People who inject drugs:methods

Goal

The study goal was to gather strategic information regarding the risk factors contributing to transmission of HIV, virus of Hepatitis B and C, and Sexually Transmitted Diseases in people who inject drugs and their steady sexual partners for a better advocacy, planning, and design of the future prevention programs.

Objectives:

  1. To collect data for non-routine HIV surveillance purposes onpeople who inject drugs and their steady sexual partners
  2. To measure knowledge,attitudes and risk practices related to HIV and AIDS, Viral Hepatitis B (HVB) and C (HVC), and Sexually Transmitted Diseases (STDs) among people who inject drugs and their steady sexual partners in three main cities (municipality of Chisinau, municipality of Balti and Tiraspol town).
  3. To measure the seroprevalence of HIV, HCV, HBV and Syphilis in the people who inject drugs and their steady sexual partners in three main cities (municipality of Chisinau, municipality of Balti and Tiraspol town)
  4. To contribute to the estimation of the size of the population of people who inject drugs in the three main cities of the Republic of Moldova (municipality of Chisinau, municipality of Balti and Tiraspol town).

Target groups

  1. Person who injects drugsis a person of both sexes aged 18 and older who injected any type of drugs at least once during the last 12 months.
  2. Sexual partner of the person who inject drugs, participating in the study and identifiedby the respondent as steady sexual partner according to the definition .

Inclusion/Exclusion Criteriafor people who inject drugs

Inclusion criteria:

  1. Self reported drug injection at least once in the last 12 months before the interview,
  2. Physical and mental ability to understand the questionnaire, testing, and other instructions in the study,
  3. Provide informed consent at least for the questionnaire,
  4. Aged 18 years and older,
  5. Oral statement of living in geographical limits for each implementation location (municipality of Chisinau, Balti and Bender and Tiraspol and surrounding localities)in the past 12 months,
  6. Valid recruitment coupon for main sample.

Exclusion criteria:

  1. Participation in the current study in another data collection site (locality)
  2. Valid recruitment coupon for another data collection site[1]
  3. Valid recruitment coupon for sexual partner
  4. Enrolment in methadone substitution treatment

Inclusion/Exclusion Criteria for steady sexual partners of the people who inject drugs recruited within the study

Inclusion criteria:

  1. Physical and mental ability to understand the questionnaire, testing, and other instructions in the study,
  2. Provide informed consent at least for the questionnaire,
  3. Aged 18 years and older,
  4. Oral statement of living in geographical limits for each implementation location (municipality of Chisinau, municipality of Balti and Bender and Tiraspol towns and surrounding localities)in the past 12 months,
  5. Valid recruitment coupon for sexual partners’ sample.

Exclusion criteria:

  1. Participation in the current study in another data collection site (locality)
  2. Valid recruitment coupon for another data collection site
  3. Valid recruitment coupon for main sample

Study Type

The study is:

  • Multi-centric (3 implementation sites – municipality of Chisinau, municipality of Balti and Tiraspol town)[2]
  • Population-based
  • Cross sectional
  • Questionnaire-based,
  • Linked with the qualitative testing for antibodies to HIV, HCV. HBV and Treponema Pallidum.

Sampling and Recruitment

Respondent Driven Sampling was applied. The recruitment was conducted independently in three established study areas (municipality of Chisinau, municipality of Balti, and Tiraspol city). In each location 6-10 persons - „seeds” were selected to represent different strata of people who inject drugs (age group, opiate/ephedrine users, males/females, beneficiaries/non beneficiaries of harm reduction services). Each respondent for participation received the primary incentive of 40-80 MDL (equivalent to US $3.3-6.7[3]). There were issued a maximum number of three coupons. The respondents received secondary incentive of 25-50 MDL (equivalent to US $2 – 4.2).

An additional coupon[4] was given to the respondents who reported having a steady sexual partner to recruit him/her as well. For recruitment of sexual partner, the respondent received the secondary incentive as well. The recruited sexual partner received incentives for participation and was not given coupons for recruitment of other respondents. Maximum one coupon per respondent for sexual partner was given and only one sexual partner per coupon was accepted in the study.

If the respondent refused blood taking, s/he received primary incentives of lower value (25 - 60 MDL or equivalent to US $2 - 5).

The recruited samples by data collection locations are presented in the Table 1.

Table 1The recruited samples by implementation locations of the Integrated Bio-Behavioral Survey in people who inject drugs and their steady sexual partners, Republic of Moldova, 2009

No / Name of implementing organization / Location / Sample size of people who inject drugs / Sample size of steady sexual partners
1. / Youth friendly center “ATIS” / Balti / 369 / 49
2. / “Medical Reforms” NGO / Chisinau / 328 / 48
3. / “Healthy Generation” NGO / Tiraspol / 281 / 19

Data Collection

Data collection was carried out during the period of June 12-October 15, 2009.

The questionnaire was available in Romanian and Russian. The questionnaire was developed on the basis of the recommendations developed by Family Health International for the Behaviour Surveillance Survey among IDUs[5] and the questionnaire applied in 2007 within the integrated bio-behavioral study[6]. The chapter on drug use initiation and overdoses was developed by UNICEF consultants and LSHTM.

According to the method, after the questionnaire was administrated, 5-ml blood samples were collected. The unique identifiers of the questionnaire and of the blood sample were identical, which allowed the analysis of the results of the behavioral and biological components to be linked. In few cases blood sample collection was refused or was impossible because of inaccessible veins (Table 16). According to the method, the blood testing was linked and the respondents were notified about the results, and pre- and post-test counseling was carried out. The testing was carried out in the national reference laboratories in the Chisinau municipality and this fact increased the time of results delivery up to 2-3 weeks.The laboratory methods applied for the testing for HIV, HCV, HBV, and Treponema Pallidum antibodies are shown in Error! Reference source not found..

Each respondent received a set of informational materials on HIV prevention and the list of service providers within the limits of the data collection locality and at national level.

Confidentiality/Anonymity

The survey was carried out under confidentiality/anonymity conditions. These conditions were assured as follows:

  1. Respondent’s name and surname were not used throughout the entire participation in the survey. No records with the respondent’s name and surname were used,
  2. Respondent’s name and surname did not serve as basis for the formula generating questionnaire unique code, thus it is not possible to identify the respondent directly or indirectly,
  3. Every person involved in survey implementation signed an agreement, committing himself/herself to respect the survey frame of confidentiality/anonymity.

Data Quality Assurance

Several procedures were used within the study to assure data quality:

  1. Staff training,
  2. Progress reports on study implementation,
  3. Field visits
  4. Different colors coupons for each of target groups and for each of data collection locations
  5. Regular verifications of the coupon management data base,
  6. Questionnaire verification,
  7. Double data entry,
  8. Statistical data comparison.

Data analysis

The data collected in people who inject drugs were analyzed using the RDSAT software version 5.6.0. For generation of numeric averages the weighted data were exported into SPSS software version 13.0.

The data collected among steady sexual partners of people who inject drugs were analyzed using theSPSS software version 13.0.

Study limitations

All data were collected on self reporting basis, which encompasses social desirability in answers. Recall bias might have occurred in answers of IDUs who experience less frequent actualization of events the questionnaire mentioned as occurring over the last year and last month (such as last injection, last sexual intercourse, etc.).

People who inject drugs living in Balti municipality:Results

Socio-Demographic Structure

Sex and Age

The study sample consists of 81.0% males and 19.0% females. The respondents’ ages vary between 18 and 52 years old. The majority of the study respondents belong to the group aged 25 years old and over (85.4%) The 30-34 age group has the largest share in the study sample (26.6%), both for males (26.1%) and females (30.8%).The mean ages are approximately the same for males and females. Significant difference is registered in case of median age, females being older than males (Table 2).

Table 2 Socio-Demographic Structure of the Sample, people who inject drugs living in Balti municipality, Republic of Moldova, 2009

Total / Males / Females
# / % / # / % / # / %
18 – 19 years old / 11 / 3.0 / 9 / 3.0 / 2 / 2.4
20 – 24 years old / 39 / 12.1 / 32 / 11.3 / 7 / 23.8
25 – 29 years old / 75 / 22.8 / 64 / 23.5 / 11 / 13.0
30 – 34 years old / 92 / 26.6 / 65 / 26.1 / 27 / 30.8
35 – 39 years old / 81 / 19.4 / 60 / 19.7 / 21 / 18.8
40 – 49 years old / 68 / 15.4 / 56 / 15.8 / 12 / 10.1
50 years old and > / 4 / 0.8 / 3 / 0.7 / 1 / 1.1
Total / 370 / - / 289 / - / 81 / -
Mean age, years / 31.9 / 31.8 / 32.0
SD, years / 7.3 / 7.4 / 6.8
Median age, years / 32 / 30 / 33

Marital status

When asked about their marital status, the largest group of respondents reported being single 42.9%. Of the sample36.7% were married or living in a partnership. The share of males who are married or who are living in a partnership (35.0%) is lower than the share of married females or females living in a partnership (44.3%). To be noted the high share of divorced (16.1%) in the recruited sample both for males (15.9%) and females (16.6%) The sample’s distribution, based on the marital status, is shown in theTable 3.

Table 3 Marital status of the respondents, distribution based on gender and age group, IDUsfrom Balti municipality, %, Republic of Moldova, 2009

Total / Males / Females / 25 years and older / Under 25 years old
Single / 42.9 / 47.8 / 22.3 / 35.9 / 83.2
Married / 12.5 / 13.8 / 7.3 / 14.8 / 0.8
Living in partnership / 24.2 / 21.2 / 37.0 / 26.0 / 16.0
Divorced / 16.1 / 15.9 / 16.6 / 18.5 / 0.0
Widowed / 4.2 / 1.3 / 16.7 / 4.9 / 0.0

The share of respondents who are married or who are living in a partnership is larger in the age group of 25 years old and over both for males (38.9%)and females (49.9%) in comparison with the age group under 25 (12.6% for males and 30.3% for females).

Educational level

The majority of the respondents completed secondary education or specialized secondary education (65.3%). About fourth of respondents (17.5%) have not finished the secondary incomplete school level (Table 4).

Table 4 Educational level, distribution based on gender and age group, people who inject drugs living in Balti municipality, %, Republic of Moldova, 2009

Total / Males / Females / 25 years and older / Under 25 years old
Primary school (4 grades) / 1.0 / 1.1 / 0.2 / 1.0 / 0.7
Less than 9 grades / 16.5 / 18.1 / 7.8 / 13.8 / 33.1
Incomplete secondary education / 6.1 / 6.4 / 5.6 / 6.2 / 6.9
Complete secondary education / 39.2 / 39.0 / 43.5 / 37.5 / 39.8
Specialized secondary education / 26.1 / 25.2 / 28.2 / 30.0 / 11.5
Incomplete higher education / 6.8 / 5.4 / 12.5 / 6.8 / 6.4
Higher education / 4.4 / 4.8 / 2.2 / 4.7 / 1.6

Language spoken and area of residency

Of the sample, 7.2% stated that most of the time they prefer to speak Moldovan/Romanian; 92.6% prefer to use Russian and 0.2% of the respondents prefer other languages. There are no differences between males (91.5% prefer Russian) and females (92.4% prefer Russian).

At the time of the interviews about 99.7% of the respondents were living in large urban areas and 0.3% in rayon centers or other small urban localities around or part of the Balti municipality.

Mobility

Of the sample, 93.3% were born in the Republic of Moldova. The rest of 6.7% were born outside, but in one of the former Soviet Union republics.

The respondents were living in the current area of residency 30.9 yearson average (median –31.0, SD=±8.7). Hence, respondents came to the Balti municipality 1-2 years old and were living there permanently during there lifetime (Table 2). The vast majority of the respondents (82.0%) had not been away from the area of their residence for longer than one month during the last year (Table 5).

Table 5 Being away from the area of residence for longer than a month during the last year, people who inject drugs living in Balti municipality, %, Republic of Moldova, 2009

Total / Males / Females / 25 years and older / Under 25 years old
Being away from the area of residence for longer than a month during the last year / 18.0 / 18.3 / 16.9 / 19.0 / 12.0

A higher rate of mobility within the last 12 months was registered in the case of respondents of 25 years and older compared to respondents younger than 25.

Economic status

Employment and Income

Only 14.5%of the sample reported permanent employment. Half of respondents (50.6%) reported to be unemployed at the interview time[7].

Figure 1 Employment status, people who inject drugs livingin Balti municipality, %, Republic of Moldova, 2009

The proportion of those unemployed is higher in the subsample of male respondents (52.1%) compared to the female subsample (44.7%). The rate of housekeepers among female respondents is of 8.0%. Respondents younger than 25 years less frequently are unemployed (48.3%) compared to those who are 25 and older (53.3%).

Of the total survey sample, 35.8% reported having no income (Figure 2). Another 2.8% lives in extreme poverty on 330 MDL[8] or less a month, equivalent to less than US$1/day, and 6.1% live on less than US$2/day. Females and those younger than 25 years old reported a higher income.

Figure 2 Monthly income, people who use injecting drugs living in Balti municipality, %, Republic of Moldova, 2009

Ability to pay

More than half of respondents could pay for water bills (55.2%), electricity bills (57.8%) and medicines for emergency situations (53.4%) (Figure 3). For less than half of respondents home heating (39.1%) and meals with meat or fish every other day (28.6%)are within their means.

Figure 3 Ability to pay for basic items, people who inject drugs living in Balti municipality, %, Republic of Moldova, 2009

Unexpectedly high percent of respondents (11.4% – 20.3%) stated that they can afford to buy new items which are part of the life comfort products (TV set, fridge, furniture, washing machine).

Drug Use

Legal drug use

Of the sample, 95.7% were smokers at the interview time and 98.6% of the sample has ever smoked tobacco. Last month prevalence of the alcohol use in the recruited sample was of 85.3%.

Length of Illegal Drug Use

According to the respondents’ answers, the length of their drug use generally varies between one year and 32 years. The mean length of drug use within the sample studied is of 12.8 years(median – 12.0, SD=±7.2).

The length of injecting drug use varies between one year and 30 years. The mean length of injecting drug use within the sample studied is 10.8 years(median – 10.0, SD=±7.1). The mean length of injecting drug use in males is 11.0 years (median – 10.0, SD=±7.2), and in females it is 10.1 years (median – 9.0, SD=±6.6). In the vast majority of cases the respondents’ first experience of injecting drugs occurred 3 years or more before the study (89.5%) (Figure 4).

Figure 4 Sample distribution based on length of injecting drug use, people who inject drugs living in Balti municipality, %, Republic of Moldova, 2009

About 10.5% of the respondents have been using injecting drugs for less than 3 years (39 respondents), these being the new entrants to the key population at higher risk. They are 24.2 years old on average (median – 23.0, SD=±6.0) and 73.7% of them are males.

Initiation of Drug Use

According to the respondents’ answers, the age at which they first injected varies between 12 and 47 years. The first injection of drugs occurred at 21.3 years old on average (median - 20.0 years, SD=±5.7 ) with homemade extract of opium (shirka) (in 91.6% of cases), after an average of 2.0 years of non injecting drug use (median –0.0[9], SD=±3.0). Among drugs used at first injection there was as well ephedron (3.8%), heroine (2.7%), metamphetamines (1.3%) or other drugs (0.7%).

While the length of the injecting drug use is increasing, the mean age at first injection is decreasing (Table 6).

Table 6 Mean age at first drug injection by length of drug injection, people who inject drugs living inBalti municipality, %, Republic of Moldova, 2009

Length of injecting drug use / # respondents / Mean / Median / SD
3 years and less / 59 / 23.6 / 21.0 / ±7.0
4 – 6 years / 46 / 24.4 / 23.5 / ±5.8
7 – 9 years / 43 / 22.5 / 20.0 / ±6.3
10 years and more / 221 / 19.9 / 19.0 / ±4.7
Total / 369 / 21.3 / 20.0 / ±5.7

In 95.3% of cases, the initiation in injection of drugs was done by somebody else than the respondents themselves. In most of the cases, the initiator has been part of the close social environment (friend - 42.1%, acquaintance - 45.0%, sexual partner - 7.0% and siblings - 3.5%) and on average 3.4 years older (mean age – 24.7 years, median –24.00, SD=±6.0) than the respondents themselves. At first injection, 14.8% of people who inject drugs used unsterile needles/syringes.

Most of the respondents agreed that prior to the first injection they had become curious as to what injecting would be like (94.0%). Almost half of them wanted to inject drugs to be the same as their friends (57.3%) and had come to see injecting as something that could be a good experience (46.0%).

About two thirds of the people who inject drugs (59.8%) have ever been asked to help with the initiation in injection of drugs and one fifth (20.6%) have ever helped, being aware of the fact of initiation. Per respondent who have ever been asked to help with the initiation, there were on average 0.5 persons in last month (median –0.0, SD=±1.1) and 1.5 persons in the last 6 months (median –1.0, SD=±2.5). Per respondent who have ever helped someone else, being aware of the fact of initiation, there were 0.5 persons on average in the last month (median – 0, SD=±1.3) and 1.2 persons on average in the last 6 months (median –1.0, SD=±1.9) who were helped with the initiation injection by the respondents themselves. There may be underreporting due to social desirability. The last initiated were 21.9 years old on average (median – 20 years, SD=±4.7).