We studied behavioural risk factors among attendees at a low-threshold support centre for drug users in Murmansk, Russia. From June till November 2006, attendees were interviewed using a structured questionnaire. 147 individuals (57 % males, 14 % under 20 years of age) participated. Among the respondents, 80 % had HCV infection and 48 % had HIV infection. Most of the respondents injected heroin. Some 70 % had injected drugs at least once a day during the last month. Sharing syringes and needles was a common practice. Sixty-five percent reported only one regular sex partner last year. The main risks among drug users in Murmansk seem to be sharing syringes, sharing other items (spoon, ampoule, filter) for drug administration and unprotected sex. There is still need for supply of condoms and sterile tools for injections as well as counselling of drug users in Murmansk.
A low-threshold support centre – called “Trust” – for drug users and commercial sex workers was established Murmansk in November 2005 by common agreement of the Murmansk oblast Public Health Committee and the National Research and the Finnish Development Centre of Welfare and Health (STAKES) under the framework of a bilateral project within the Northern Dimension Partnership in Public Health and Social Wellbeing (NDPHS) and Barents Region Partnership. Since January 2006, the centre has been located in the Murmansk oblast Centre for Prevention and Control of AIDS and Infectious Diseases.
We aimed to study behavioural (drug using and sexual) risk factors for HIV infection among intravenous drug users (IDUs) and commercial sex workers (CSW) living in Murmansk by conducting a questionnaire survey among visitors to “Trust”.
Materials and methods
We developed a questionnaire based on two previous questionnaires, one called “EURO Snowball 2002” and one used at a similar centre in Vyborg. The questionnaire contained the following question blocks: Demographic characteristics, “Trust” centre visits, drug use, drug addiction treatment, syringe and needle use procedures, sexual contact history and HIV/AIDS awareness.
From June 2006, when the centre had been open for seven months, until November 2006, all IDUs who visited the “Trust”, regardless of reason for visit, were invited to an anonymous, private interview with a nurse or counsellor. Exceptions were made for those who were obviously intoxicated at the moment. Some patients declined to be interviewed, usually because of lack of time. The interviewers posed each question from the questionnaire and ticked the response that was closest to the patients answer. Only if the respondent had difficulties in answering, did the interviewer read the alternative answers from the questionnaire.
During 2006, 645 drug addicts (53 % males) visited the “Trust” centre. In June – November that year, 147 individuals (57 % males) participated in the survey. Twenty (14%) of them were younger than 20 years of age. The mean age was 26 years for males and 24 for females. Almost all had completed specialised comprehensive education. 65 % had never been married while 28 % were married and 7 % were divorced.
Fifty-three (36 %) of respondents had heard about the”Trust” centre from friends or fellow drug users. Almost half of the respondents (48 %) had been told about the centre from specialists in the AIDS centre which is located in the same building. Even though many of the respondents had used drugs for many years, only two thirds were patients at the outpatient clinic for drug users. Fifty-nine percent had ever received treatment against drug addiction.
Among the 147 respondents, 117 (80 %) had HCV infection and 71 (48 %) had HIV infection. Sixty-three respondents (43 %) had both infections while 22 (15 %) had none of these two blood borne infections.
The respondents had a wide range of drug use experience, from less than one year (12 persons) to 25 years (one woman, aged 39) (Figure1).
Figure 1. Duration of intravenous drug use among IDU in Murmansk
Most of the respondents (92 %) injected heroin, the others used “hand made” ephedrine and opiates. Some 70 % had injected drugs at least once a day during the last month (Figure 2).
Figure 2. Frequency of injecting drug use among IDUs in Murmansk. N=147.
Figure 3. Frequency of sharing others syringes among IDUs in Murmansk
Sharing syringes and needles was a common practice (Figure 3). For instance, 30 % of respondents did this periodically. The practice was independent of gender. Thirty percent of females and 17 % of males mentioned their regular sexual partner as their syringe sharing partner, whole 24 % of females and 20 % of males mentioned their friends.
Among the 69 HIV-positive respondents, 41 (59 %) denied sharing syringes with anybody. Seven reported sharing syringes and needles with their regular sexual partner.
One fourth (25 %) of respondents reported that they at least once had given their own used syringe to someone else, while 72 % denied ever having done this. Among males, 30 % had done it, and among females 20 %. Among HIV negative respondents, 34 % had shared their used syringe while among HIV positives the proportion was only 16 %. Many of the latter indicated that their syringe sharing partners were known to be HIV-positives.
Even though needle and syringe sharing was common, 98 % of respondents reported that they could get hold of new syringes and needles when they needed them. Sixty percent of them mentioned the exchange programme as a source.
The number of regular sex partners last year per respondent was on average 1.3 (Figure 4).
Figure 4. Number of regular sex partners during the last 12 month among IDUs in Murmansk
Sixty-five percent reported only one regular sex partner last year. Around one third of respondents (more females than males) used condoms “every time” they had sex with their regular partners (Table 1). Around half of the males, but only a third of females “never” use condoms with their regular partner.
Table 1. Frequency of condom use among IDUs in Murmansk
One third (36 %) of respondents reported at least one causal sex partner during the last year. The proportion was 29 % among males and 47 % among females. There were ten commercial sex workers among the female respondents. These women reported a very high number of casual sex partners the last year. Around a half of the males and 62 % of females used a condom “always” when they had sex with a casual partner.
Only 18% of males and 33% of females stated that they had sex “often” or “always” after using drugs or alcohol (Table 2). In such situations less than one third of both males and females “always” use condoms.
Table 2. Frequency of contacts after alcohol and drug use among IDUs in Murmansk
The respondents reported that they had been afraid of being infected through drug use. Practically all of them knew that HIV could transmit by needle sharing, but only 65 % of the HIV-negative patients reported using clean syringes themselves to avoid HIV-infection.
Discussion and conclusion
The average age of IDUs who visited “Trust” was 25 years and they had used drugs for an average of 7 years, meaning that they had started drug use quite early in their lives. Almost half the respondents were HIV positive while around 80% had HCV infection.
The main potential risks of being infected with HIV and HCV seem to be:
- Sharing syringes. 41% of cases do this. Among women, 30% share syringes with their regular sexual partner.
- Sharing other items (spoon, ampoule, filter) for drug administration. 58% of cases do this.
- Unprotected sex. Only 1/3 of respondents “always” use condoms with their regular sex partners and about a half of female IDUs never use condoms with their regular sex partners.
The use of clean syringes and other items for drug administration and condoms are the main measures to prevent the spread of blood borne infections in the IDU community. Supply of condoms and sterile tools for injections as well as counselling may lead to safer behaviour and less spread of HIV. IDUs share syringes given to them by others partly because they do not want to carry their own syringe out of fear of being detected by family members or the police.
Improved testing procedures for HIV and HCV infection, including anonymous testing, and counselling is a great need. Rapid testing as in this project contributed to increasing testing rates among “Trust” visitors.
Treatment and rehabilitation of drug users is also a measure to reduce HIV spread. The “Trust” became very popular among IDUs because it served as a contact point to the service institutions, including those responsible for drug addiction treatment.
This project suggests that IDUs in Murmansk may change their behaviour if they receive appropriate support.
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