HIV AND STI RISK FACTORS AMONG GEORGIAN YOUTH.

Designing effective interventions for youth to address STI/HIV risk factors requires local context knowledge. This study gathers information about STI/HIV knowledge among Georgian youth, identifies STI/HIV risk behaviors and quantifies associations between socio-demographic factors and risk practices with HIV/STIs knowledge. Cross-sectional survey was conducted among 411 students using self-administered questionnaire. Bivariate analysis was conducted and prevalence ratios with 95% confidence intervals were computed. Study participants were more knowledgeable about HIV/AIDS than other STIs, though still lacked information about HIV/AIDS transmission routes. Only 10.1% had ever received HIV testing. Men were less likely to have current permanent sex partner (44.5% vs 79.2%; PR=0.2; 95% CI:0.1-0.5) and more likely to have occasional sex partner past 12 months than women (51% vs 19%; PR=4.3; 95% CI:1.8-10.2). Study describes relatively low awareness of STIs in Georgian youth and revealed possibilities to influence STI transmission through designing gender-tailored public health interventions.

GENDER RELATED BARRIERS AMONG HIV INFECTED INDIVIDUALS.

Late detection of HIV infection still remains serious problem for Georgia. During the last years prevalence and late detection of HIV infection is increasing among females and therefore, attempts to implement services adapted to female needs have significantly increased. It is essential to conduct research to create a basis for country's national response of HIV infection to become more gender sensitive. The goal of our study was to conduct survey among HIV-positive individuals to identify potential gender-based barriers and contributing factors that might influence timely diagnosis and treatment of HIV infection. Cross sectional study design was used. Target population included HIV-infected persons. Study subjects were selected by simple random sampling. Study participants were sampled from the registry of HIV infected patients. Quantitative data were collected through individual, face-to-face interviews, using specially designed questionnaire for this study. In total 182 HIV-infected individuals participated in survey, of whom 74 (40.6%) were females and 108 (59.6) were males. The level of awareness and knowledge on HIV/AIDS was similar in both male and female HIV positive individuals, although a higher proportion of men than women have heard of HIV/AIDS before their diagnosis. HIV infection is more stigmatizing for women than men. Fear of being abandoned by both community and family due to HIV/AIDS diagnosis was higher among female respondents. Higher proportion of male respondents than women reported an illness-related unemployment. Women were more likely to hide their diagnosis from other people compared to men. Higher proportion of female compared to male respondents reported notifying family members about their HIV status. Significantly higher proportion of female HIV-infected individuals have been accompanied by a family member on visit to physician due to HIV/AIDS compared to male HIV-infected respondents. A higher proportion of men than women reported an interruption/discontinuation of treatment regimen. Georgia has ensured free and unrestricted access to HIV service for all HIV infected individuals in the country. However, the stigma related to HIV still creates barriers to service utilization. Therefore, HIV national program should continue implementation of focused and concerted interventions to improve HIV awareness among gender populations.

KNOWLEDGE, ATTITUDE AND PRACTICE SURVEY AMONG GEORGIAN HEALTH CARE WORKERS TOWARDS BLOOD BORNE INFECTIONS.

The prevalence of viral hepatitis B and C in Georgia is among the highest in the region. US Centers for Disease Control and Prevention (CDC) has selected Georgia as a pilot country for hepatitis C elimination program. Since 2015, Georgia launched a multi-year program of HCV elimination, including treatment of infected individuals with Direct Acting Antivirals (DAAs) and implementation of prevention programs, including infection control in health care facilities. The objective of this study was to evaluate the attitude and knowledge of blood borne infections (HIV, HCV, HBV) among Georgian Health Care Workers (HCWs). HCWs were recruited from six participating multi-profile hospitals and dental care institutions in three large cities of Georgia (Batumi (Western Georgia), Rustavi (Eastern Georgia) and the capital city, Tbilisi). A self - administered questionnaire included sections regarding sociodemographic and professional characteristics; awareness of blood-borne infections; practice for transmission risk reduction and perceived educational interventions acceptable among HCWs. The selection of HCWs was done through simple random sampling from the list of staff as a sampling frame. HCW's survey results were compared to the one from Dental health care workers (DHCWs). The total number of surveyed individuals was 442. Among them, 246 (55.6%) were HCWs (physicians, nurses, physician assistants and residents) from different departments, including family medicine (38.6 %), surgery (21.7%), gynecology (23.4%) and intensive care (13.9%) and 196 DHCWs (44.6%). Only few respondents (15.6%) correctly identified the prevalence of HIV infection in Georgia. HCWs have better understanding about the prevalence of viral hepatitis compared to DHCWs (Prevalence of HBsAg was correctly identified by 33.2 % vs 22.3%; prevalence of HCV- by 18.9 % vs 17.3%). Knowledge regarding transmission risks of blood-borne infections (HIV, HCV, HBV) among HCWs is higher compared to DHCWS (for HIV 73% vs 45.3%, for HCV 49.2% vs 37.9% and for HBV 54.8% vs 33.7%) (p<0.005). Vast majority of DHCWs as well as HCWs believed that probability of transmission of blood-borne infections after contaminated needle stick is 50-70% (p<0.05). There was a poor knowledge on availability of post exposure prophylaxis (42.9% of HCWs compare to 36.1% DHCWs believed that HCV post-exposure prophylaxis is available) (p<0.005). The practice of using facemasks (81% vs 74.4% always use, respectively), protective clothes (96.8% vs 83.3% always use) and eyewears (46.9% vs 27.4% always use) was reported by DHCWs and HCWs. Some nosocomial risk events were reported by higher proportion of DHCWs, compared to HCWs and included accidental needle stick injuries (65.1% vs 45.5%) and blood splashes (48.3% vs 28.2%). Cuts with contaminated instruments was more common among HCWs compared to DCHWs (41.4% vs 35.1%) during medical procedures. The study suggests that level of knowledge on blood borne infections among both HCWs and DHCWs is not adequate. Data from this study can be utilized to design educational programs for Georgian HCWs/DHCWs to improve knowledge and practice about blood borne diseases.

ASSOCIATION OF QUALITY OF LIFE WITH LIVER FIBROSIS AMONG PATIENTS TREATED FOR HEPATITIS C IN GEORGIA.

A seroprevalence survey was conducted in 2015 in Georgia among adults aged ≥18 years. This survey data was used to estimate anti-HCV seroprevalence in Georgia at 7.7% and HCV RNA prevalence at 5.4%. Treatment adherence, recovery and quality of life are interrelated, however, there are limited data on the role of successful antiviral treatments in changing the quality of life (QOL) of patients in Georgia. A questionnaire assessed the QOL for patients involved in the hepatitis C elimination program. Patient responses were analyzed to estimate the magnitude of any association between quality of life with the degree of liver fibrosis and various laboratory parameters. Liver fibrosis status was measured by the FIB4 score and liver elastography. We recruited 378 eligible adult participants who were beneficiaries of the hepatitis C elimination program (HCV RNA-positive) before the start of antiviral treatment. Of the surveyed individuals, 283 (77.5%) were males; the median age was 47 years (range 20 to 83). Almost 30% of participants had advanced liver fibrosis. The following factors were associated with advanced liver fibrosis: older age (PR=7.05; 95% CI:3.93-12.65), general weakness (PR=5.88; CI:2.23-15.45) and insomnia (PR=3.5, CI:1.37-9.19). Muscle pain (PR=2.75, CI:1.91-3.96) and abdominal pain (PR=3.23, CI:2.19-4.77) were more common among participants with a high FIB4 score; these patients were also more likely to report that liver disease affects family life (PR=4.23, CI:2.94-6.09). This study suggests that advanced liver fibrosis is associated with poorer QOL, an association that has been noted by research elsewhere in Europe. Given that the Georgian experience appears to be similar to other European countries, public health interventions to improve QOL may be expedited by collaboration with regional neighbors.

KNOWLEDGE RELATED TO HIV/TB/HCV AMONG PRIMARY HEALTH CARE WORKERS AND THE INTEGRATED SCREENING IN KVEMO KARTLI REGION.

Integration of TB/HIV/HCV screening into primary health care has been implemented in Georgia since 2018. The aim of the program is to strengthen TB, HIV/HCV screening and early detection capabilities in the primary health care, as early detection and treatment are considered to be the most effective strategies to prevent these infections. The goal of the study was to evaluate and compare the baseline and follow-up knowledge about TB, HIV and HCV infectious among primary health care workers in Kvemo Kartli Region. The study instrument was a self-administered questionnaire. A total of 459 primary HCWs from Kvemo Kartli region were surveyed. The proportion of HCWs correctly knowing MDR TB definition increased from 34.6% to 82.8% and this difference was statistically significant (p<0.01). Nurses were less informed about HIV infection. Only 70.7% of them knew modes of HIV transmission, while 89.3% of physicians answered this question correctly (p<0.001). An assessment of knowledge among primary health care workers (PHC) providers is important, as they represent the first level of community contact with health care. The post-test after the training showed significant improvement in knowledge among trained HCWs. Follow-up knowledge and practice surveys are needed to understand the long-term impact of training on the rate screening referrals by PHC providers.

GENDER RELATED BARRIERS TO TUBERCULOSIS IN GEORGIA.

The morbidity and mortality burden of tuberculosis (TB) remains high in Georgia, including drug-resistant TB. A survey was conducted to identify potential gender-based barriers and contributing factors that might influence the timely diagnosis and treatment of TB among active and former TB patients. To assess TB-related stigma and discrimination, a quantitative study was conducted to identify gender-based barriers to the diagnosis and treatment of TB among current and former patients. The study subjects were selected by a simple random sampling method with a 1:1 gender ratio. Participation in the study was voluntary. Data were collected by individual, face-to-face interviews. The patients' registry of the National Center for Tuberculosis and Lung Disease was used as the sampling frame to select patients either currently on anti-tuberculous treatment as well as former TB patients, who completed or discontinued treatment. A total of 230 patients on current anti-tuberculosis treatment or former patients who have been treated for tuberculosis participated in the study. Half of the participants (115, 50%) were male. No significant gender difference was detected with respect to awareness and knowledge about tuberculosis. Stigma associated with TB was found to be higher among women than men. Compared to men, more female respondents than males reported a negative change in attitude from other people after their TB diagnosis (14.8% vs 8.7%, respectively). A higher proportion of women than men notified a family member upon deciding to visit a doctor due to TB symptoms and, similarly, more women were accompanied by a family member for the first physician visit related to tuberculosis. In Georgia, as in other countries around the world, men are more likely to be infected with TB than women. However, the stigma related to TB introduces barriers to service utilization. Barrier reduction programs should consider more comprehensive gender assessment and in-depth analysis of the epidemiological situation by economic status, living conditions, regions, employment status, and ethnicities. Effective interventions may reduce barriers and contribute to the timely diagnosis and treatment of TB.

CONFIDENCE IN THE GEORGIA NATIONAL HCV ELIMINATION PROGRAM AMONG WOMEN OF REPRODUCTIVE AGE.

Georgia is among the countries with a very high prevalence of hepatitis C virus (HCV) infection. The recent availability of highly effective, direct-acting antivirals (DAAs) capable of curing >90% of persons treated has made HCV elimination a possibility. All adult citizens infected with HCV are eligible to receive free DAAs through the Georgia National HCV Elimination Program (Program). From April 2015 to December 2018, 54,087 persons were enrolled in the Program throughout the country. However, more than 20,000 individuals are aware of their HCV antibody positive status but did not have HCV RNA testing, a necessary step to determine treatment needs. We hypothesized that a reason for hesitance to enroll in the Program may be a low level of trust of the Program. A cross-sectional study was conducted in Tbilisi, the capital of Georgia. Reproductive aged women were randomly selected from three maternity care centers during prenatal care. The self-administered questionnaire included questions on socio-demographic information, knowledge about HCV infection and trust in the Program. A total of 2185 women of reproductive age were enrolled in the study. The mean age was 28.5 (age range: 17-46) years. The majority of the study participants (76.4%) had a university degree. The vast majority of study participants (>95%) were married and 95.1% were Georgian ethnicity. Almost 90% of the participants were aware of their HCV infection status. Most women (85.3%) had heard of HCV elimination program in Georgia; 74.6% stated that they trust the Program. However, almost 10% of surveyed women stated they would refuse to get enrolled in the Program if their anti-HCV test result is positive. Trust in the Program was higher among women aged >25 years (80.7%) compared to younger women (68.4%) (p<0.0001). Level of education was also associated with trust to the program: more women with higher education level reported that they trust the Program (78.7%) compared to women with lower education level (68.5%) (p<0.0001). Trust in the Georgia National HCV Elimination Program is not sufficiently high among women of reproductive age in Georgia. Effective educational campaigns are needed to improve trust to the Program for this targeted group.

HEPATITIS B VACCINATION: KNOWLEDGE AND ATTITUDE AMONG WOMEN OF REPRODUCTIVE AGE IN GEORGIA.

Georgia is a country with high prevalence of hepatitis B. Based on a 2015 population serosurvey, the prevalence of hepatitis B surface antigen (HBsAg) is 2.9% and prevalence of anti-HBc is 25.5% in general population. Hepatitis B vaccine has been included in the national immunization schedule of Georgia only since 2002. Thus, most reproductive aged women were not vaccinated during young childhood. Cross-sectional study was conducted in the capital of Georgia, Tbilisi. Reproductive aged women were randomly selected and then recruited from three maternity care centers during prenatal care. The self-administered questionnaire included questions on socio-demographic information, hepatitis B vaccination status and awareness of HBV infection status. A total of 2185 reproductive aged women were enrolled in the study. The mean age was 28.5 (age range 17-46) years. Most (76.4%) had a bachelor and/or master's degree. 20.0% of respondents never heard about HBV. Very few (3.3%) knew they were infected with HBV. We could not determine if women were chronically infected or were exposed and developed antibodies. HBV knowledge was limited: 57.5% were not aware of available HBV treatment; 51.6% didn't know HBV infection could be prevented (35.8% named HBV vaccination, 29.3% named condom use). Only 10% of study participants reported being vaccinated for HBV. Awareness of HBV infection was higher among women over age 25 (72.1%) compared to women aged 25 years or less (27.9%) (P<0.0001). Among women who reported having an HBV infection, 40.6% did not name vaccine as a prevention method and 38.2% did not have information about availability of HBV treatment (P<0.05). Based on our study results, knowledge about HBV infection and vaccination is very low among reproductive aged women in Georgia. Women's health centers can be a good place to reach reproductive aged women for counseling on HBV infection and promote vaccination against hepatitis B.

SELF-PERCEIVED HEALTH STATUS AND ILLNESSES AMONG INTERNALLY DISPLACED PEOPLE IN GEORGIA.

Georgia had several waves of internally displaced people (IDPs) as a result of military conflicts on the territories of Abkhazia and Samachablo starting from 1990's with the latest large wave in 2008. Most of the IDPs live in compact settlements, such as old administrative buildings or specially constructed camps. In both cases, living conditions and social-economic status of IDPs are below Georgia's national average. There is extremely limited data on the health status of the IDPs in Georgia. Health Research Union (HRU) with support from ELRHA/R2HC program conducted a survey to study health service utilization and expenditures among IDPs, and measure the effect of targeted intervention versus untargeted, integrated approach to health financing. The aim of the current study was to analyze the self-reported health status among IDPs on the basis of the data collected through this survey. The survey was carried out among IDPs currently living in Georgia mainly residing in compact settlements. Sampling from the target population was performed by a multi-stage cluster sampling approach. In total 1.319 households with 4,359 household members were recruited and interviewed for the survey. Male accounted for almost 55% of all household members in the survey. Slightly less than half of respondents were married; children under the age of 15 constituted 23% of all IDPs surveyed. In total, 40% of all respondents (1729 persons) report being chronically ill and identify a wide range of conditions. Of them 532 report having 2 or more chronic diseases. About a third of occurrences (29%) of chronic diseases is attributed to cardiovascular diseases. Musculoskeletal and gastrointestinal diseases (each) constitute 13% of all occurrences of chronic diseases. During last 24 months 129 household members gave birth. The prevalence of chronic diseases among adult population increases as the age advances with the highest rate among those aged above 65 with 84% reporting having at least one chronic disease. Self-perceived overall health status was characterized as excellent, very good and good by 53%, as fair by 32% and as poor and very poor by 16% of the respondents. The conducted research was the first wide-scale study of the health status among internally displaced people in Georgia. These data may contribute to better understand the problems in this vulnerable population and evaluate impact of the implementation of the different models of the health care including targeted health insurance for IDPs.

MEASUREMENT OF PERSONAL RISK BEHAVI-OR IN OCCUPATIONAL RISK STUDIES AMONG HEALTH CARE WORKERS.

Risky behaviours, particularly illegal and heavily stigmatized behaviours, are difficult to measure through self-report in both high risk groups and the general population. Underreporting can result in substantially biased estimates of non-injection drug use (IDU) risk of hepatitis C virus (HCV) infection. We hypothesized that asking about the existence of social networks injection drug use may be a useful marker of IDU. A cross-sectional survey of physicians and nurses was conducted in seven hospitals in Georgia. Based on survey responses participants were categorized into three IDU risk groups: ever used injecting drugs (Self IDU), reported a friend, family member or colleague used injecting drugs (Associate IDU), or reported neither (No IDU). Testing on anti-HCV was done using third generation ELISA methods. Both unadjusted and adjusted prevalence ratios between IDU risk groups and HCV prevalence were estimated. Of the 1312 (82.2%) participants, 10 (0.8%), 75 (5.7%), and 1227 (93.5%) were categorized as Self IDU, Associate IDU and No IDU, respectively; with HCV prevalence of 20%, 9.3% and 4.6%, respectively (p=0.016). The association was due primarily to women's reports. Those who reported some IDU risk were more likely to report other personal risk behaviors (e.g., multiple sex partners) and occupational risk behaviors (e.g., frequent exposure to blood and body fluids). This study represents a start of measurement development by assessing the potential usefulness of a marker to measure of IDU. Improved measurement of stigmatized behaviors is needed for confounding adjustment to improve estimates of occupational risks of blood-borne infections.

GENOTYPIC DISTRIBUTION OF HPV AMONG WOMEN OF REPRODUCTIVE AGE IN GEORGIA.

Of the 100 types of human papillomaviruses (HPV), approximately 35 infect the genital tract. The viruses are categorized as "high risk" and "low risk" depending on whether they are known to cause cancer or not. Cervical cancer is an important cause of cancer mortality in Georgia, and worldwide. Only limited and incomplete data are available about the epidemiology of HPV infection and related molecular and cellular changes in Georgia. Objectives of our study included the estimation of the prevalence and the distribution of HPV genotypes among women in Georgia. The study participants were women (~2000) aged 18-49 years randomly selected during a clinic appointment with a gynecologist for a regular check-up at one of the women's consultation centers (WCC) participating in the study. Venous blood (5 ml) was drawn and the prevalence of HPV evaluated by the detection of the HPV DNA. For genotyping, HPV DNA were extracted from the cervical samples, amplified first by consensus and then by primer-specific PCR, followed by a detection step on agarose gel. Of the total samples, 250 were positive for HPV DNA; these were further tested to identify the specific HPV genotype. The genotype distribution was as follows: type 6, 98 women (39.2 %); type 16, 64 (25.6%); type 18, 47 (18.8%); type 33, 23 (9.2%); type 11, 27 (10.8%); type 45, 19 (7.6%); and type 66, 9 (3.6%). In 37 women (14.8%), we found coexistence of several different HPV genotypes. The HPV genotypic profile among Georgian women is similar to data generated from studies conducted among the populations in other European countries. Presence of the subset of HPV genotypes not covered by quadrivalent anti-HPV vaccine (types 33, 45 and 66) was demonstrated among Georgian women.

KNOWLEDGE, ATTITUDE TOWARD DISEASE AND PRACTICE SURVEY ON DIABETES IN GARDABANI DISTRICT.

In 2014-2016, the Georgia Red Cross Society (GRCS) implemented a project to improve diabetes prevention, detection and care in rural Georgia, namely in the Gardabani district. The KAP survey was conducted to determine current levels of knowledge, attitudes and practices regarding diabetes among the general population in the Gardabani district. We compared current findings with baseline results from a 2014 survey to identify trends. A cross sectional study design with multi-stage random sampling was used to select participants. Data were collected at households through face-to-face individual interviews using a specially designed questionnaire. In total, 716 individuals were surveyed, the majority of whom (98.9%) were aware of diabetes. Most respondents (85.3%) believed that diabetes can be prevented and correctly identified measures of diabetes prevention. Compared to the previous survey, the level of knowledge regarding risk factors, symptoms and complication of diabetes had improved significantly. Knowledge of diabetes prevention correlated positively with individuals having a higher education level (62.6% vs. 50.8%; p=0.05), higher family income (62.2% vs. 53.5%; p=0.03) and residing in rural settlements (58.6% vs. 25%; p<0.001). Knowledge of diabetes management was significantly associated with type of residence (rural 50.3% vs. urban 28.4%; p<0.001) and family income (high family income 52.3% vs. low family income 45.5%; p=0.05). Respondents identifying GRCS as a source of information tended to have a higher awareness of diabetes prevention and management. Knowledge of diabetes has significantly improved among the general population of the Garabani district from 2014 to 2016. The development and implementation of similar public health programs to increase the level of awareness and knowledge about diabetes is required in other parts of Georgia to improve control and management of the disease throughout the country.

Occupational exposure to body fluids among health care workers in Georgia.

BACKGROUND: Health care workers (HCWs) are at increased risk of being infected with blood-borne pathogens. AIMS: To evaluate risk of occupational exposure to blood-borne viruses and determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among HCWs in Georgia. METHODS: The sample included HCWs from seven medical institutions in five cities in Georgia. A self-administered questionnaire was used to collect information on demographic, occupational and personal risk factors for blood-borne viruses. After obtaining informed consent, blood was drawn from the study participants for a seroprevalence study of HBV, HCV and HIV infections. RESULTS: There were 1386 participating HCWs from a number of departments, including surgery (29%), internal medicine (19%) and intensive care (19%). Nosocomial risk events were reported by the majority of HCWs, including accidental needlestick injury (45%), cuts with contaminated instruments (38%) and blood splashes (46%). The most frequent risk for receiving a cut was related to a false move during a procedure, reassembling devices and handing devices to a colleague. The highest proportion of needlestick injuries among physicians (22%) and nurses (39%) was related to recapping of used needles. No HIV-infected HCW was identified. Prevalence of HCV infection was 5%, anti-HBc was present among 29% with 2% being HBsAg carriers. CONCLUSIONS: Data from this study can be utilized in educational programs and implementation of universal safety precautions for HCWs in Georgia to help achieve similar reductions in blood-borne infection transmission to those achieved in developed countries.

Barriers to hepatitis B vaccine coverage among healthcare workers in the Republic of Georgia: An international perspective.

BACKGROUND: While the Republic of Georgia has a high prevalence of hepatitis B virus (HBV) infection (3.4% of blood donors tested positive for HBV surface antigen [HBsAg]), relatively few healthcare workers (HCWs) are thought to be immunized. OBJECTIVE: To measure rates of HBV vaccination coverage and identify predictors of vaccine acceptance among HCWs. DESIGN: Cross-sectional survey. METHODS: A study was conducted among full-time physicians and nurses at 2 large hospitals. Self-administered questionnaires included questions about demographic characteristics, HBV vaccine status, willingness to recommend vaccination to other HCWs, and barriers to vaccination. Laboratory tests were conducted for identification of HBsAg and antibody to hepatitis B core antigen. RESULTS: A total of 297 (91%) of 325 randomly selected HCWs provided information for the study (124 physicians and 173 nurses). The rate of HBV vaccination coverage was 12%, and 54% of respondents indicated that they would recommend vaccination to other HCWs. Perception of vaccine safety was identified as the most important predictor for acceptance (prevalence ratio [PR], 3.3 [95% confidence ratio {CI}, 1.2-8.9]) and for willingness to recommend HBV vaccination to other HCWs (PR, 5.5 [95% CI, 3.1-9.4]). Vaccinated HCWs were more likely to recommend vaccination to other healthcare personnel (PR, 1.7 [95% CI, 1.5-2.1]), as were those younger than 40 years of age (PR, 6.0 [95% CI, 2.8-12.6]). Multivariate analyses identified 2 additional factors associated with vaccine acceptance and willingness to recommend vaccination: the hospital at which the HCW was employed and the perception of risk of infection for HCWs. CONCLUSION: Georgia plans a major HBV vaccination campaign for HCWs in 2009. The campaign's success will depend on addressing vaccine safety concerns identified in this study and educating HCWs about risk factors for infection and benefits of immunization.