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

Population prevalence rates of injection drug use in Eastern Europe and Central Asia (EECA) are extremely high compared with the global rate; rates are 1–2% in Ukraine, 1.6% in Kazakhstan, and > 2% in Russia, compared with a global rate of 0.27% [1, 2]. With an estimated 52,000 people who inject drugs (PWID) [3], the prevalence of injection drug use in Georgia (2.24%) ranks third highest in the world [2]. PWID are a driving force behind the growing human immunodeficiency virus (HIV) epidemic in this region, with an estimated 1.7 million people living with HIV [4, 5]. Since 2010, the annual incidence of HIV has increased in the EECA by 60% [6]. Although HIV prevalence among PWID in Georgia is relatively low (1–4%) [7] at present, the public health consequences of injection drug use are high and include high rates of hepatitis C virus (HCV) (61–92%) [8], as well as multiple social and health problems [7, 9]. About 45% of cumulative HIV cases in the country are attributed to injection drug use [10]. The annual incidence of HIV in Georgia has steadily increased over the last decade by 10–25% [11] and has reached 17.9 per 100,000 population in 2015 [12].

Needle and syringe programs (NSP) are an effective, evidence-based intervention for reducing HIV/HCV transmission via unsafe injection among PWID [13–17]. However, the major problem with NSP implementation in the region is low coverage. To date, no countries have achieved recommended coverage targets for HIV prevention among PWID (60% for NSP and 40% for OST) [18, 19]. In Georgia, implementation of harm reduction programs, including NSP, started in 2003 and since then has expanded in scope and the scale [8]. In 2017, there were 14 fixed sites and 6 mobile harm reduction units operational in the country [20]. In the Georgian context, “harm reduction” refers to low-threshold services that include provision of needles and syringes, condoms, naloxone for overdose prevention, voluntary counseling and testing (VCT) for blood-borne infections, case management and social support, referral to specialized medical and non-medical services, and provision of information and education materials. In 2016, these programs provided HIV/HCV rapid testing to more than 26,000 PWID and their partners [21]. However, only 15–30% of PWID received sterile injection equipment from these programs during the last 12 months [7], and the number of syringes distributed per PWID per year reached 72 in 2015, only a fraction of the internationally recommended target of 200 syringes per PWID per year [18]. About one third of PWID (18,000) in the country are using injection opioids and are at increased risk of overdose [22]. Due to flaws in proper documentation of drug overdose-related cases, official data on opioid-related overdose mortality is virtually nonexistent [21]. An indirect source of related information—a client survey implemented by the Georgian Harm Reduction Network (GHRN)—suggests that there were at least 792 non-fatal and 50 fatal opioid overdoses in the country in 2015 [8]. However, these results also have limitations—double counting of overdose cases cannot be excluded. Although naloxone remains on the list of prescription medications, the Georgian government has agreed to allow distribution to high-risk groups via harm reduction services. In 2016, the GHRN distributed 10,876 ampules of naloxone through its network of low-threshold services [23].

Many countries in the EECA region, including Georgia, are in the process of transitioning from funding provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to national funding. This transition poses significant challenges to sustainability of harm reduction programs, particularly NSP. Currently NSP in Georgia are fully funded by the Global Fund [8]. In countries from which GFATM has already withdrawn (fully or partially), programs focusing on HIV prevention among PWID were the first to be affected [19, 24, 25]. There is a critical need to adopt innovative approaches to HIV/HCV prevention in order to optimize resource allocation and sustain programs currently receiving external donor support.

Syringe vending machines (SVM) are an effective and cost-effective supplement to standard NSP and can reach hard-to-reach groups and cover geographic areas where fixed or mobile NSPs do not operate [26]. SVMs supply sterile needles and syringes and other injection paraphernalia, condoms, risk reduction and other health information, and contact information for available services, and other minor health supplies. Although evidence on effectiveness is limited, available evidence shows that in addition to providing 24/7 access for regular NSP service users, SVMs are successful in reaching sub-groups that for a variety of reasons do not normally attend fixed site NSPs, such as younger PWIDs and women [26–30]. Non-stigmatized access to sterile equipment, anonymity, and privacy has been reported as important advantages of SVM [31, 32]. In addition, SVMs were shown to be a cost-effective mode of NSP [27]. While there have been some studies examining acceptability of SVM, no studies to date have explored attitudes towards SVM among out-of-service PWID either in the Republic of Georgia, or in EECA—a region greatly in need of supplement harm reduction services.

The aim of the current study was to explore the perceived acceptability of syringe vending machines among out-of-service PWID in Tbilisi, Georgia’s largest city, and to assess barriers to introducing SVMs in local settings. We also aimed to learn about PWID interest and need for a variety of additional items (e.g., sterile equipment, health products, and others) to be potentially distributed via SVMs in the country. This cross-sectional study was part of a formative phase of a parent hybrid (implementation + efficacy) cluster randomized trial—Georgia Syringe Vending Machine Trial (GSVMT)—to evaluate process and effectiveness outcomes of introducing syringe vending machines in Tbilisi.

This study assessed the perceived acceptability of and willingness to use SVM among PWID in Tbilisi who were not in contact with harm reduction or substance use-related treatment services. The perceived acceptability of the novel syringe delivery model was extremely high. The most endorsed reasons provided by participants for potentially using SVM were free access to injection equipment and confidentiality. Other reasons included having uninterrupted access to injection instruments, fast service (no waiting in a queue in a pharmacy), and access to HIV self-testing kits.

The majority of participants in the sample were at very high risk for HIV, being poly-drug users, injecting in groups, and reporting recent sharing of injection instruments with others. The majority (85%) reported never having been in contact with a harm reduction program. In fact, the prevalence of injection risk behavior in this sample was notably higher than the prevalence reported by other authors in Georgian NSP clients and non-clients [7, 39], potentially due to their lack of contact with harm reduction or treatment facilities and low knowledge of harm reduction practices. Available studies have suggested that SVMs have the capacity to attract hard-to-reach and high-risk PWIDs [26, 30] and those who have never been in substance use-related treatment [40]. If SVMs in Georgia are able to attract PWID like those in this study sample, they could, at a minimum, substantially expand access to sterile equipment for wider groups of very high-risk drug users, but also could facilitate linkage to prevention and treatment services, offering substantial public health benefits. Like NSP, SVM could facilitate the linkage with substance use-related and general health services [15, 41]. Importantly, almost 80% of those who confirmed they would be willing to use SVM claimed that they would prefer to receive a multi-use plastic card to have permanent access to machines. This suggests that they might be willing to get in contact with a fixed NSP through which SVM plastic cards would be distributed.

Eight out of ten participants who have never been tested for HIV stated that they would take an HIV test if self-test kits were available through vending machines. A number of countries have already started implementing HIV self-testing or included it in their strategic plans or policy frameworks [44]. In Georgia the significant gap in HIV case detection (only 48% of the estimated number of people living with HIV is aware of their status) [45] prompted the government to acknowledge the need for engaging out-of-service PWID (testing, early diagnosis, inclusion in treatment) as a critical priority for the HIV national response. SVMs and HIV self-testing are both included in the HIV/AIDS National Strategic Plan 2019–2022 as innovative and potentially beneficial approaches for the country [45]. There is a growing volume of research assessing the feasibility, acceptability, and accuracy of HIV self-tests. This research has suggested that self-testing is a reliable and convenient form of testing for many individuals and groups who may not test otherwise, including key affected populations [46–49]. Self-testing is highly acceptable among various users in different settings [44, 50–55] and increases access to and the uptake and frequency of HIV testing [56–58]. In addition, feasibility and acceptability studies suggest that providing HIV self-testing kits through vending machines has the potential to improve testing rates in key risk groups [42, 43]. However, there are concerns regarding the further confirmatory HIV testing and linkage to care [44, 59]. We certainly acknowledge that there is a need for research, including in Georgia, to assess strategies that would ensure that self-testing leads to more people knowing their HIV status and more HIV-positive individuals linked to treatment and care. There has been promising research showing that self-testing could facilitate HIV case-finding in some settings [60] and post-test linkage to care using community-based proactive interventions [61].

As expected, the majority of participants were willing to receive from vending machines a relatively standard set of items used for drug preparation and injection—needles and syringes, cotton, sterile water, and alcohol swabs. There also were high rates of endorsement for HIV and HCV (if/when available) self-test kits, as well as for naloxone. In addition, participants indicated moderate endorsement of female condoms and pregnancy kits and proposed to include some new (not in a predefined list) items, such as drug-testing kits. These results suggest potential broader utility of vending machines and the need to experiment with distribution of a wider variety of consumables and health products beyond the relatively narrow, traditional set of items that are usually vended from SVMs.

As expected, the vast majority of our sample had obtained needles and syringes in pharmacies. This finding is similar to findings from other PWID-focused studies in Georgia [22]. Needles, syringes, and other injection paraphernalia are available via unrestricted sale through pharmacies, some of which provide 24/7 service to customers. However, strict drug-related legislation, police harassment, and severe social stigma associated with drug use represent major barriers to PWID obtaining syringes in pharmacies (and, in some cases, to using prevention and treatment services as well) [9]. In many cases, female partners of drug users are tasked to show up at pharmacies to buy injection supplies for their drug-using male partners [62, 63]. Not surprisingly, the overwhelming majority of respondents in this study ranked confidentiality (no need to deal with pharmacies), as a principal advantage to using SVM. Similar to our findings, a number of other authors have found confidentiality and stigma-free access to sterile equipment to be important factors in attracting PWID to syringe distribution modalities [26, 30].

We had only one female and a very few young (18–25 years of age) respondents in the sample. Although we invited a female seed as initial recruiter to the study and hoped she would recruit other female PWID, she did not recruit any participants. The lack of drug-using women and young people in contact with substance use-related services and their extremely low representation in PWID-focused studies reflect a common trend in Georgian drug-related service delivery and research setting. Females and young drug users represent a tiny fraction (1–5%) of clients in harm reduction and substance use-related treatment services in the country [8, 64]. Previous research has shown that social and cultural stigmatization and lack of services shape the help-seeking behavior of these populations [65, 66]. Research in other settings suggests that compared to traditional NSP, SVMs are more likely to attract younger PWID, female PWID, as well as others who are not likely to be in treatment [27, 28, 30]. Given this potential for attracting hard-to-reach sub-groups of PWID, implementation of SVM in Georgia could offer a breakthrough to harm reduction efforts across the country.

Given the issues of stigmatization and need for confidentiality in Georgia and other legally and socio-culturally constrained settings, SVM implementation needs to address a number of environmental challenges and employ risk minimization strategies. There was little agreement among respondents on the locations for installing SVMs. Interestingly, major concerns were related to possible resistance from residents and the general public, and there was less fear regarding police harassment since many believed that “police know all drug users anyway”. Most arguments for or against any specific locations were driven by participants’ willingness to make the process either less visible for outsiders (quiet, distant locations) or to employ approaches that would reduce the possibility of labelling the SVM as a vending machine for PWID. One such approach to mitigating stigma was our suggestion to have SVMs distributing simple health products for the general population. This suggestion received approval from the vast majority of respondents in our sample. We acknowledge that at this stage, it is difficult to propose any strategy that would assure acceptance of SVMs by the general public or different groups of PWID. Having SVMs distributing general health products is just one possible means to counter potential risks. Further research will illuminate more about these and other challenges as we implement the first two SVMs, planned within our ongoing SVM trial.

Acceptability of SVM was extremely high, with the most highly endorsed features being uninterrupted free access to sterile injection equipment and privacy and anonymity. In addition, acceptability of self-testing HIV kits was also high, including among PWID who have never been tested for HIV. Results of this study suggest that introducing SVM in Georgia holds the potential to deliver significant public health benefits through attracting hard-to-reach PWID, reducing unsafe injection behavior, and facilitating HIV testing and linkage to care.