Hepatitis C Risk and Protective Factors Associated With Drug Policies in the Republic of Georgia

• Author: Tamar Keshelava,Nato Ivanashvili,Dessa Bergen‐Cico,Mikheil Ivanishvili,Ketavan Sikharulidze
• Date: 01 March 2017
• Published date: 01 March 2017
• DOI: http://doi.org/10.1002/wmh3.213

Hepatitis C Risk and Protective Factors Associated With

Drug Policies in the Republic of Georgia

Dessa Bergen-Cico, Ketavan Sikharulidze, Nato Ivanashvili,

Mikheil Ivanishvili, and Tamar Keshelava

The hepatitis C (HCV) epidemic in the Republic of Georgia has been fueled by injection drug use

(IDU) and compounded by punitive drug policies. This cross-sectional study examined HCV risk

and protective factors among two high-risk populations in Georgia: people enrolled in opioid

substitution therapy (OST) (n ¼967) and people entering the prison system (n ¼500). Results

revealed that because of the universal HCV screening and treatment protocols within the prison

system, incarcerated individuals were more likely to be tested and aware of their HCV status (85

percent) compared to people in OST (73 percent). The percentage of people with HCV was higher

among OST patients (84 percent) than incarcerated individuals (60 percent); the percentage of

people in OST with HCV awaiting treatment was higher (25 percent) than incarcerated individuals

(0 percent). Logistical regression analysis revealed that NGO funding signif‌icantly predicted the

likelihood of being tested for HCV, knowing one’s HCV status, and being HCV negative. In

conclusion, the study found that the universal HCV testing and treatment of incarcerated

individuals provide a seemingly paradoxical opportunity for risk reduction and public health

protection by interrupting the chain of HCV transmission among these high-risk populations whose

vulnerability increases within the very system that also treats them.

KEY WORDS: risk factors, hepatitis C, opiate substitution therapy

Introduction

Harms associated with drug use include physical harms and public health

risks associated with drug consumption methods as well as social harms

associated with behaviors deemed illegal. The illegality of drug use and

associated behaviors also increases the risks of becoming involved in the criminal

justice system. Since 2006, the Republic of Georgia has exerted legal jurisdiction

over personal drug use (including past drug use) and the country’s drug policies

have focused primarily on supply reduction, repression, and punishment of drug

users, giving rise to increasing rates of incarceration. As a result, there is a

bidirectional relationship between drug use and incarceration in Georgia, because

people who use drugs are more likely to be imprisoned due to their involvement

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with illicit drug markets and illegal behaviors. Concomitantly, Georgia has

experienced a Hepatitis C (HCV) epidemic that has been fueled by the

intersection of risk factors linked to injection drug use (IDU), punitive drug

policies, and the country’s prison system.

Globally, IDUs are the group at highest risk for infection with HCV; and

Georgia is no exception with an estimated 70–92 percent HCV prevalence rate

among people who use drugs, and a 50 percent HCV prevalence rates among the

prison population (Bouscaillou et al., 2014). Our current study examines the drug

policies and public health practices in an emerging democracy (Georgia), which

faces challenges similar to those of many countries of the former Soviet Union—

namely IDU, homemade drugs, and IDU-related disease transmission (Tkeshe-

lashvili-Kessler, del Rio, Nelson, & Tsertsvadze, 2005; Van Hout, 2014). The aims

of our study are to examine the HCV-related risk and protective factors associated

with the intersection of Georgia’s drug policies and public health policies among

two populations at highest risk for HCV: prisoners and people addicted to drugs,

particularly IDUs.

Problem Drug Use Trends in Georgia

To understand the connection between drug use and HCV risk in Georgia, it

is important to examine problematic drug use trends among both the general

population and prison populations. The European Monitoring Center for Drugs

and Drug Addiction (EMCDDA) def‌ines problematic drug use as recurrent drug

use that causes actual harms to the person, or which places the person at a high

risk of suffering such harms (Thanki & Vicente, 2013). The Republic of Georgia

def‌ines problematic drug use more narrowly, limiting it primarily to IDU. Using

Georgia’s def‌inition of IDU as the key indicator of problematic drug use, the

prevalence rate of problematic drug users in Georgia is estimated at 2 percent

(n ¼49,700) of the population age 15–64 (Rukhadze, Chikovani, Goguadze,

Sirbiladze & Tavzarashvili, 2009). This represents a 25 percent increase in the

percentage of problematic drug users, since the f‌irst scientif‌ic benchmark study

was conducted in 2009 when the rate was estimated at 1.5 percent (Javakhishvili,

Kirtadze, Otiashvili, & Sturua, 2015). Problematic drug use encompasses stimu-

lant and depressant drugs that are consumed by injection. The drugs of

preference vary by age group; among people aged 18–25, homemade stimulant

drugs are most popular, whereas depressants and synthetic opioids are the drugs

of choice for people over 25 (Javakhishvili et al., 2015).

In 2014, Georgia signif‌icantly expanded the list of pharmaceuticals for which

a person needs a prescription in an effort to reduce the illicit use of prescription

drugs (e.g., Subutex). As a result of the decrease in access to pharmaceutical

drugs, there has been a concomitant increase in the development and use of

homemade drugs, most of which are injection drugs (Otiashvili, Tabatadze,

Balanchivadze, & Kirtadze, 2016). On the one hand, Georgia’s policies appear to

have greatly reduced access to pharmaceutical opioid-based drugs; however, the

strict policies are also indicated as a catalyst for increased development of

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