A mixed methods exploration of injection drug use risk behaviors and place-based norms in Ukraine

Abstract

Introduction:

Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use–related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk.

Methods:

This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment.

Results:

Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a “common practice,” PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash.

Conclusion:

Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to “close the gap” and further reduce HIV and other infections among PWID.

1. Introduction

Between 2010 and 2019, incident HIV infections and AIDS-related deaths increased by 72 % and 24 %, respectively, in Eastern Europe and Central Asia (Joint United Nations Programme on HIV/AIDS, 2020). The HIV epidemic in this region is concentrated among people who inject drugs (PWID) (Dumchev, Sazonova, Salyuk, & Varetska, 2018; LaMonaca et al., 2019); nearly 20 % of new HIV infections occurred among this population in 2019 (Joint United Nations Programme on HIV/AIDS, 2020). Despite global reductions in HIV incidence and mortality and significant investment in local harm reduction services, expanded access to opioid agonist therapy (OAT) (Dumchev, Dvoryak, Chernova, Morozova, & Altice, 2017; Morozova, Dvoriak, Pykalo, & Altice, 2017), and increased antiretroviral therapy (ART) coverage (Sazonova et al., 2020), Ukraine continues to experience an expanding epidemic (Barska & Sazonova, 2015; Dutta et al., 2013; Makarenko et al., 2016; Sazonova & Saliuk, 2018). Estimates from epidemiological reports indicate that >20 % of PWID in Ukraine were living with HIV in 2019 (Kuzin, Martzynovska, & Anontenko, 2020). Information from Ukraine’s nationally representative integrated biobehavioral survey (IBBS) suggest that the prevalence of HIV among PWID declined from 24 to 20 % between 2008/2009 and 2020; however, this mode of transmission continues to play a substantial role in driving the HIV epidemic (Dumchev et al., 2018; Titar et al., 2021). Data from the IBBS also indicate decreasing or stabilizing HIV incidence among PWID in Ukraine, estimating the annual percent of PWID recently infected with HIV to be 1.36 % (95 % CI: 0.85–1.87 %) and 1.06 % (95 % CI: 0.61–1.52 %) in 2015 and 2020, respectively. Additionally, estimated HCV prevalence among PWID is around 58 %, with an estimated HCV prevalence among PWID as high as 85 % in some cities (Zelenev et al., 2019).

Complex social, economic, historical, and structural factors shape drug use and its concomitant health risks (Strathdee et al., 2010). Historically, the drug market in Ukraine was dominated by small-scale, home-based drug production, procurement, and use (often within small social networks) that contributed to high rates of HIV and HCV among PWID. Ukrainian PWID often obtained drugs in liquid form from dealers’ syringes through frontloading or backloading, pre-loaded syringes from a 3rd party, and common containers from which multiple users draw (Booth, 2013; Booth, Lehman, Dvoryak, Brewster, & Sinitsyna, 2009; Chintalova-Dallas, Case, Kitsenko, & Lazzarini, 2009). Anywhere from 6 to 12 PWID could load their syringes from the dealer’s syringe (Booth et al., 2011), and Ukrainian PWID typically shared drug solution and injected with social network members (Booth, Kennedy, Brewster, & Semerik, 2003). More recently, the introduction of technologies such as encrypted messaging and mobile banking have changed the way that PWID in Ukraine procure and use drugs. While people still purchase drugs “hand-to-hand” by going to a seller’s apartment, buying drugs through “stashes” (zalkadka [закладка]) is increasingly common. In stash-based purchasing, the person buying drugs calls a supplier to determine whether drugs are available, transfers money through widely available cash transfer machines, confirms through text messaging that the transaction was complete, receives instructions on where to pick up the drugs, and obtains the drugs at the specified location. Typically, the drugs are wrapped in plastic and tape and hidden in public places, such as behind hedges, inside discarded tires, or under piles of debris and leaves (Mazhnaya et al., 2021). The structure of the drug market, mechanisms for obtaining drugs, and context for drug use, including place and the people who are present when drugs are consumed, contribute to differential risks for HIV and HCV transmission.

Decades of research has established the crucial role that social norms play on individual drug use behavior (Latkin et al., 2013). Social norms include descriptive norms, or the interpretation of what behaviors are practiced among a social group, and injunctive norms, or how individuals perceive how others may respond to their behavior (Latkin, Kuramoto, Davey-Rothwell, & Tobin, 2010). Social norms maintain behaviors and changing social norms, although difficult, can lead to subsequent behavior change. For HIV risk that stems from injection drug use, norms around drug injection equipment can have harmful or protective effects. Research on this relationship emerged early in the HIV epidemic, with Friedman et al. (1987) illustrating how descriptive norms shape personal risk behaviors among PWID. In their seminal work on drug sharing, Grund et al. (1996) argued for the importance of additional factors that impact norms around drug and equipment sharing, including economic considerations (e.g., pooling money to make bulk/cheaper purchase), concerns about the amelioration of withdrawal (e.g., helping alleviate the suffering of a fellow PWID), and creating mutual obligations and building reciprocity. More recently, Latkin et al. (2011) found that PWID who endorsed risky needle-sharing norms were more likely to engage in risky drug use practices such as sharing cookers and needles (Latkin et al., 2011). Similarly, Davey-Rothwell, Latkin, and Tobin (2010) found that believing that other PWID practiced risky injection behaviors predicted sharing syringes.

More recent scholarship has explored the relationship between drug use social norms and place and how the physical environment can shape risk and protective behaviors related to HIV/HCV transmission. This perspective on the physical environment proposes a more dynamic, interactional interpretation of place that centers agency of both the place and individuals in that place and connections between places. As Duff (2013) argues, place mediates relations between individuals and has material, affective, and temporal dimensions that shape individual agency and group dynamics. Places mediate relationships between actors and objects, and it is through interactions among place, actors, and objects that the meaning of a place is both created and transformed (Williams, 2016). Social networks and drug use norms are embedded in specific places (Cooper & Tempalski, 2014; Egan et al., 2011; Tobin et al., 2012; Wylie, Shah, & Jolly, 2007). For example, HIV/HCV risk varies based on whether a drug use space is private (homes, apartments) or public (parks, forests) (Mazhnaya et al., 2018; Saliuk, 2013). Injection in public places has been linked to increased risk behaviors for HIV/HCV transmission through: decreased control of the environment (DeBeck et al., 2012; Roy & Arruda, 2015), limited access to unused needles or running water (Rhodes et al., 2006), and social norms and power dynamics (Janulis, 2016; Macintyre, Ellaway, & Cummins, 2002; Tobin et al., 2010). Conversely, drug use places can also support safe injection practices through “environmental interventions,” such as creating supervised injecting facilities, increasing access to sterile water, or providing containers for safe disposal of injection equipment (Ip et al., 2012).

Despite this growing recognition of the ways in which social norms as embedded in place affect drug use-related risk factors, research has paid little attention to the relationship between drug use practices and place in Ukraine or how these factors may contribute to HIV/HCV risk and safety. In this article, we used a mixed methods approach to explore how risk for HIV and HCV acquisition is influenced by specific places where interactions related to drug use occur. We used a quantitative survey to determine the frequency of injection risk and protective behaviors and the range of places in which these behaviors occurred, and in-depth interviews to understand the contexts, situations, and explanations for engaging in and avoiding these behaviors. Accounting for the unique ways in which drugs are procured and used, and the place-based contexts that exacerbate or mitigate HIV/HCV risk has implications for the development of harm reduction policies and interventions.

2. Methods

The parent study for this project used an exploratory sequential mixed methods design in which in-depth, semi-structured qualitative interviews informed the development of a quantitative survey (Creswell, Plano Clark, Gutmann, & Hanson, 2003) (Table 1). We used in-depth interviews to understand the relationship among drug use norms, practices, and places where drugs were purchased and used. We then used these findings to develop an ego-centric social network survey that assessed the relationship between social network members, drug use practices, and place among a larger sample of PWID. This article describes a post hoc analysis of these qualitative and quantitative data sources; the study team analyzed the in-depth interviews and quantitative survey separately and simultaneously with subsequent integration of the results to explore concordance and discordance between findings (Creswell & Creswell, 2017).

Table 1.

Overview of the data sources.

Characteristic	Qualitative interviews	Quantitative Survey
Data source	In-depth interviews	Computer-based survey
Study population	149 participants	30 participants
Timeframe	March to August 2018	May 2019 to March 2020
Research objective	To elucidate the contexts, situations, and explanations for engaging in and avoiding these behaviors	To quantify the occurrence of injection risk and protective behaviors and the range of places in which these behaviors occurred
Anticipated outcomes	Enhanced understanding of the relationship between drug use norms, practices, and places	Frequency and settings of injection risk and protective behaviors

We conducted this study in Dnipro, Ukraine, an industrial center with a population of about 1 million people. HIV incidence in the broader Dnipropetrovsk region is among the highest in the country, with most new infections occurring in urban areas such as Dnipro. Estimates indicate that between 11,000 and 30,000 PWID live in Dnipro, with the majority of PWID indicating opioids as their main drug (Berleva & Sazonova, 2016). Estimates indicate HIV and HCV prevalence among PWID as 39.7 % and 63.8 %, respectively (Barska & Sazonova, 2015).

2.1. Qualitative data collection

Between March and August 2018, we interviewed 30 PWID in Dnipro. The study recruited participants through direct contact with agencies that provide services to PWID. To include the perspectives of PWID who are not engaged with service agencies, we also recruited participants through street-based outreach and participant referral. Throughout recruitment, we periodically reviewed characteristics of enrolled participants to support inclusion of diverse respondents with respect to demographic, drug use, and geographic characteristics. Eligibility criteria included being 18 years or older, living in the study city, and injecting drugs in the previous 30 days. Eligible participants provided oral consent. This study was reviewed and approved by Institutional Review Boards at Johns Hopkins Bloomberg School of Public Health and the Ukrainian Institute on Public Health Policy. Study participants completed a single interview that lasted between 1 and 2 h in which they were asked to describe their “typical day:” where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. In parts of the interview that explored drug injection and injection equipment practices, the interviewer probed about typical experiences, atypical experiences, and the circumstances in which typical behaviors changed. Interviewers were staff from local agencies who provide services to PWID, had background in psychology, were trained in methods for conducting in-depth interviews, and were Dnipro residents familiar with the city’s drug use context.

2.2. Quantitative data collection

Between May 2019 and March 2020, we recruited 150 PWID to complete a one-time survey. Participants completed the survey on computers at local service agencies. Recruitment strategies, eligibility criteria, and consent procedures remained the same as in the qualitative phase, with the exception that we enrolled participants who reported injecting drugs within the last 3 months. The survey consisted of three components: an interviewer-administered activity space inventory, an interviewer-administered egocentric social network inventory, and a participant-administered HIV risk behavior assessment (Tobin et al., 2013). This article focuses on data gathered through the Activity Space Inventory, which explored three types of places: drug use, drug procurement, and nondrug related places. Participants “free-listed” places where they live, work, and socialize without using drugs (nondrug spaces), places where the procured drugs (drug procurement spaces), and places where they used drugs (drug use spaces); places could overlap in that one place could be listed as where the person lives and where the person uses drugs (multiplexity). For each place listed, participants described how much time they spent at each place and drug use behaviors that occurred there, including those associated with drug procurement (e.g., giving a syringe to a dealer, partner, or middle person for filling, using a common container shared by other people, front or back loading) and drug injection (e.g., using a syringe before or after other people, sharing cotton/flushing water with other people). The current analysis assessed only behaviors that occurred in drug use spaces. Separately, participants listed “needle acquisition spaces,” which included any place where participants obtained needles or syringes, and answered questions related to age, gender, education level, financial situation, housing status, employment status, and HIV/HCV status.

2.3. Qualitative data analysis

Interviews were transcribed verbatim, translated from Russian to English, and uploaded to MAXQDA (VERBI Software, 2021) for coding and analysis. The analysis took place deductively and inductively by exploring a priori topics but remaining open to unanticipated, emergent themes. The study team developed the coding tree through an iterative and collaborative process to ensure reliability and consistency (Carey, Morgan, & Oxtoby, 1996). A priori codes reflected topics and content areas in the interview guide, such as drug market characteristics, norms around sharing drugs, and needle and syringe acquisition. Inductive codes or themes that emerged from the data but were not explicitly asked in the interview included “unforeseen circumstances” that affected drug use behaviors and change in drug use norms over time. A team of researchers independently coded all remaining transcripts with the final coding tree, periodically checking for consistent use of codes. An in-depth description of the analysis has been outlined previously (Mazhnaya et al., 2021).

After this initial coding of each transcript, two members of the research team constructed a summary profile for each participant that explored several categories, such as needle and syringe acquisition, drug sharing and splitting, needle sharing behavior, and changing norms around drug use, relation to place of drug use. We subsequently analyzed these profiles across participants to identify patterns related to the higher-level domains of acquisition, use, sharing, and norms related to needle and syringes.

2.4. Quantitative data analysis

The primary aim of the quantitative analysis was to explore variation in risk and protective behaviors that occurred within the last 90 days in the places where participants reported cooking or using drugs. First, we used descriptive analyses to characterize survey participants, including gender, employment, education, HIV status, and HCV status. Next, we quantified the number of “needle acquisition spaces” described by survey participants. Last, for each behavior measured in the survey, we summed the number of reported behaviors in each place and classified them into three mutually exclusive categories: 0 times, 1 time, or ≥ 2 times. These categories were informed by measures of central tendency (data not shown). For example, the survey asked participants to answer the following question for each drug use place: “How many times did you choose the drug from a common container, which was used by other people?” For each place, we calculated the number and percentage of times that participants reported this behavior, and classified these as 0 times, 1 time, or ≥ 2 times. We performed all statistical analyses using STATAv.14 (2014) (StataCorp, 2015).

2.5. Data synthesis and triangulation

Following completion of the separate quantitative and qualitative analyses, we compared findings across the two data sources to examine concordance and contextualize the quantitative results. This integration occurred for each of the main domains in the quantitative survey (acquisition of needles and syringes, drug procurement-related behaviors, drug injection-related behaviors); we used a side-by-side comparison joint display to juxtapose the quantitative reporting of behaviors in the survey with quotations from the in-depth interviews that explored participants’ behaviors, including the social norms and environment that shaped these experiences (Guetterman, Fetters, & Creswell, 2015). All names below are pseudonyms.

3. Results

3.1. Study populations

Of the 30 participants who completed the in-depth interview, 22 were men (73 %) and 8 were women (27 %) (Table 2). The mean age of interview participants was 37 years. About one-third of participants indicated being employed (full or part time) at the time of interview (10/30; 33 %) and 21/30 (70 %) reported being unable or barely able to meet their financial needs. Two-thirds of participants (19/30; 63 %) completed technical school or some higher education. Nearly half of participants self-reported living with HIV (13/30; 43 %) or HCV (12/30; 40 %) infection.

Table 2.

Select characteristics for participants in the quantitative survey and qualitative interviews¹.

Characteristic	Quantitative survey (N = 149)		Qualitative interviews (N = 30)
	Number	Percent	Number	Percent
Gender
Male	106	71	22	73
Female	43	29	8	27
Employment status
Working full- or part-time	81	54	10	33
Not working	66	44	20	67
Educational status
≤9 years	32	21	2	7
10–12 years	28	19	7	23
Technical school or some college	77	52	19	63
Finished higher education	12	8	2	7
Financial situation
Unable to meet needs	14	9	14	47
Barely able to meet needs	55	37	7	23
Able to meet needs	79	54	9	30
Living with HIV	66	44	13	43
Living with HCV	71	48	12	40

¹Numbers may not sum to the totals because of missing or unknown data.

In the quantitative phase, 149 participants completed surveys; 1 survey was excluded from final analysis due to incompleteness. Most participants were men (106/149; 71 %). Around half of participants reported working regularly or occasionally at the time of the survey (81/149; 54 %) and described being unable or barely able to meet their financial needs (69/149; 46 %). Just over half the sample (77/149; 52 %) completed technical school. Similar to participants from the qualitative interviews, almost half of those who completed surveys reported living with HIV (66/149; 44 %) or HCV (71/149; 48 %) infection.

3.2. Acquisition of needles and syringes

In the quantitative survey, participants reported 179 unique places where they obtained needles or syringes in the past three months. They categorized most of these places as pharmacies (150/179; 84 %), with some respondents naming a specific location or network of pharmacies. Participants in the qualitative interviews also reported consistent use of pharmacies to acquire syringes, describing how the accessible hours and locations of pharmacies in Dnipro made this a convenient and consistent way to obtain new drug injection equipment. The broad availability of syringes through pharmacies and their cheap price enabled use of new syringes when injecting drugs, as illustrated by one participant: “In general, we use new [syringes] as a rule. You can easily buy syringes” (Ruslan, male, 27 years old).

Furthermore, participants highlighted how packaged syringes from pharmacies may provide protection and safety during encounters with the police: “We always buy new syringes at the pharmacy…[it’s] unsafe to carry [syringes] with you in case they stop you…Well packaged ones, I can say that I’m sick with something, so I went to the pharmacy and bought it” (Ivan, male, 18 years old).

In addition to pharmacies, participants reported obtaining syringes at non-governmental organization needle distribution sites, including mobile facilities (19/179; 11 %). The other sources of syringes listed in the survey included hospitals or other medical services, from volunteers, and on the street (unspecified). However, the location and operating hours of syringe services restricted their use and resulted in participants choosing to pay for syringes at pharmacies, despite the option of free syringes at needle distribution sites:

Interviewer: Which is more comfortable for you, to buy syringes from the pharmacy or to go and exchange a syringe at the syringe exchange site?

Respondent: From the pharmacy, most likely.

Interviewer: Why is that?

Respondent: Well, it takes less time and…a pharmacy, you know, they operate at every corner, whereas the sites are only in certain locations. And a pharmacy is available left and right, it’s quick…This specific pharmacy is located very near my home…I walk past it all the time.

Interviewer: Is that more convenient?

Respondent: Yes, more convenient. And it offers low prices, so that… it’s a trifle, but I sure do need syringes.

(Pavel, male, 40 years old)

Accessibility of injecting equipment influenced participants’ decisions around using new syringes, and participants described how place and other people occasionally led to reuse of syringes. For example, one participant illustrated how restricted access to syringes in prison necessitated reuse of others’ syringes: “I got HIV and hepatitis in prison…because in prison you have problems finding new syringes, and you know how it happens: ‘Are you healthy? - Yes, I’m healthy - Well, let me use your syringe after you shoot up’…I would never do this out of prison” (Stas, male, 30 years old).

3.3. Drug procurement-related behaviors

In the quantitative survey, participants reported 315 places where they cooked or injected drugs in the last 90 days (Table 3). Respondents visited these places consistently, with most places frequented on either a daily basis (144/315; 46 %) or several times a week (78/315; 25 %).

Table 3.

Risk and protective behaviors reported at injection and/or cooking places (N = 315) by respondents to the quantitative survey.

Behavior reported per place	Number of places	Percent
Drug procurement-related behaviors
How many people did you give your syringe for filling it for you?
0	168	53 %
1	100	32 %
≥2	47	15 %
How many times did you choose the drug from a common container, which was used by other people?
0	148	47 %
1	41	13 %
≥2	126	40 %
With how many different people did you fill the syringe in front or behind?
0	120	38 %
1	71	23 %
≥2	124	39 %
Drug injection-related behaviors
After how many different people have you used their needles or syringes?
0	288	91 %
1	25	8 %
≥2	2	1 %
How many times did you use cotton (filter) or flushing water after another person who used drugs before you?
0	283	90 %
1	20	6 %
≥2	12	4 %
How many people have you allowed to use a needle or syringe after using it yourself?
0	263	83 %
1	39	12 %
≥2	13	4 %

When examining behaviors involved in the drug procurement process, around half of respondents reported sharing equipment (Table 3). In the places where they cooked or injected drugs, about half of survey participants reported giving their syringe to 1 or more persons for filling (147/315; 47 %) and/or drawing drugs from a common container 1 or more times (167/315; 53 %). Front-loading and back-loading were the most frequently endorsed behaviors, with more than half of survey participants responding that they filled a syringe in front or behind 1 or more persons (195/315; 62 %).

Interview participants provided several examples of the places and circumstances in which these behaviors occurred. These contexts were heavily shaped by the participant’s method for drug procurement—buying ready-made drugs hand-to-hand from a dealer or “chipping-in” with other PWID to purchase a stash. The drug procurement method, in turn, shaped the places visited by PWID. Buying hand-to-hand typically involved meeting at the seller’s location; participants described meeting sellers in multiple settings, including on-the-street or in their dealer’s apartment or home. Contrastingly, stash-based purchasing required traveling to a specified location to obtain the drugs and then, often, communal preparation with other PWIDs, a process that often occurred in residential apartments.

Throughout the interviews, participants illuminated how these unique places influenced social norms and behavior. For participants who purchased drugs hand-to-hand, the behaviors of giving a syringe to another person for filling and receiving drugs from a common container were often intertwined. After participants transferred money for the drug, they often observed the dealer drawing their dose from a common container, as described by one respondent who purchased drugs hand-to-hand on the street: “[The dealers] have “fanfurik“ - a small glass jar. There are around… I do not know…fifty-one hundred cubes there… And they draw (the drug) from the jar with a syringe… a normal, a sealed one, 2ml” (Evgeniy, male, 29 years old). Participants described similar experiences in other settings, including another participant who illustrated giving another person (a dealer) their syringe for filling in the dealer’s residence:

Respondent: I enter the room, give money…I unpack a syringe, I give the syringe, they pour [drugs for] me.

Interviewer: Where from, from some container? What is it?

Respondent: Well, it’s usually a 20-cc syringe…It’s the container from which they pour. They take, say, as much as I give them money for, they draw, pour [drugs for] me and give it to me. I inject.

(Oleksiy, male, 51 years old)

In addition to this mechanism for filling syringes when purchasing drugs hand-to-hand, respondents described other approaches as well. For example, in one dealer’s apartment, either the participant or the dealer poured the dose: “I take my syringe… Unpack it. If I need a milliliter, I draw in a milliliter…I pull the piston back to leave an empty space of one unit mark, I pull it by one centimeter. I take…or [the dealer] takes it and pours specifically one milliliter in there” (Vanya, male 40 years old).

Behaviors presented differently among participants who used stash-based purchasing. Communal preparation and distribution of a shared stash often occurred in a common container, as shown by one participant who cooked drugs from stashes with group members in an apartment: “When we have a dish, then everything is set. By all means, we pour it in and cook it. It is cooked quickly these days. We used to spend two hours on making it, and now…20 minutes later, we are receiving an injection” (Pavel, male, 40 years old). Participants mentioned use of multiple types of common containers to cook drugs, such as ladles, metal bowls, saucepans, bottles, and buckets.

After cooking the stash, participants often stated that each group member poured their individual dose: “Everyone takes the amount… They pour into syringes and that’s it” (Veronika, female, 34 years old). Participants described this process—which does not involve giving a syringe to others for filling—in both public (e.g., park, ravine) and private (e.g., friend’s apartment) locations. While interview respondents who purchased stashes described individually filling their syringes, this behavior often occurred in front or behind of another person. For example, one participant, who partners with an acquaintance to purchase and prepare stashes in an apartment, illustrated front-loading:

Respondent: We’ve cooked 50 cubes, we have drawn it in two 20 ml syringes and one 10 ml one, three syringes. And the ones we use to shoot up, we open them at the last moment, right before the injection…unpack them, pour the drug into them, shoot up and that’s all.

Interviewer: From this big one he pours it into a small one.

Respondent: Yes…He pours it into the syringe from the syringe.

Interviewer: Into the tip?

Respondent: Yes, he opens it, takes off the needle, and pours it.

Interviewer: I see. Tell me please, does he always pour it into the new syringes?

Respondent: Well, of course, always the new ones.

(Stas, male, 30 years old)

Regardless of the mode or place of drug procurement, interview participants emphasized the importance of using new injection equipment when engaging in behaviors related to drug acquisition. For example, one participant, who purchased drugs hand-to-hand on the street, described a requirement to supply or purchase a new syringe to give to the dealer for filling:

Respondent: And here [in the garages at on city outskirts] they sell drugs too…I gave money, a syringe. They poured me (a drug).

Interviewer: The same system or are there any other rules?

Respondent: Everything is the same there. No, it is the same everywhere.

Interviewer: So they also have syringes with them?

Respondent: No. I came with my syringe there. They just have a jar, I mean, with a sealed syringe. If you come with an unsealed one – they will also turn you down, well, they will not give you drugs.

(Evgeniy, male, 29 years old)

When discussing splitting drugs from a common container, interview participants also discussed the need for new syringes, as one participant articulated when describing the process for drawing drugs from a shared iron bowl: “With a syringe…of course, a new, unpacked one! Everyone (pours it) in his own syringe and we shoot up” (Nestor, male, 27 years old). When questioned about the location where drug splitting occurs, Nestor emphasized the consistency of behavior and norms across different places:

Interviewer: And where do you do this?…

Respondent: At my place, at [my close friend’s] place, anywhere. It doesn’t matter. In a nearby park…

Interviewer: How can you do this in a nearby park?

Respondent: The same way we do it at home, just in a nearby park.

Interviewer: Will you tell me?

Respondent: Well, everything is the same, only use a burner instead of a cooking range. A jar with a rubbing alcohol…, well, you put a cotton wool, soaked with alcohol in a bottle neck, you set it on fire and it burns…

Interviewer: Do you bring a bowl with you?

Respondent: Well, yes.

Interviewer: And the water?

Respondent: Well, of course. I bring it too.

Interviewer: And what kind of nearby parks are these? Any nearby parks?

Respondent: Absolutely any nearby parks where no one will distract you, no one will walk around.

Last, in parallel with the other behaviors related to drug procurement, respondents described use of new syringes when front- or back-loading across different settings. When partnering with workplace colleagues to purchase drugs, and then subsequently prepare and distribute these from a shared syringe, one participant stated: “[Reuse of personal syringes] does not happen nowadays…there is a new one by all means, if you inject additionally, you will use a new one by all means. If you do not have it, you go over and buy it” (Ruslan, male, 34 years old). Some participants also noted use of other harm reduction measures when filling syringes in front or behind of others: “We split all this among three of us… everyone has a new syringe, we open them…We pour a cube and one to one person, a cube and one to the second one, and a cube and one – to the third one. And that’s all…I always use alcohol wipes” (Roman, male, 27 years old).

3.4. Drug injection-related behaviors

While around half of respondents endorsed engagement with behaviors that increase risk for HIV acquisition during drug procurement, participants reported generally avoiding sharing equipment during injection. Respondents reported minimal reuse of other people’s needles or syringes (27/315; 9 %) (Table 3). Findings from the qualitative interviews echoed this result, with many providing strong affirmation of “always” using new needles or syringes, including the following participant who repeatedly reinforced this social norm:

Interviewer: Does [your friend] have syringes available most of the time?

Respondent: No, I buy them, we come over, either he buys them, or I do. We always use new ones. We do not reuse syringes.

Interviewer: And haven’t you ever reused them?

Respondent: No, never.

(Denis, male, 30 years old)

This standard of using new injection equipment spanned the different places where participants injected drugs (e.g., on the street, public parks, residential apartments, workplaces). Despite consistent reinforcement of this social norm, participants also described how injection behavior varied based on their surroundings. Many participants expressed a preference for injecting at home because it was a more comfortable environment. Denis elaborated about his own preference for where to use drugs, “Most likely I go home, because doing it at home is more calm and cleaner.” Participants juxtaposed the comfortable home setting with injecting in the street, a setting that necessitated “quick” action:

Interviewer: Do you always shoot up at home?

Respondent: No, why always? Not always.

Interviewer: And how does it happen sometimes?

Respondent: Well, you can go behind the garages. Well, if…you’re going to some other place, you will not carry it around with you. You go somewhere, you shoot up quickly, that’s it…

Interviewer: How much time does it take?

Respondent: About 40, 30 s. It’s fast.

Interviewer: How often does it happen that you use drugs not at home?

Respondent: Well, not so often; mostly I try to go home.

Interviewer: And why do you try to go home?

Respondent: Well, at home it’s more comfortable, it’s better at home…

(Oleg, male, 42 years old)

This interaction between public injection and the need to move rapidly has been well-documented in research (Mazhnaya, 2018; Spicer et al., 2011, Mimiaga et al., 2010), and participants in this study provided additional evidence of how creating private and sterile places to inject drugs promotes the health and safety of PWID: “If they allowed some nice little shops, specifically designated for…people to inject there…just to make sure everything is sterile. And there would be no HIV or other things, or at least there’d be less of it. Because, being scared of cops,’come on inject it quickly’, he makes a shot, the other one draws in, uses the same syringe and gets infected” (Rostik, male, 35 years old).

Participants also reported not allowing people to use a needle or syringe after using it themselves in most places where they cooked or injected drugs in the survey (263/315; 83 %). Participants described how this behavior is currently viewed as both infrequent and unacceptable, despite being a “common practice” in the 1990s and early 2000s: “I remember at the beginning, when we just started, this syringe, instead of washing it, they would go pee on it. Everyone shoots up with the same syringe…Now everyone is afraid of HIV. There is no such thing already that someone shot up, give me your syringe to shoot up…and before it was common practice” (Tetiana, female, 42 years old). Participants linked this shift in norms to several factors, including the emergence of HIV (as highlighted by Tetiana) and the increased accessibility and affordability of syringes. Participants reiterated this current norm of using new injection equipment by describing repercussions for PWID who violate it by reusing needles or syringes:

If you are in normal company [в коМпании норМальной], where people are normal, then, of course, everyone always uses clean, sterile, new ones. And if these are just some creeps, total freaks, then I saw those who are looking… picking (syringes) up straight from the floor… They don’t do this in your presence, because they understand that you will beat them up for this. Of course, you will not let this happen, because you’re just going… to kick her!… But when no one sees this, yes, of course, they do this.

(Nestor, male, 27 years old).

By using the adjective “normal” to describe people who do not reuse or share injection equipment, Nestor employed a shorthand echoed by other participants. A “normal” PWID represented someone who was in control of their behaviors and environment and did not act in a way that was harmful or dangerous to themselves or others. While sometimes respondents referred to non-PWID as “normal,” PWID could also be normal if they did not violate social norms around sharing injection equipment. Participants often characterized themselves as normal because they adhered to these norms and contrasted this adherence to norms with PWID who were “reckless” and “hopeless” (Evgeniy, male, 25 years old).

Despite many participants’ sanctioning of current norms related to using new, unopened drug use equipment, participants also illustrated the conditions that led to reuse of syringes. These situations often involved personal reuse in a solitary setting where the social norms reinforcing use of new syringes may not be present. For example, one participant reported reuse of personal needles and syringes at home and “late at night” when obtaining new equipment may be inconvenient:

Interviewer: Have you ever seen someone drawing a drug with a used syringe?

Respondent: Well, of course, not in someone’s presence. Because no one will allow it…they can even beat you up for this.

Interviewer: So you’ve never witnessed such a thing?

Respondent: No, of course not. And if I have, I would not have drawn a drug from there after that. Even if I was feeling bad, I would turn around and leave.

Interviewer: Tell me please…do you always have a syringe?

Respondent: Well, of course, always. Let’s say, it’s late at night, I don’t feel like looking for a syringe, going to a drug store…then I can take my own syringe, which I shot up with…rinse it with water and shoot up with it in the morning. Well, I mean, I can do it with my own syringe several times.

(Nestor, male, 27 years old)

Participants reported similar experiences in other isolated settings as well; these descriptions framed personal reuse as an exception to “always” using new syringes and highlighted additional factors (e.g., money) that influenced this behavior. One participant who injected drugs in a “not very clean” public toilet stall stated:

Respondent: I always try to use a new syringe. But, it happens that…Well, first of all, it’s my (syringe) which I use repeatedly… I wash it, of course, before this…I wipe a needle with a napkin…I clean it with alcohol wipes…

Interviewer: And tell me, do you wash it immediately after the injection or before the next one?

Respondent: No, right after the injection, if I know that I’ll still need it, and I do not have the money, I wash it right after the injection. So, for the needle not to become blunt, well, not to get clogged up, for the blood not to dry up in the needle. I do all this right away, I wrap it in a bag and that’s it.

(Volodya, male, 28 years old)

4. Discussion

This article used in-depth interviews and a survey to explore the interaction between HIV/HCV risk and protective behaviors, social norms, and place among PWID in Ukraine. Participants in both the quantitative and qualitative data sources reported obtaining syringes primarily at pharmacies. This preference remained despite the need to pay for syringes at pharmacies, rather than obtain them for free through needle exchange programs, and underscores how strongly convenience shapes how participants obtain syringes. In addition, the finding that participants perceived packaged syringes purchased through pharmacies as protective against potential negative encounters with police parallels research from Ukraine and elsewhere (Beletsky et al., 2014; Mimiaga et al., 2010; Spicer et al., 2011). Even though participants endorsed not sharing or reusing syringes in both data sources, the qualitative data revealed the contexts in which participants either justified or felt compelled to share or reuse injection equipment. These situations often involved restricted access to syringes, such as in prison or late at night, as well as solitary environments where the impact of social norms may be more limited.

Participants described diverse motivators for using new needles and syringes, including practical, protective, and symbolic factors. Participants also expressed strong social sanctioning against reusing needles or syringes. These reasons reflect many years of public health campaigns and programs to normalize using new injection equipment, indicating that norms can be changed and that they can become deeply ingrained in the culture and behaviors surrounding injection drug use. Significant prior work has aimed to change drug use norms in Ukraine, particularly peer and social network–based approaches (Booth et al., 2009, 2011). These efforts should be adapted to account for the changing drug market in Ukraine (Mazhnaya et al., 2021) and build on the existing norms that support use of new injection equipment. However, while public health campaigns targeting PWID have contributed to shifting norms around needle/syringe sharing, drug dealers and sellers have not been targets of behavior change campaigns. While such interventions may present logistical and legal barriers, public health campaigns to change how PWID interact with sellers in these markets could be an important part of “closing the gaps” in the contexts in which reuse of drug injection equipment persists. Furthermore, despite participants’ strong endorsement of using new injection equipment, HIV prevalence and incidence remains high among PWID in Ukraine, pointing to the need for further investigation of HIV transmission risk during drug sharing, especially for behaviors impacted by changing drug market dynamics (e.g., drawing from a common container) (Mazhnaya et al., 2021).

While participants consistently reported “only” using new syringes, they also described the circumstances that may lead to reuse of drug injection equipment. Participants further illustrated how protective behaviors (e.g., using new syringes) often co-occurred alongside risk behaviors (e.g., drawing from a common container) in the same setting and interaction. These rich accounts provide critical insight into opportunities for both behavioral and structural interventions. Prior research in other contexts strongly indicates that changing norms and behaviors around injection drug use is only possible if new needles, syringes, and other injection equipment are accessible, affordable, and endorsed (i.e., not stigmatized), whether through pharmacies (Davidson, Martinez, Lutnick, Kral, & Bluthenthal, 2015), needle and syringe exchange programs (Aspinall et al., 2014), or syringe vending machines (Otiashvili, Kirtadze, Vardanashvili, Tabatadze, & Ober, 2019). Providing access to safe injection equipment is a critical harm reduction technique, especially ensuring maximal convenience of these resources for PWID. These harm reduction services must be in places where people procure, prepare, and inject drugs to increase the likelihood that they will be available during unpredictable drug use situations (Owczarzak et al., 2022). These services must also consider the complexity and co-occurrence of both risk and protective behaviors.

Last, we must note that these findings on drug use norms and proposed applications occur within the broader sociopolitical context of Ukraine. Carroll (2019) argued that PWID in Ukraine constitute an undesirable “other” in the social order. Participants drew on this “othering” language when describing other PWID in this investigation (e.g., drawing boundaries between “normal company” and “total freaks”), highlighting potential internalization of belonging to a “toxic” and “socially dangerous” group. Additionally, Russia’s invasion of Ukraine in February 2022 has the potential to undermine the ability of PWID to obtain and use new injection equipment. Many pharmacies have closed, and the supply of new needles and syringes may be limited in those pharmacies that remain open. Nongovernmental organizations continue to provide mobile syringes services and other programs for PWID, but the COVID-19 pandemic and Russia’s invasion have reduced the capacity of these programs. Safety concerns in a context in which Russia deliberately targets health care facilities, internal displacement of service providers and PWID, and supply chain disruptions may undermine access to safe injection equipment and the ability of PWID to practice safe injection behaviors.

4.1. Limitations

This study had several limitations. To include the viewpoints of PWID who were not clients of service agencies, we used participant referral and street-based recruitment. While this study did not routinely collect information on referral source, most enrolled participants had some relationship to a service agency. Therefore, findings may not reflect the experiences of the most marginalized PWID in Ukraine. While most participants in both the quantitative and qualitative data sources reported limited sharing of needles and syringes, many qualitative interviewees endorsed “always” engaging in this behavior. This especially strong affirmation of not reusing others’ syringes in the interviews may have been influenced by social desirability bias, as we collected these data in-person, whereas the quantitative data were gathered on a computer. Furthermore, in specific instances, interviewer questions (e.g., “Tell me please…do you always have a syringe?”) may have prompted respondents to report socially desirable behaviors. Triangulation of the qualitative findings with survey results allowed for deeper interrogation into the specific contexts in which drug use behaviors occurred. Additionally, interview participants were not consistently asked to elaborate on where they obtained their syringes and interviewers did not significantly probe to understand when and how drug injection equipment other than needles and syringes (e.g., cookers, rinse water) was shared. Last, we did not investigate differences in the relationship among drug use behaviors, place, and social norms by gender or other demographic characteristics. Gender plays a crucial and complex role in shaping drug use practices and access to essential services; future research should investigate this topic (Owczarzak, Fuller, et al., 2023; Owczarzak, Phillips, et al., 2023; Owczarzak et al., 2021).

4.2. Conclusion

The HIV epidemic in Ukraine is dynamic and has continually evolved in response to public health campaigns, changing norms, and new technologies. While today the country has fewer new HIV infections among PWID than in the past, injection drug use continues to represent a significant route of new acquisition. The persistence of high rates of HIV infection among PWID indicate that work around harm reduction must continue. In addition to easily accessible and affordable drug injection equipment, programs that reinforce strong social norms against reusing and sharing drug injection equipment should be supported. PWID need to be given the skills and resources to practice safe behaviors in all places.