We conducted 12 focus group discussions (6 per city) with six to 10 participants per group and 100 total in Khorog (n = 47) and Kulob (n = 53). All 100 participants were male and ranged in age from 20 to 78 years with a median age of 43 years. The mean number of injections per week was 15 (range 1–35); 75 % reported obtaining needles and syringes from NSPs.
Below we present the results of the analysis in line with the key themes identified - availability and purity of drugs, preparation and injection practices, and injection-related risks.
Drugs consumed, availability, price and purity
In both cities, the vast majority of participants reporting injecting cheap Afghan heroin almost exclusively, however, a few participants mentioned injecting acetylated opium (“khanka”). According to focus group participants, a very small fraction of heroin users, mostly beginners, use heroin by smoking or snorting instead of injecting it. Most of those who smoked or snorted heroin when they started reported shifting to injection because of the limited supply of heroin and constantly increased tolerance towards drug. A few participants in Kulob mentioned a specific type of drug (“crystal” or “synthetic” heroin, “Chinese” heroin), which is sold as heroin but looks slightly different from the regular heroin and “glitters like a glass”. Solutions of this type of “heroin” “become like alabaster in the syringe”, can cause sharp pain in a limb, and can increase the probability of overdose. The chemical composition of this “crystal heroin” is unknown. One participant mentioned injection of Tropicamide eye drops to “relieve agonies (withdrawal syndrome)”.
Participants in all focus-group discussions mentioned limited availability (compared to previous years) of heroin on a local black market. Almost all participants reported that suppliers heavily adulterate heroin available for end users. Most participants believe that drug dealers in Aghanistan and Tajikistan adulterate heroin, with dealers in Tajikistan being blamed the most. According to participants, dealers mix heroin with sugar, medicines such as antihistamines, specifically Dimedrol (Dyphenhydramine), non-steroid painkillers (Acetaminophen, Analgine, Baralgine), psychotropic drugs (Zopiclone), calcium chloride and oral rehydration salts. Some participants reported that drug dealers may use such admixtures as flour, lime powder, alabaster. When heroin is in short supply, drug dealers cut it more heavily. The retail price of heroin depended on a purity and quantity purchased, but on average was about $10 (50 Somoni) per gram, while one average dose (“shponka”, approximately 0.15 g) was about $2 (10 Somoni) at the time of data collection. More pure heroin sold for $20 (100 Somoni) per gram.
Preparation of drug solution
Many participants reported that they usually injected in groups of two or three people, usually the same people and rarely with strangers. They reported preparing heroin in a variety of metal (spoons, metal cups from safe injection kits), glass (bottles, vials) and plastic (bottle caps) mixing vessels. Many participants mentioned mixing heroin with other medicines. “Half [of people] use Dimedrol, half do not” (FGD#8, Khorog), usually adding one or two crushed tablets to the cooker per dose of heroin. The main reason for adding Dimedrol is to potentiate the effects of heroin “so the high is stronger” (FGD#11, Khorog), particularly if the amount of heroin is small or it is heavily adulterated. However, some participants reported adding Dimedrol to avoid nausea caused by heroin. Although people usually used Dimedrol tablets, they also use liquid Dimedrol in ampules, which they substitute for water to dissolve the heroin. Although somewhat less common, people occasionally add non-opioid painkillers containing Metamizole (Analgin) or Paracetamole. Some participants reported using alcohol to potentiate the effect of heroin and “get more high (from a dose)”.
Many participants reported injecting with sterile water in ampules provided by NSPs. When sterile water is not available or a person is in withdrawal, people may use water from a tap, river, ditch or a rainwater puddle. People usually use from one-half ml to one ml of water per dose of heroin, using more water when two or more people inject together. Some participants believe that adding more water to the solution makes it less concentrated resulting in weaker effect, while others preferred to add more water making it appear like a larger dose, which is more comforting psychologically.
Sometimes, users filter and heat the drug solution but these steps can be skipped when the powder is easily soluble. The drug solution must be heated when “…there are kinds of drugs that do not melt, do not get dissolved” (FGD#8, Khorog) and to make sure “there is no infection there, so all extra stuff gets burned there” (FGD# 10, Khorog). Some participants reported that boiling causes the drug solution to thicken and gel if it contains certain impurities, making it impossible to inject. A few participants also believed that injecting hot, uncooled drug solution can cause hepatitis and/or other liver damage. The overall agreement was that “…heroin is a universal drug; if you want you can boil the solution, or mix it with cold water, or with water from a ditch. It will go” (FGD#3, Kulob).
Participants reported using filters supplied by the NSP or using improvised filters from a cotton swab or a cigarette filter. Prior to drawing drug solution into a syringe through a filter, many participants reported removing the needle to reduce the risk of the needle becoming clogged or accidentally jamming it into the cooker and dulling it. Others draw the solution through the needle using a piece of cotton rolled over the tip of a needle as a filter. Filtering the drug solution reduces the presence of solid particles that can clog the needles, which allow people to inject with thinner needles that do less damage to veins.
Drug division and injection
The rules regarding division of heroin purchased by two or more people vary depending upon situational factors. Often, the person who contribute the most money receives the largest share of heroin. In other cases, people apportion the heroin based on individual dosage needs (e.g., tolerance, presence of withdrawal symptoms, etc.). Despite these “rules” people often divide the drug equally regardless of who paid how much - for example, between good friends, or if a person paid less (or no money) but helped to find and to buy heroin. Cheating during division of drug is not common and is not tolerated. The rules of drug division are negotiated in advance. Although heroin can be divided either before dissolving (the powder is divided) or after dissolving (the liquid is divided), none of the focus group participants reported dividing powder heroin. When liquid is divided, PWID may prepare the drug in a common container and then take turns drawing it into their syringes. Alternatively, they may draw everything into one relatively large volume syringe and then transfer it into individual syringes by frontloading (i.e., inserting the needle of one syringe into the tip of another syringe (with the needle detached from the latter syringe). Frontloading may also happen if one of partners accidentally draws more solution than agreed.
Many participants mentioned that they check if the needle is in the vein by drawing some blood into the syringe, calling this practice “kontrol’ka” in Russian slang language. If the needle hub is translucent, they need to draw less blood; if it is opaque, they need to draw more blood into the syringe. Many participants reported the practice of “flushing” any residual drug solution from the syringe by drawing additional blood into it and reinjecting the blood. Others may add some more water to the syringe to use the leftover. However, a substantial share of participants, primarily in Khorog, stressed that they do not try to use the drug leftovers because it does not matter much for them.
Dosing and frequency
For many heroin users, the amount of money they have strongly determines the number of times that they inject heroin and the amount of heroin in each injection. Some participants mentioned that PWID would inject as much heroin as they can get, up to 3–5 g in a day. Others mentioned that because heroin is heavily adulterated, people needle inject larger amounts of it. When heroin users have trouble obtaining heroin, they often use less, perhaps only a fraction of a gram per day. In general, the most common frequency of injection is 2–3 times per day. Participants reported that as with the daily dosage, the frequency of injection depends on the amount of heroin available. When little heroin can be found, people only inject 1–2 times a day. Many participants said that when plenty of heroin is available, most people will consume it all in one or two days by injecting more frequently, 5–6 times a day or every 2–3 h. Some participants indicated that they have to inject more frequently due to the lower potency of heroin.
Use of sterile equipment
Focus group participants agreed that NSPs are the primary source of needles and syringes for most PWID, but many PWID also obtain needles and syringes from pharmacies. The choice of source depends on several factors: location and distance, time (NSP do not work on weekends or after regular office hours), range and quality of the injecting equipment, and availability of money to buy syringes. In some cases PWID get syringes from a relative or a neighbour who works in a hospital. The main advantages of NSP are free injecting equipment and the possibility of getting many syringes (although in Kulob some participants mentioned limited daily quotas of three syringes) as well as the convenience of receiving syringes from outreach workers (without the need to visit the NSP site). It was acknowledged that unlike other health care providers, NSP staff have nonjudgmental and empathetic attitude towards PWID. However, NSP disadvantages are limited hours and days of operation and the need to commute to the site if outreach workers are not around.
Accordingly, many participants reported that they also buy syringes in pharmacies. This is particularly common if they are experiencing withdrawals from heroin and are unwilling to wait for an outreach worker or travel to the NSP site. Unlike NSP, pharmacies are open for extended hours seven days a week, are located everywhere and can be easily accessed when people need syringes in a hurry. In addition, syringes are relatively cheap (0.25 Somoni, or approximately 0.05 USD as per exchange rate in 2014) and most pharmacists will sell them. Nevertheless, several participants reported that some pharmacists scold PWID who try to buy syringes, and some pharmacists refuse to sell syringes. Pharmacists may suspect that a buyer is a drug injector if the latter asks for both a syringe and Dimedrol. Another concern with the pharmacies is harassment by police who may wait outside of pharmacies looking for potential PWID. Some pharmacists may report suspected PWID to police. The quality of syringes in pharmacies may also be lower as compared to NSP since pharmacists do not take into account specific needs of PWID while ordering syringes.
Unsafe injection practices
Almost all participants in Khorog and many in Kulob reported using sterile needles and syringes only. PWID appear to have accurate and sufficient knowledge about risks of sharing needles and syringes. Many reported that they had shared needles and syringes before they were aware of HIV transmission risks and before sterile instruments were widely available through NSPs. As stated by one participant “…since [NSP] started working, we use one thing only once, then throw it away” (FGD#1, Kulob). Participants reported that PWID rarely share syringes anymore and generally only in situations when someone is in acute withdrawal and sterile syringes are not available.
“…it happens, say, they are sitting there, and no syringes, and he is in agony [from withdrawal], so he would take [the used syringe] from anywhere, he is sick [from withdrawal], he has no money even to buy a syringe, or to go [to get a syringe], he is in agony…” (FGD#8, Khorog).
In some cases, one “…would shoot half of it and then would give it to another one, so he shoots up another half [of the solution]” (FGD#12, Khorog). In other situations “…if there is no [other syringe], one would hit, then another one would wash it and draw [the rest of solution] for himself” (FGD#1, Kulob). Some participants mentioned replacing the needle and injecting with a shared syringe.
“We would clean it, then replace the needle, that’s it. (Many voices): just the needle, just would replace the needle, that’s it” (FGD#11, Khorog).
A number of participants mentioned that many young injectors lack awareness and knowledge regarding injection risk behaviors. Consequently, young injectors may share syringes and engage in indirect sharing practices.
“…these young ones, beginners, I personally saw them [sharing]. …he also was there, sitting, and he was without a syringe, so he is like, “Bro, give me one, so I shoot too”. And I told him “What if I am sick, if I’ve got that disease?” But he, he is young, so he is like, “C’mon, c’mon, it won’t be a problem” (FGD#10, Khorog).
Although PWID rarely engage in direct syringe sharing, sharing other injection equipment (e.g., mixing vessels [i.e., cookers], cotton filters, rinse water) occurs much more frequently. Several participants report that many PWID use a shared container to prepare heroin. However, participants did not perceive any transmission risks because each person uses his own sterile syringe. If a PWID does not have any heroin, he may inject the residual heroin that remains trapped in a cotton filter from a previous injection, calling it “vtoryak” (second-hand drug) in Russian slang language. This may introduce risk if they use someone else’s vtoryak. In particular, cottons may be used by “… a beginner, when he starts [to use drugs]…and his dose is small, …so vtoryak is enough for him…” (FGD#10, Khorog). Moreover, a number of respondents reported on injecting equipment being re-used. According to the participants, after the injection they may rinse their own used syringes and hide them in some places to use later when no clean syringes are available. PWID perceive re-injection with one’s own syringe as acceptable and safe.
“If it is a situation where there is no [syringe], when you don’t have one, then I, for example, hide some [syringes] at the backyard of my house, so I know they are there, I would go take them, rinse them. They would be there for 10 days, 20 days. However, I will rinse them, they are mine, so I’ll shoot with them. But I would never use with someone else’s [syringe]” (FGD# 6, Kulob).
When syringes are reused, repeated rinsing with water is a common practice. Some participants reported using alcohol swabs provided by NSP for superficial cleaning of syringes when no water is available. While reusing one’s own does not place a PWID at risk of HIV or HCV transmission, if a PWID uses the syringe to add water to prepare drugs that will be split with another PWID it may place the other PWID at risk.
The setting in which PWID inject plays an important role in the process of drug preparation and injection. Many PWID prefer to inject in their homes due to perceived safety, and, in most instances, access to new injection equipment or their own equipment as well as sterile or boiled water. However, due to withdrawal symptoms or fear of arrest, PWID may decide to prepare the drug solution and inject on the street or in a secluded location (e.g., riverbank, mountain). In these cases, users often hurry and skip boiling water and filtering the drug solution, and use tap water or water from a ditch to prepare their drugs. Some participants mentioned that PWID in withdrawal prepare the solution right in the syringe, by pouring the drug into the syringe barrel, adding water and shaking it to dissolve the drug mixture.