Are cannabis use problems comparable across individuals using for recreational and medical purposes? An international cross-sectional study of individuals who use self-grown cannabis.

BACKGROUND: Little is known about cannabis use problems among individuals who use cannabis for medical purposes and whether rates and determinants of cannabis use problems in medical users differ to those observed among individuals using for recreational reasons. This study examines whether Severity of Dependence Scale (SDS) scores differ across individuals who use self-grown cannabis for the following reasons: "recreational only", "medical and recreational" and "medical only". Furthermore, the study tests whether cannabis use frequency, cannabis strain, and type of cannabis influences the strength of the association between purpose of use and cannabis use problems. METHODS: Data (n = 5,347) were collected from a subsample of the Global Cannabis Cultivation Research Consortium project, focusing on small-scale cannabis growers in 18 countries. Robust regressions analyzed differences in SDS scores across the three use motivation groups. RESULTS: Compared with respondents reporting only recreational motivations of cannabis use, those with medical (with and without recreational) motivations were associated with lower SDS scores (B: -0.190 and B: -0.459, p < 0.001 respectively). Daily use was associated with significantly higher SDS scores across all cannabis motivation groups, albeit the magnitude of the association was significantly smaller among individuals with medical motivations of use. CONCLUSION: The extent to which people experience cannabis use problems, and the determinants of these problems may differ depending on whether cannabis use is motivated by recreational or medical purposes. As such, the findings of the current study suggest that public education efforts, harm reduction approaches and policy responses should be tailored depending on whether cannabis is used for recreational or medical purposes.

Costs of syringe vending machines in Tbilisi, Georgia.

BACKGROUND: Syringe vending machines (SVM) can improve access to sterile injecting equipment, but they have not been widely implemented or evaluated. We evaluate the cost of SVM installed between July 2019-December 2020 in Tbilisi, Georgia. METHODS: The SVM were stocked with several kit types, including injecting equipment for opioid or stimulant users, naloxone, male and female condoms, and pregnancy tests. We gathered financial data from the project to estimate fixed (staff time, start-up costs, equipment, running costs, and consumables) and variable (harm reduction kits) costs. We calculated the full cost of the SVM intervention, cost per user, cost per additional syringe accessed by SVM users, and cost per kit distributed (2020 Euros). RESULTS: SVM access cards were issued to 1132 users, and 29,238 kits were distributed through SVM, total cost €204,358. Staff costs were 51% of total, consumable costs 28%, equipment 10%, and start up, recurrent costs, and overheads 5% or less each. Opioid and stimulant kits were most accessed (35% and 32% of total). Cost per user was €66/year, and cost per transaction €7, of which €5 fixed costs and €2 variable. If monthly transactions increased from the average of 1622/month to highest monthly usage (4714), fixed costs per transaction would decrease to < €1. It cost €0.55 per additional syringe accessed/user/month. CONCLUSIONS: This study provides evidence for governments about the cost of SVM, a novel harm reduction intervention. This is particularly relevant where Global Fund is withdrawing and harm reduction services need to be incorporated into national budgets.

The impact of the COVID-19 pandemic on illicit drug supply, drug-related behaviour of people who use drugs and provision of drug related services in Georgia: results of a mixed methods prospective cohort study.

BACKGROUND: This study examines the effects of COVID-19 related restrictions on the supply of illicit drugs, drug-use behaviour among people who use drugs (PWUD) regularly (at least weekly), and drug-related service provision in Tbilisi, Georgia. METHODOLOGY: In this mixed methods study, a cohort of 50 Georgian PWUD recruited through a snow-ball sampling participated in a bi-weekly online survey in April-September, 2020. They also took part in the qualitative telephone interviews at 12- and 24-week follow-up time points. In addition, four key informants (field experts) were interviewed monthly to assess their perceptions of changes in the illicit drug market and drug service delivery. RESULTS: Mean age in the sample was 36 (range 18-60); 39 (78%) were males. Perceived availability of drugs was reduced during the lockdown, and many PWUD switched to alternative substances when preferred drugs were not available. On average, participants used significantly fewer substances over the course of the study, from 3.5 substances in the preceding 14 days to 2.1 (aOR 0.92; 95% CI 0.90-0.94). Consumption of cannabis products declined significantly (aOR 0.89; 95% CI 0.84-0.95), likewise alcohol (aOR 0.94; 95% CI 0.88-1.0), diverted medicinal methadone (aOR 0.85; 95% CI 0.8-0.9) and diverted medicinal buprenorphine (aOR 0.91; 95% CI 0.84-0.99). PWUD cited fewer contacts with drug dealers, the lack of transportation, and the lack of conventional recreational environment as the main reasons for these changes. When access to sterile injection equipment was limited, PWUD exercised risk-containing injection behaviours, such as buying drugs in pre-filled syringes (aOR 0.88; 95% CI 0.80-0.96). Harm reduction and treatment programs managed to adopt flexible strategies to recover services that were affected during the initial stage of the pandemic. CONCLUSIONS: COVID-19-related restrictive measures mediated specific changes in supply models and drug-use behaviours. While adjusting to the new environment, many PWUD would engage in activities that put them under increased risk of overdose and blood-borne infections. Harm reduction and treatment services need to develop and implement protocols for ensuring uninterrupted service delivery during lockdowns, in anticipation of the similar epidemics or other emergency situations.

Implementation and evaluation of a syringe vending machine trial in Tbilisi, Georgia.

BACKGROUND: Syringe vending machines (SVM) have proven to be an effective vehicle for providing an uninterrupted supply of sterile equipment to PWID, but they have not been implemented or disseminated broadly. The aim of this study was to implement and evaluate outcomes of introducing SVM in Tbilisi, Georgia. METHODS: We installed SVM at five HIV prevention sites in 10 locations in Tbilisi, Georgia and studied implementation over 20 months. We used the RE-AIM framework to assess outcomes across four RE-AIM domains: reach, effectiveness at providing syringe access, adoption and implementation. RESULTS: Reach. SVM reached 8% of the target population. Effectiveness at Providing Syringe Access. SVM dispensed 14% of all syringes distributed by HIV prevention services. Using SVM was associated with PWID receiving more sterile syringes from HIV prevention outlets. Adoption. All HIV prevention sites (N=5) invited to implement SVM agreed to participate. Sixty one percent of PWID who received SVM access cards used SVM at least once. Women and young PWID were more likely to use SVM compared to other PWID. IMPLEMENTATION: At some sites adherence of the outreach staff to the operational protocol was suboptimal. CONCLUSIONS: SVM are an acceptable, feasible and effective intervention for improving access to sterile injection equipment for PWID. Future research will need to elaborate approaches to build the sense of ownership and improve motivation of the field staff to engage with the new intervention, and to examine strategies for attracting groups of PWID who are not in contact with prevention and treatment services.

Smart Syringe Vending Machines: Research Capabilities and Implications for Research Data Collection.

OBJECTIVE: Syringe vending machines (SVMs) are intended to supplement the standard syringe exchange programs to access hard-to-reach groups and to cover unserved geographical areas. This report describes how we adapted SVMs to deliver interventions and collect research data as part of a study of smart SVMs (SSVMs) in Tbilisi, Georgia. METHOD: To create SSVMs, we upgraded commercial vending machines and developed a computer program to track and record interactions and to display messages related to study procedures. Preferred locations for SSVMs, product specifications, and the mode of operation were determined through formative input from people who inject drugs (PWID). SSVMs were installed near pharmacies and serve both the general population and PWID. The "hidden" interactive menu for the PWID prevention kits was displayed on the screen only when a special plastic card was used. The plastic cards were distributed to the clients of fixed syringe exchange programs and to their peers who were not in contact with harm-reduction services. RESULTS: Ten SSVMs were operational in Tbilisi as of March 2021, with more than 800 PWID using them on a regular basis. More than half of sterile equipment kits were distributed during weekends and night hours. CONCLUSIONS: Our innovative SSVM integrates features for intervention delivery and research data collection. It can be used for testing a variety of interventions beyond syringes (e.g., distribution of HIV/hepatitis C virus self-tests) and provides opportunities for serving various at-risk groups that might not otherwise access these products and services (e.g., men who have sex with men, commercial sex workers).

Hidden populations: risk behaviours in drug-using populations in the Republic of Georgia through subsequent peer-driven interventions.

BACKGROUND: Georgia has a significant risk of ongoing HIV and HCV outbreak. Within this context, harm reduction aims to reduce risk associated with drug use through community activities, such as peer recruitment and involvement. The aim of this study was to identify significant differences between known and hidden populations, and attest to the ongoing utility of peer-driven intervention across multiple years in recruiting high-risk, vulnerable populations through peer networks. It was hypothesised that significant differences would remain between known, and previously unknown, members of the drug-using community, and that peer-driven intervention would recruit individuals with high-risk, vulnerable individuals with significant differences to the known population. METHODS: Sampling occurred across 9 months in 11 cities in Georgia, recruiting a total of 2807 drug-using individuals. Standardised questionnaires were completed for all consenting and eligible participants, noting degree of involvement in harm reduction activities. These data underwent analysis to identify statistically significant different between those known and unknown to harm reduction activities, including in demographics, knowledge and risk behaviours. RESULTS: Peer recruitment was able to attract a significantly different cohort compared to those already known to harm reduction services. Peer-driven intervention was able to recruit a younger population by design, with 25.1% of PDI participants being under 25, compared to 3.2% of NSP participants. PDI successfully recruited women by design, with 6.9% of PDI participants being women compared to 2.0% in the NSP sample. Important differences in drug use, behaviour and risk were seen between the two groups, with the peer-recruited cohort undertaking higher-risk injecting behaviours. A mixture of risk differences was seen across different subgroups and between the known and unknown population. Overall risk, driven by sex risk, was consistently higher in younger people (0.59 vs 0.57, p = 0.00). Recent overdose was associated with higher risk in all risk categories. Regression showed age and location as important variables in overall risk. Peer-recruited individuals reported much lower rates of previous HIV testing (34.2% vs 99.5%, p = 0.00). HIV knowledge and status were not significantly different. CONCLUSIONS: Significant differences were seen between the known and unknown drug-using populations, and between previous and current research, speaking to the dynamic change of the drug-using culture. The recruitment strategy was successful in recruiting females and younger people. This is especially important, given that this sampling followed subsequent rounds of peer-driven intervention, implying the ability of peer-assisted recruitment to consistently reach hidden, unknown populations of the drug-using community, who have different risks and behaviours. Risk differences were seen compared to previous samples, lending strength to the peer-recruitment model, but also informing how harm reduction programmes should cater services, such as education, to different cohorts.

Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study.

BACKGROUND: Georgia has a high prevalence of hepatitis C, with 5·4% of adults chronically infected. On April 28, 2015, Georgia launched a national programme to eliminate hepatitis C by 2020 (90% reduction in prevalence) through scaled-up treatment and prevention interventions. We evaluated the interim effect of the programme and feasibility of achieving the elimination goal. METHODS: We developed a transmission model to capture the hepatitis C epidemic in Georgia, calibrated to data from biobehavioural surveys of people who inject drugs (PWID; 1998-2015) and a national survey (2015). We projected the effect of the administration of direct-acting antiviral treatments until Feb 28, 2019, and the effect of continuing current treatment rates until the end of 2020. Effect was estimated in terms of the relative decrease in hepatitis C incidence, prevalence, and mortality relative to 2015 and of the deaths and infections averted compared with a counterfactual of no treatment over the study period. We also estimated treatment rates needed to reach Georgia's elimination target. FINDINGS: From May 1, 2015, to Feb 28, 2019, 54 313 patients were treated, with approximately 1000 patients treated per month since mid 2017. Compared with 2015, our model projects that these treatments have reduced the prevalence of adult chronic hepatitis C by a median 37% (95% credible interval 30-44), the incidence of chronic hepatitis C by 37% (29-44), and chronic hepatitis C mortality by 14% (3-30) and have prevented 3516 (1842-6250) new infections and averted 252 (134-389) deaths related to chronic hepatitis C. Continuing treatment of 1000 patients per month is predicted to reduce prevalence by 51% (42-61) and incidence by 51% (40-62), by the end of 2020. To reach a 90% reduction by 2020, treatment rates must increase to 4144 (2963-5322) patients initiating treatment per month. INTERPRETATION: Georgia's hepatitis C elimination programme has achieved substantial treatment scale-up, which has reduced the burden of chronic hepatitis C. However, the country is unlikely to meet its 2020 elimination target unless treatment scales up considerably. FUNDING: CDC Foundation, National Institute for Health Research, National Institutes of Health.

Perceived acceptability of and willingness to use syringe vending machines: results of a cross-sectional survey of out-of-service people who inject drugs in Tbilisi, Georgia.

BACKGROUND: The growing HIV epidemic in Eastern Europe and Central Asia has been driven by high rates of injection drug use. The Republic of Georgia has among the highest injection drug use rates globally, with a prevalence of 2.24%. The reach of evidence-based HIV prevention interventions like needle and syringe programs (NSP) among people who inject drugs (PWID) has remained below rates that could significantly impact the epidemic. Syringe vending machines (SVM) are an effective and cost-effective supplement to standard NSP; if acceptable to PWID, SVM could reach hard-to-reach PWID and cover geographic areas where fixed or mobile NSPs do not operate. The aim of this study was to assess the perceived acceptability of SVM among out-of-service (harm reduction or substance use treatment) PWID in Tbilisi, Georgia. METHODOLOGY: Participants were recruited using respondent-driven sampling (RDS) to participate in cross-sectional, face-to-face interviews. We conducted individual interviews using a structured questionnaire that covered participants' socio-demographics, drug use practices, and perceived acceptability of SVM. Uni-variate analyses were employed for data analysis. RESULTS: The final sample (n = 149) was almost exclusively male with a mean age of 42.2 years and mean years of injection drug use of 14.4 years. Heroin, buprenorphine, and stimulants were the main drugs injected. Eighty-five percent of the sample had never received any harm reduction services, and 30% had never been tested for HIV. Fifteen percent of the sample reported sharing injection equipment with others during last month. All but one participant agreed that PWID would benefit from SVM and 145 (97%) said they would personally use SVM. Ninety percent of those sampled stated that they would use HIV self-tests if available from vending machines. The most highly endorsed features of SVM were provision of free injection equipment, no need to deal with pharmacies, uninterrupted 24/7 access, and availability of HIV self-testing kits. DISCUSSION: Perceived acceptability of syringe vending machines was extremely high among PWID not currently receiving any harm reduction or treatment services, with strong support indicated for uninterrupted free access to sterile injection equipment, privacy, and anonymity. Introducing SVM in Georgia holds the potential to deliver significant public health benefits by attracting hard-to-reach PWID, reducing unsafe injection behavior, and contributing to HIV testing uptake and linkage to care.

Nightlife and Drug Use in Tbilisi, Georgia: Results of an Exploratory Qualitative Study.

Tbilisi is fast becoming a regional hub for electronic dance music. This study describes the use of illicit psychoactive drugs by frequent nightclub visitors in a club setting. We conducted 16 qualitative in-depth interviews with young nightclubbers with a history of drug use in Tbilisi. The majority of respondents had experience with two or more drugs consumed in a club setting, with the most prevalent substances being MDMA/ecstasy, amphetamines, and synthetic cannabinoids. Most respondents had limited information regarding the drugs they consumed. Often this information was provided by dealers or friends and was limited to the name of the drug (but not the substance) and its expected effects. Receiving often unknown substances from unknown people was prevalent. The majority of respondents reported combining psychoactive substances with alcohol, or mixing the use of other substances. Participants by their own account indicated a lack of knowledge about the adverse effects of drugs, as well as an ignorance of overdose signs and response strategies. Study findings may guide future efforts to investigate the prevalence and context of club drug use in the country, to assess health risks associated with it, and to propose strategies to mitigate those risks.

Republic of Georgia estimates for prevalence of drug use: Randomized response techniques suggest under-estimation.

BACKGROUND: Validity of responses in surveys is an important research concern, especially in emerging market economies where surveys in the general population are a novelty, and the level of social control is traditionally higher. The Randomized Response Technique (RRT) can be used as a check on response validity when the study aim is to estimate population prevalence of drug experiences and other socially sensitive and/or illegal behaviors. AIM: To apply RRT and to study potential under-reporting of drug use in a nation-scale, population-based general population survey of alcohol and other drug use. METHODS: For this first-ever household survey on addictive substances for the Country of Georgia, we used the multi-stage probability sampling of 18-to-64-year-old household residents of 111 urban and 49 rural areas. During the interviewer-administered assessments, RRT involved pairing of sensitive and non-sensitive questions about drug experiences. RESULTS: Based upon the standard household self-report survey estimate, an estimated 17.3% [95% confidence interval, CI: 15.5%, 19.1%] of Georgian household residents have tried cannabis. The corresponding RRT estimate was 29.9% [95% CI: 24.9%, 34.9%]. The RRT estimates for other drugs such as heroin also were larger than the standard self-report estimates. DISCUSSION AND CONCLUSIONS: We remain unsure about what is the "true" value for prevalence of using illegal psychotropic drugs in the Republic of Georgia study population. Our RRT results suggest that standard non-RRT approaches might produce 'under-estimates' or at best, highly conservative, lower-end estimates.

Comprehensive Women-Centered Treatment for Psychoactive Substance Use in the Republic of Georgia: Outcomes of a Randomized Clinical Trial.

This study aimed to assess the impact of a culturally sensitive, comprehensive women-centered intervention on psychoactive substance use among women in the Republic of Georgia. Study participants included 128 women who had injected psychoactive substance(s) in the past 30 days and had enrolled in a randomized controlled trial that compared Reinforcement Based Treatment and the Women's CoOp (RBT+WC) to usual care (UC). RBT+WC provided a structured 12-session intervention designed to reduce HIV/HCV risk and psychoactive substance and alcohol use, and to improve mental and physical health; whereas UC provided information booklets on the same topics and case management for 12 sessions. Urine drug screening was conducted at baseline, treatment completion, and 3-month follow-up. The findings showed that RBT+WC was not more effective than UC, although both treatments positively impacted opioid, benzodiazepine, and amphetamine/methamphetamine use. The findings suggest that RBT+WC represents a promising comprehensive women-centered intervention for reducing substance use and HIV risks for Georgian women who use substances.

Exploring the New Phenomena of Home-Made Extraction and Injection of Ephedra Plant Product in Georgia.

BACKGROUND: Since the end of 2015, reports by service providers have indicated a new trend in kitchen (homemade) production of an injection drug prepared from an ephedrine-containing conifer bush that is indigenous to the region. OBJECTIVE: The aim of this report is to describe an emerging new homemade psychoactive drug synthesized from the ephedra plant, and the drug consumption methods associated with its' use in the Eurasia. METHODS: Focus groups conducted with 16 people, self-identified as injection drug users (IDU's) who reported at least one incidence of ephedra preparation injection during the previous 30-days. RESULTS: Participants were male, mean age of 43 and mean length of drug use of 22.2 years. Participants identified "conifer vint" as the most frequently injected drug during the 30-day period preceding the focus group. The source plant of the drug identified, as "conifer vint" is plant-based ephedra extracted from a common conifer bush that grows wild and is pervasive in the region. The process of synthesis resembles the production of "vint" (conversion of ephedrine to methamphetamine by reduction) and involves several legal and widely available chemical precursors. The final product of the synthesis is a strong injectable CNS stimulant solution. Conclusions/Importance: The production and use of raw ephedra from a pervasive indigenous plant reflect a new trend in psychoactive drug preparation and use that warrants international attention and has global implications for emerging trends in drug use.

Drug preparation, injection, and sharing practices in Tajikistan: a qualitative study in Kulob and Khorog.

BACKGROUND: Sharing injection equipment remains an important rout of transmission of HIV and HCV infections in the region of Eastern Europe and Central Asia. Tajikistan is one of the most affected countries with high rates of injection drug use and related epidemics.The aim of this qualitative study was to describe drug use practices and related behaviors in two Tajik cities - Kulob and Khorog. METHODS: Twelve focus group discussions (6 per city) with 100 people who inject drugs recruited through needle and syringe program (NSP) outreach in May 2014. Topics covered included specific drugs injected, drug prices and purity, access to sterile equipment, safe injection practices and types of syringes and needles used. Qualitative thematic analysis was performed using NVivo 10 software. RESULTS: All participants were male and ranged in age from 20 to 78 years. Thematic analysis showed that cheap Afghan heroin, often adulterated by dealers with other admixtures, was the only drug injected. Drug injectors often added Dimedrol (Diphenhydramine) to increase the potency of "low quality" heroin. NSPs were a major source of sterile equipment. Very few participants report direct sharing of needles and syringes. Conversely, many participants reported preparing drugs jointly and sharing injection paraphernalia. Using drugs in an outdoor setting and experiencing withdrawal were major contributors to sharing equipment, using non-sterile water, not boiling and not filtering the drug solution. CONCLUSION: Qualitative research can provide insights into risk behaviors that may be missed in quantitative studies. These finding have important implications for planning risk reduction interventions in Tajikistan. Prevention should specifically focus on indirect sharing practices.

Policing, massive street drug testing and poly-substance use chaos in Georgia - a policy case study.

BACKGROUND: Since early 2000, intensive policing, wide scale street drug testing, and actions aimed at limiting the availability of specific drugs have been implemented in Georgia. Supporters of this approach argue that fear of drug testing and resulting punishment compels drug users to stop using and prevents youth from initiating drug use. It has been also stated that reduction in the availability of specific drugs should be seen as an indication of the overall success of counter-drug efforts. The aim of the current review is to describe the drug-related law enforcement response in Georgia and its impact on illicit drug consumption and drug-related harm. METHOD: We reviewed relevant literature that included peer-reviewed scientific articles, stand-alone research reports, annual drug situation reports, technical reports and program data. This was also supplemented by the review of relevant legislation and judicial practices for the twelve year period between 2002 and 2014. RESULTS: Every episode of reduced availability of any "traditional" injection drug was followed by the discovery/introduction of a new injection preparation. The pattern of drug consumption was normally driven by users' attempts to substitute their drug of choice through mixing together available alternative substances. Chaotic poly-substance use and extensive utilization of home-made injection drugs, prepared from toxic precursors, became common. Massive random street drug testing had little or no effect on the prevalence of problem drug use. CONCLUSIONS: Intensive harassment of drug users and exclusive focus on reducing the availability of specific drugs did not result in reduction of the prevalence of injecting drug use. Repressive response of Georgian anti-drug authorities relied heavily on consumer sanctions, which led to shifts in drug users' behavior. In most cases, these shifts were associated with the introduction and use of new toxic preparations and subsequent harm to the physical and mental health of drug consumers.

Feasibility and initial efficacy of a culturally sensitive women-centered substance use intervention in Georgia: Sex risk outcomes.

BACKGROUND: This paper reports on the feasibility and initial efficacy of a culturally sensitive, comprehensive women-centered substance use intervention for women who inject drugs in Georgia in terms of the primary and secondary sex risk outcomes. The hypothesis under examination was that, relative to case management participants, participants in a culturally sensitive, comprehensive women-specific and -centered intervention would, on average, show significant decreases in past-30-day frequency of unprotected sex, unprotected sex at the last sexual encounter, and increases in condom use and safer sex actions. METHODS: The study was a two-arm randomized trial, in which 173 potentially eligible women were screened, and those 128 women determined to be eligible were assigned at random to either Reinforcement-based Treatment plus Women's Co-Op (RBT + WC) or case management (CM). RBT + WC participants received 12 sessions of a structured intervention with the goal of reducing risky sex and substance use and improving physical and mental health. CM participants received 12 sessions of case management and informational brochures that focused on the same issues on which RBT + WC focused. Participants were assessed at baseline, post-treatment, and 3 months following treatment enrollment. RESULTS: Analyses revealed case management having significantly overall higher Safer Sex action scores than RBT + WC, and a significant decrease over time for past 30-day number of unprotected sex acts. Unprotected sex at the last encounter and Condom Use action scores were nonsignificant. CONCLUSIONS: Women who inject drugs in Georgia are engaging in risky sexual practices, and are in need of an intervention that addresses these risky behaviors. Reasons for the failure to find differences between a culturally sensitive, comprehensive women-centered intervention and case management tailored to the needs of women who inject drugs in Georgia may have been the result of inadequate power to detect an effect in a sample whose drug use was not as serious as warranted by the intervention. (ClinicalTrials.gov Identifier: NCT01331460 ).

Factors that influence the characteristics of needles and syringes used by people who inject drugs in Tajikistan.

BACKGROUND: "Low dead space" syringes with permanently attached needles retain less fluid, blood, and HIV after use than standard "high dead space" syringes. This reduces the probability of HIV transmission if they are shared by people who inject drugs (PWID). The World Health Organization recently recommended that needle and syringe programs (NSP) offer clients low dead space syringes. The success of this recommendation will depend on PWID switching to low dead space needles and syringes. This paper examines the needles and syringes that PWID in Tajikistan use and factors that influence their choices. METHODS: In May 2014, we conducted six focus groups in Kulob and six in Khorog, Tajikistan, with a total of 100 participants. NSP staff members recruited participants. Focus group topics included the needles and syringes used and factors that influence choice of needles and syringes. Focus groups were conducted in Russian and Tajik, audio recorded, transcribed, and translated into English. The translated files were imported into NVivo 10 for coding and analysis. RESULTS: All participants in both cities were male and reported injecting heroin. Everyone also reported using syringes with detachable needles almost exclusively. The most popular syringe sizes were 2 and 5 ml. Needles ranged in gauge from 25 to 21 g. Needle gauge was influenced by the size of the vein, the viscosity of drug solution to be injected, and problems with blood clotting. Needles ranged in length from 12 to 38 mm, with 25 and 32 mm being the most popular. Needle length was influenced by the depth of the vein being used. Many PWID inject volumes of fluid greater than 1 ml into deep veins that require needles at least 25 mm long and 25 g in diameter. CONCLUSION: Most low dead space syringes are 1-ml insulin syringes with 12 mm 28 g permanently attached needles. Findings from this project suggest that these will not be acceptable to PWID who need larger syringes and longer and thicker needles that are detachable. Low dead space detachable needles appear to be an acceptable option that could overcome barriers to the widespread use of low dead space equipment for reducing HIV and HCV transmission.

Gender-Specific HIV Prevention Interventions for Women Who Use Alcohol and Other Drugs: The Evolution of the Science and Future Directions.

The use of alcohol and other drugs (AODs) is an important driver of gender disparities in HIV prevalence. Consequently, there is a need for women-specific HIV interventions that are conceptualized to address (1) women's risk behavior, their roles in sexual relationships, and gender power dynamics and (2) other issues commonly faced by women who use AODs, such as gender-based violence and victimization. This article presents the evolution of HIV prevention intervention research with women who use AODs. It looks at 3 generations of women-focused HIV research interventions, including first-generation projects that started in the 1990s, second-generation efforts where projects expanded in scope and included adaptions of evidence-based interventions for global relevance, and finally third-generation projects currently underway that combine biobehavioral methods and are being implemented in real-world settings. Because women who use AODs continue to report risk behaviors related to HIV, emphasis should be placed on training scientists to conduct gender-specific studies, increasing funding for new studies, and advocating to ensure that stigma-free services are available for these at-risk women.

Women who inject drugs in the republic of georgia: in their own words.

This study describes the initiation and maintenance of illicit drug use, risky behaviors, and the substance use treatment experiences of women in Georgia. Qualitative interviews with 55 drug-using women (mean age 36 years; SD = 9.52), were conducted during April-September 2011. Participants presented diverse histories of drug use initiation and substance use, risky behaviors, and drug treatment participation. All participants reported concurrent use of different substances, including home-produced injection preparations. Women described their experiences of both the positive and negative effects (physical and psychological) that they attributed to their use of drugs. Findings enrich our understanding of the environment in which substance use is initiated and maintained in a female population in Georgia, and illustrate the importance of culture and the role of social factors in the development of injection drug use. Results can provide direction for tailoring the development of interventions for substance use disorders, public policy discussions regarding the treatment of women who use drugs, and future research on substance use among women in Georgia and other post-Soviet nations.

Comprehensive Women-centered Treatment for Substance Use Disorders in Georgia: Current Status and Future Directions.

The present paper examines the current status of women-centered substance use disorder treatment in Georgia. Four major issues are identified that adversely impact the delivery of effective services for women with substance use disorders: Policy Issues; Sociocultural Issues; Programmatic/Structural Issues; and Personal/Interpersonal Issues. These four issues are seen to form a complex, dynamic system that serves to maintain the current ineffective service delivery system and suppresses movement toward an effective service delivery for this highly marginalized and at-risk population. How these issues, and their interplay, present continuing barriers to the development and implementation of effective treatment for this population are outlined and discussed. In order to overcome these barriers, solutions must be sought in four areas: Policy reform; Public health campaigns; Development and implementation of comprehensive women-specific confidential treatment models; and Empowering women. Specific goals in each of these areas that would achieve a positive impact on various aspects of the functioning of the current service delivery system for women with substance use disorders are suggested. Simultaneously seeking solutions in all four of these areas would improve the service delivery system and benefits women with substance use disorders.

Process and product in cross-cultural treatment research: development of a culturally sensitive women-centered substance use intervention in georgia.

Women who inject drugs (WID) are highly marginalized and stigmatized and experience ongoing discrimination in Georgia. Few opportunities exist for WID to receive publicly funded treatment for substance use disorders. The IMEDI (Investigating Methods for Enhancing Development in Individuals) project was developed in response to the need for women-specific and women-centered treatment services. This paper described our approach to understanding the Georgian culture-and WID within that culture-so that we could integrate two interventions for substance use found effective in other Western and non-Western cultures and to outline how we refined and adapted our integrated intervention to yield a comprehensive women-centered intervention for substance use. Reinforcement Based Treatment (RBT) and the Women's CoOp (WC) were adapted and refined based on in-depth interviews with WID (N = 55) and providers of health services (N = 34) to such women and focus groups [2 with WID (N = 15) and 2 with health service providers (N = 12)]. The resulting comprehensive women-centered intervention, RBT+WC, was then pretested and further refined in a sample of 20 WID. Results indicated positive pre-post changes in urine screening results and perceived needs for both RBT+WC and a case management control condition. The approach to treatment adaptation and the revised elements of RBT+WC are presented and discussed.