to get a hit, including sharing needles 44.5 Believes that even new injecting drug users could be infected with HIV, so you 85.5 should not share needles/syringes with them Believes that it is appropriate for couples in steady relationship to use condoms 53.2 There is no need to worry about condom use because my sex drive is low 27.2 Thinks that suggesting condom use to a regular partner means that you are 37.2 cheating on him/her Availability Can always find new needle\syringe when ready to inject 83.2 Is able to find condoms within 10 minutes walk of venue where usually meet 76.8 partners Knowledge Was able to cite 3 correct HIV prevention methods 10.0 Had no misconception about ways of HIV transmission 75.5 Recognizes that the following is false: Using water is enough to clean

19 Monitoring Table (1 of 2) needles/syringes Recognizes that the following is false: It is OK to leave someone alone if 88.6 they are suffering from an overdose Recognizes that the following is true: After you have quit for a while, 92.7 restarting at the same dose of heroin\ opiates can increase the risk of overdose Not letting someone else to use my equipment (spoon, cup, cotton, rinse water ) 81.4 Knows consistent condom use reduces risk of HIV transmission 96.8 Attitude It doesn t matter if I give someone else my used needle\syringe 23.3 Locus of control If I am meant to get HIV/AIDS, it is my destiny 54.8 I am more likely to have sex without condoms when I am high 47.5 Exposure Has ever been tested for HIV 87.3 Has had contact with outreach worker at least once in the last 6 months 59.1 Has had contact with outreach workers at least 4 times each months over 52.3 last 6 months Has received condoms from an outreach worker in last 6 months 56.4 Has received IEC materials from an outreach worker in the last 6 months

20 Monitoring Analysis Monitoring Analysis: Trends in Behavior, Opportunity, Ability and Motivational determinants of behavior and exposure among IDUs in Tashkent, 2006 The preceding monitoring table was prepared in accordance with PSI s behavior change framework and presents baseline (2006) data, including determinants of behavior for overdose, as well as for factors related to the opportunity, ability and motivation, to adopt targeted behaviors in Tashkent. These indicators will be monitored over a period of time to detect trends in behavior and the IDUs opportunity, ability and motivation to adopt measures to reduce exposure of nonusers to injecting drug use and to reduce risk behavior for overdose. 5.9% of surveyed IDUs were new injectors (defined as having initiated injecting drugs during the last 12 months). 85.9% of IDUs reported that they had assistance on their first time injecting drugs. About 23.2% of surveyed IDUs reported that they had helped someone else to make a first injection in the last 6 months. 30.5% of IDUs injected in the presence of a non-user in the previous 6 months. 34.5% of IDUs talked about the perceived benefits of injecting (i.e. the more intense high, the cheaper cost, etc.) with non-users in the last 6 months. In addition, very interesting findings were that those who had injected within the last 7 days comprised 70% of surveyed IDUs. Moreover, only 46.6% of surveyed IDUs reported that they had received drug addiction treatment such as detoxification, rehabilitation, and/or substitution therapy. Overdose is a critical issue among the surveyed IDUs. 24.5% had personally suffered from overdose in the last 12 months, 36.8% of IDUs increased their consumption of drugs in the last six months, 47.7% of respondents had witnessed someone else s overdose, and 20.9% had seen someone else die from an overdose. 75.5% of surveyed IDUs had no misconception about the ways HIV is transmitted but only about 10% of those same IDUs were able to spontaneously cite three correct HIV prevention methods. About 92.7% of IDUs had considered that the following is true: After you have quit for a while, restarting at the same dose of heroin\opiates can increase the risk of overdose. In addition, there were very interesting findings among the surveyed IDUs who had recognized that the followings are false: using water is enough to clean needles/syringes (76.4%) and it is ok to leave someone alone if they are suffering from overdose (88.6%). 18

21 Monitoring Analysis The table revealed that 10.5% of IDUs in Tashkent reported sharing a needle/syringe at their last injection and that 30.5% of those surveyed shared other equipment (i.e. spoon, cup, cotton, rinse water), with 50% reported sharing water or solutions for mixing drugs. More than half of IDUs (51.4%) report that it is common among IDUs to share other injecting equipment. 83.2% of those surveyed report that they can always find new needle/syringes when they are ready to inject. 75.5% of surveyed IDUs had no misconceptions about the ways HIV is transmitted, but only about 10% of those same IDUs were able to spontaneously cite three correct HIV prevention methods. Interestingly however, was that 81.5% of the surveyed IDUs report that they can prevent getting HIV by not letting others use their equipment, i.e. spoon, cup, cotton and rinse water. 85.5% of respondents believed that new injecting drug users could be infected with HIV, so they should not share their needle/syringe with them, yet nearly 23.3% of the respondents agreed with the statement It does not matter if I give someone else my used needle/syringe and 54.8% of those surveyed agreed with If I am meant to get HIV/AIDS, it s my destiny. The table above indicates that IDU condom use rates differ according to partner type. Among the IDUs who reported having sex with commercial partners, the majority (87.9%) used condoms at their last sexual intercourse, although they were less likely to have consistently used condoms with their commercial partners in the last 6 months (76%). IDU knowledge that consistent condom use reduces the risk of HIV transmission was very high (96.8%) among those who have had sex with commercial partners. Nearly 77% of respondents were able to find condoms within a 10-minute walk of the venue where they usually socialize. In addition, surveyed IDUs were less likely to consistently use condoms with regular and non-regular partners (33.7% and 63.5% respectively). However, almost 43.6% of respondents reported condom use during their last sexual intercourse with their regular partner. Surveyed IDUs reported significant negative attitudes to condom use and condoms. 70.5% of those surveyed agreed with the statement I do not like condoms. 72.7% believed that using condoms feels unnatural. About 56.4% believed it appropriate to use condoms with regular partners and 66.8% believed that using condoms decreases sexual pleasure. 29.1% reported they do not care about using condoms, indicating significant apathy. Only 57.7% of the surveyed IDUs 19

22 Monitoring Analysis agreed that condoms are necessary with regular partners and 37.2% think that suggesting condom use to a regular partner means that you are cheating on him/her. Only half of the IDUs surveyed believed it appropriate for couples in a steady relationship to use condoms and 48% of the respondents agreed with the statement I am more likely to have sex without condoms when I am high. Exposure to services, outreach workers and/or peer educators was moderate to high. 87% of surveyed IDUs reported having been tested for HIV. 59.1% reported having had contact with outreach workers at least once in the last 6 months. 52.3% reported having had regular contact with an outreach worker (i.e. at least 4 times each month over the last 6 months). 56.4% had received condoms and 58.6% had received IEC materials from outreach workers in the last 6 months. Comparing these exposure levels to the reports of the programs working with IDUs, these exposure levels seem high and may suggest a possible bias in the sampling. In the following rounds of this survey, the methodology will be amended to address this possibility. In the comparison of this and other rounds, positive impact of the programs these studies measure may be harder to measure. At the same time, IDUs are aware that police have been instructed to interfere less with IDUs who report being linked to HIV services and IDUs may overestimate their linkage with these services as a result. 20

23 Monitoring Table (2 of 2) Monitoring Trends in Behavior, Opportunity, Ability, and Motivational determinants of behavior and exposure among IDUs in Bishkek, 2006 Risk Group: Injecting Drug Users aged Behavior: (1) Has injected in the presence of non-users, has talked about benefits of injecting with non-users, and has been imitated to injecting for the first time in the last six months, new injectors during last 12 months, and received help from IDU when they first injected drugs (2) Needle/syringe and other injecting equipment sharing (3) Consistent condom use with regular partner, with non-regular partner, Condom use at last sexual intercourse with commercial partner in the last six months INDICATORS 2006 N=220 % Behavior Has injected in the presence of non-users in the last 6 months 27.7 Has talked about benefits of injecting with non-users in the last 6 months 26.8 Has helped to make injection for the first time in the last 6 months 17.3 Have you ever received drug addiction treatment (detoxification, 60.4 rehabilitation, substitution therapy)? Has been initiated injecting drugs during last 12 months ( new injectors ) 9.5 Injected within the last 7 days 80.0 Has reported that they got help the first time they injected drugs 85.5 Has suffered from an overdose in the last 12 months 38.2 Has witnessed someone else suffered from an overdose 81.8 Has seen someone die from an overdose 42.3 Increased consumption of drugs in the last six months 49.5 Has shared water or solution for mixing drugs in the last 6 months 46.4 Has shared needle/syringe at last injection 10.9 Condom use at last sexual intercourse with regular partner 31.6 Consistent condom use with regular partner in the last 6 months 20.4 Consistent condom use with non-regular partner in the last 6 months 60.4 Condom at last sexual intercourse with commercial partner 79.3 Consistent condom use with commercial partner in the last 6 months 74.8 Availability Can always find new needle/syringe when ready to inject 90.5 Is able to find condoms within 10 minutes walk of venue where usually 83.2 meet partners Social Norms It is common in my group to share spoon, cup, cotton, rinse water 47.7 Knowledge Was able to cite 3 correct HIV prevention methods 24.5 Had no misconception about ways of HIV transmission 54.1 Recognizes that the following is false: Using water is enough to clean needles/syringes 64.5 Recognizes that the following is false: It is OK to leave someone alone if they are suffering from an overdose 86.8 Recognizes that the following is true: After you have quit for a while, restarting at the same dose of heroin\ opiates can increase the risk of overdose 91.8 Not letting someone else to use my equipment (spoon, cup, cotton, rinse water) can prevent HIV infection

24 Monitoring Table (2 of 2) Knows consistent condom use reduces risk of HIV transmission 99.5 Attitude It does not matter if I give someone else my used needle/syringe 15.9 I do not like condoms 72.3 It is inappropriate to use condoms with regular partner 54.1 Agrees that condoms are necessary with regular partner 55.0 Believes that using condoms feels unnatural 70.0 Believes using condoms decreases sexual pleasure 73.6 Do not care about using condoms (apathy) 35.9 Belief Believes that even new injecting drug users could be infected with HIV, so you should not share needles/syringes with them 91.8 Thinks that suggesting condom use to a regular partner means that you are cheating on him/her 31.1 Believes that it is appropriate for couples in steady relationship to use condoms 50.0 There is no need to worry about condom use because my sex drive is low 19.0 Population characteristics In the past 6 months, seen someone else give his/her needles/syringes to someone else to use 53.2 Exposure Has ever been tested for HIV 87.3 Has had contact with outreach worker at least once in the last 6 months 63.6 Has had contacts with outreach workers at least 4 times each months over last 6 months 68.6 Has received condoms from outreach worker in last 6 months 60.0 Has received IEC materials from outreach worker in the last 6 months

25 Monitoring Analysis Monitoring Analysis: Trends in Behavior, Opportunity, Ability, and Motivational determinants of behavior and exposure among IDUs in Bishkek, 2006 The preceding monitoring table was prepared in accordance with PSI s behavior change framework and presents baseline (2006) data, including determinants of behavior overdose, as well as factors related to opportunity, ability and motivation to adopt targeted behaviors in Bishkek. Indicators will be monitored over time to detect trends in behavior and IDU opportunity, ability and motivation to adopt safer injecting and sexual practices. 9.5% of respondents were new injectors, defined as having been initiated into injecting drugs during the last 12 months. 85.5% of respondents reported that they got help when it was their first time of injecting drugs. 17.3% of surveyed IDUs reported that they had helped someone else to make their first injection in the last 6 months. 27.7% had injected themselves in the presence of non-users in the last 6 months. 26.8% of IDUs talked about the benefits of injecting practice with non-users in the last 6 months. 80% of IDUs reported injecting within the last seven days. The findings indicated an encouraging percent of surveyed IDUs reported that they received drug addiction treatment such as detoxification, rehabilitation and substitution therapy; 60.4% of the surveyed population. Overdose is a critical issue amongst surveyed IDUs. 38.2% had personally overdosed, 81.8% had witnessed someone else overdose, and 42.3% had seen someone die from an overdose in the last 12 months. Moreover, 49.5% of surveyed IDUs increased consumption of drugs in the last six months. More than half of surveyed IDUs (54.1%) had no misconception about the ways HIV can be transmitted. Nearly 24.5% were able to spontaneously cite three correct HIV prevention methods. About 91.8% of IDUs had recognized that the following is true: after you have quit for a while, restarting at the same dose of heroin\opiates can increase the risk of overdose. Survey results also indicated that respondents recognized that the following statements are false: Using water is enough to clean needles/syringes (64.5%) and It is ok to leave someone alone if they are suffering from over dose (86.8%). 23

26 Monitoring Analysis Exposure to HIV prevention services, outreach workers, and/or peer educators was moderate to good. 87% of IDUs reported having been tested for HIV. 63.6% reported having contact with outreach workers at least once in the last 6 months. 68.6% of IDUs had regular contacts with outreach workers (at least 4 times each month over the last 6 months). 60% of respondents received condoms and 70.9% received IEC materials from outreach workers in the last 6 months. Comparing these exposure levels to the reports of the programs working with IDUs, these exposure levels seem high and may suggest a possible bias in the sampling. In the following rounds of this survey, the methodology will be amended to address this possibility. In the comparison of this and other rounds, positive impact of the programs these studies measure may be harder to measure. At the same time, IDUs are aware that police have been instructed to interfere less with IDUs who report being linked to HIV services and IDUs may overestimate their linkage with these services as a result. The table revealed that 10.9% of IDUs in Bishkek reported sharing needle/syringe at last injection. 46.4% reported sharing water or solution for mixing drugs in the last 6 months and 27.7% other sharing equipments. 47.7% of IDUs reported social norms of sharing injecting equipment (i.e. spoon, cup, cotton, and rinse water); moreover, 90.5% of surveyed IDUs reported that can always find new needle/syringes when ready to inject. 91.8% of respondents believed that new injecting drug users could be infected with HIV, so they should not share needle/syringes with them. IDU knowledge that not letting someone else use their other equipment (spoon, cup, cotton, and rinse water) can prevent HIV infection was high at 88.6%. More than half of surveyed IDUs (54.1%) had no misconception about the ways HIV can be transmitted. Nearly 24.5% were able to spontaneously cite three correct HIV prevention methods. The table indicates that IDU condom use differs according to partner type. Amongst IDUs who reported having sex with commercial partners, nearly 79.3% used condoms during their last sexual intercourse, while they were less likely to have consistently used condoms with their commercial partners during the last 6 months (74.8%). IDUs were also less likely to consistently use condoms with regular and non-regular partners (20.4% and 60.4% respectively), while about 31.6% of respondents reported condom use at last sexual intercourse with regular partners. 24

27 Monitoring Analysis Many IDUs reported negative attitudes to condom use and condoms. 72% of surveyed IDUs agreed with the statement I do not like condoms. 70% believed that using condoms feels unnatural. 73.6% believed that using condoms decreases sexual pleasure. 35.9% do not care about using condoms (apathy), but 55% of surveyed IDUs agreed that condoms are necessary with regular partners. IDUs displayed low results on locus of control (meaning they have control over their environment and surroundings), with 35% agreeing with the statement If I am meant to get HIV/AIDS, it is my destiny and 42% more likely to have sex without a condom when they are high. 83.2% of IDUs are able to find condoms within a 10 minutes walk of the venue where they usually meet partners. Only half of IDUs surveyed believed that it is appropriate for couples in a steady relationship to use condoms. In addition 31.1% of them believed that suggesting condom use to a regular partner means that you are cheating on them. IDU knowledge that consistent condom use reduces the risk of HIV transmission was very high (99.5%) among those who have had sex with commercial partners. 25

28 Segmentation Table (1 of 4) Determinants of those who suffered an overdose during the past 12 months Risk: Injecting drug users aged in Tashkent, Behavior: Suffered from overdose. INDICATORS Suffered from overdose in the past 12 months ORs Sig. ODed n=54 (24.5%) Did not OD n=166 (75.5 %) Behavior/use Has witnessed someone else overdose in the last 12 months 73.4% 39.4% 4.35 *** Have you ever been arrested for a drug related offense, such as using, possessing, buying or selling drugs? 63.7% 42.5% 2.46 * Injected within the last 7 days 83.2% 65.0% 2.61 * Increased consumption of drugs in the last 6 months 48.5% 33.0% 2.10 * ABILITY Knowledge someone is suffering from an overdose it is necessary to make him/her vomit Mixing several drugs together is one cause of overdose It is OK to leave someone alone if they are suffering from an overdose Overdose can be caused by taking too pure a dose of heroin or opiates If someone is suffering from an overdose, you should put him/her in a cold bath After you have quit for a while, restarting at the same dose of heroin/opiates can increase the risk of overdose. A good method for preventing death is to inject saline into someone who is suffering from an overdose MOTIVATION Threat I am less likely than most people to get HIV/AIDS If I am meant to get HIV/AIDS, it is my destiny I am not concerned about protecting myself from HIV/AIDS Population Characteristics Gender Injecting for more than 1 year Education Employed 71% 51% * Injects daily Helped by someone else to initiate Where do you usually inject? Age (34-46 years) 21.5% 52.7% *** *=p<0.05; **=p<0.01; ***=p<0.001;. Hosmer and Lemeshow Test: Chi-square=7.656 DF=8, Sig=0.468; Omnibus Test: Chi-square=52.879, DF=6, p<0.001; Cox & Snell R²=0.214 Nagelkerke R²=0.318 Each variable is adjusted for all other variables in the model. 26

29 Segmentation Analysis Segmentation Analysis: Determinants of suffered from overdose in the past 12 months IDUs aged in Tashkent, 2006 Segmentation is the process of dividing a heterogeneous population into a homogenous audience; in other words, the population is divided into those who practice the desired behavior and those who do not, e.g., condom users and non-users. Then each group is profiled according to the barriers to behavior change that were captured in the surveys, which, in turn, can allow programmers to design and implement behavior change interventions. Has witnessed someone else overdose in the last 12 months was the most significant factor in the model to determine who suffered from overdose. Respondents who report suffering from an overdose in the past 12 months were more likely to have witnessed someone else overdose than respondents reporting not having suffered from an overdose in the past 12 months (73.4% vs. 75.5%, p<.001). In terms of odds ratios, respondents that have witnessed someone overdose are 4.3 times more likely to suffer from over dose in the past 12 months than those have not witnessed. Have you ever been arrested for a drug related offense, such as using, possessing, buying or selling drugs? was significantly associated with those who suffered from an overdose. Respondents who reported having overdosed in the past 12 months were times more likely to have ever been arrested for a drug-related offense than respondents who have not reported having overdosed (63.7% vs. 42.5%, p<.05). Respondents have been arrested for drug related offences are 2.46 more likely to suffer from overdose than those have not been arrested. Injected within the last 7 days was revealed to be a significant determinant of suffering from overdose. Respondents reporting having overdosed were more likely to have injected within the last 7 days (83.2%) compared to those who did not report having overdosed (65.7%) with p- value <0.05. In terms of odds ratios, among people who injected within the last seven days are 2.6 times more likely to suffer from overdose than who did not inject within the last seven days. Increased consumption of drugs in the last 6 months was also a significant determinant of those who had suffered from overdose. Respondents who had reported suffering 27

30 Segmentation Analysis from overdose were more likely to have reported having increased consumption of drugs in the last 6 months than those who did not report suffering from overdose (48.50% vs. 33.0%, p<.05). Respondents that increased consumption of drugs are 2.1 times more likely to suffer from overdose than those not increasing it. Amongst employed IDUs there is a significant association between those who overdosed and those who did not (71.0% vs. 51.0%, p<.05). Employed respondents are 2.59 times more likely to suffer from overdose than unemployed ones. With IDUs aged 34-46, certain significant relationships were found between IDUs who suffered from an overdose during the last 6 months and those who did not report suffering from an overdose (21.5% vs. 52%,p<0.001). 28

31 Segmentation Table (2 of 4) Determinants of Helper IDUs: IDUs who Reported Helping a Non-User Initiate Injecting Drug Use in the Past Six Months, Tashkent, 2006 Risk Group: Injecting Drug Users aged Behavior: Helped someone inject for first time in the last six months. INDICATORS helped someone inject for first time ORs Sig. Behavior/use Helped N= % Did not help N= % Helped by someone else to initiate 95.3% 83.6% * Injected self in front of non-injectors, In the last 6 months Talked to non-injectors about the benefits of injecting drugs, In the last 6 months 49.2% 29.8% * Seen someone else give his/her needles/syringes to someone else to use, In the past 6 months Injects daily OPPORTUNITY Social Norms Most of friends inject drugs Belief Using water is enough to clean needles/syringes (false) 65% 80% * Locus of Control When I am dope sick, I will do anything to get a hit, including sharing needles ABILITY Knowledge Was able to cite 3 correct HIV prevention methods Had no misconception about ways of HIV transmission Not letting someone else use my equipment (spoon, cup, cotton, rinse water) can prevent HIV infection MOTIVATION Threat I am less likely than most people to get HIV/AIDS Exposure Contact with PEER educator at least 4 times each month for the past 6 months Population Characteristics Gender Injecting for more than 1 year Education Employment Monthly income under 1,600 sum 31% 48.8% * 65% 48% * *=p<0.05; **=p<0.01; ***=p< Hosmer and Lemeshow Test: Chi-square=1.347 DF=7 Sig=0.987; Omnibus Test: Chi-square=18.420, DF=5, p<0.002; Cox & Snell R²=0.081Nagelkerke R²=0.123 Each variable is adjusted for all other variables in the model. 29

32 Segmentation Analysis Segmentation Analysis: Determinants of helped someone inject for first time, among IDUs aged in Tashkent, The logistical regression analysis revealed five significant predictors concerning who or what it was that helped someone inject for the first time. Results for each significant variable are shown in the preceding segmentation table (with significant variables marked by an asterix) divided between helped someone inject and did not help someone inject. Proportions for each significant predictor are presented and adjusted for the effects of other significant factors in the model. Unadjusted proportions are presented for items not significant at the multivariate level. Certain relationships are observed between IDUs who were helped by someone to initiate a first injection and who helped someone inject for the first time. The study shows that respondents who were helped by someone else to initiate their first injection were more likely to help another noninjector inject for the first time compared to respondents reporting not having been helped for their first injection (95.3% vs. 83.6%, p<.05).respondents are helped by someone else to initiate first injection are 3.27 times more likely to help non- injectors to inject for first time than those are not having been helped for their first injection. Talked to non-injectors about the benefits of injecting drugs in the last six months was significantly associated with the IDUs who helped someone inject for the first time compared with IDU s who did not report having helped someone inject for the first time.(42.9% vs. 29.8%, p<.05). In terms of odds ratios, IDUs that talked to non-injectors about the benefits of injecting drugs are 2.4 times more likely to help someone to inject for first time than those not talking about this subject. Belief was found to be a significant factor in the model to determine IDUs who helped someone inject. Significantly more respondents who helped someone inject the first time, agree with the statement Using water is enough to clean needles/syringes as compared with respondents who did not help someone inject the first time (0.654 for helped someone compared with who did not help someone, p<.05). Locus of control was found to be a significant factor in the model to determine respondents who helped someone inject. Significantly more IDUs who did not help someone inject for the first time agree with the statement When I am dope sick, I will do anything to get a hit, including sharing needles compared with IDUs who helped someone inject for the first time (48.8% for did not help someone inject compared with 31% for helped someone inject, p<.05). 30

33 Segmentation Analysis Exposure item Contact with a peer educator at least 4 times each month for the past 6 months had a negatively significant association between IDUs who helped someone inject for the first time compared with IDUs who did not help someone inject for the first time (48.1% did not help someone inject compared with 65.5% helped someone, p<0.05). As this is the baseline, this may mean that the peer educators (from any program) may be targeting with IDUs who are most likely to be helpers. The evaluation comparing exposure to HIV prevention programs to likelihood of helping others to inject will be possible in the endline study. 31