This article is based on a paper published in the Journal of Studies on Alcohol and Drugs on smart syringe vending machines (SSVMs). While it was not possible to provide a hyperlink to all articles used as the basis for this paper, they are listed in ‘Further reading’ at the end of the article. Introduction People who inject drugs (PWID) and men who have sex with men (MSM) are a driving force behind the HIV epidemic in the Eastern Europe and Central Asia (EECA) region. In the Republic of Georgia, research suggests increasing prevalence of HIV among PWID and MSM and points to the critical need to improve earlier diagnosis and to scale up the coverage and accessibility of combination prevention packages ( With an estimated 52,000 PWID and a 2.2% HIV prevalence among PWID, the country ranks third highest in the world for HIV prevalence among drug users. The availability of HIV prevention interventions among PWID, including low-threshold harm-reduction services, has expanded in the past decade. Harm-reduction services for PWID are available through 18 fixed harm-reduction sites (five in the capital city of Tbilisi) and eight mobile van-based laboratories for HIV and Hepatitis C virus (HCV) testing that also provide needle and syringe exchange services. In 2019, such services (testing and counseling, needle and syringe distribution, and other auxiliary services) were provided to about 28,000 PWID and their partners. Several studies have shown that syringe exchange programs are effective in reducing HIV and the hepatitis C virus (HCV) transmission risk among PWID. Available data suggest that SVMs are an effective and cost-effective intervention to supplement standard syringe exchange programs to access hard-to-reach groups that, for a variety of reasons, are not using facility-based services, and to cover underserved geographical areas (research shows that SVMs are an acceptable service delivery vehicle for Georgian PWIDs, with privacy, convenience, and uninterrupted (24/7) service mode being the most appreciated features. This article describes the features of an SSVM model developed for an implementation and effectiveness study and discusses its advantages for future research and expanded intervention delivery. Method parent study overview The parent study is a hybrid (implementation + effectiveness) cluster-randomized trial—Georgia Syringe Vending Machine Trial—to evaluate process and effectiveness outcomes associated with the introduction of SSVMs in Georgia. Within a three-year study period, ten SSVMs were installed and tested in Tbilisi. The study was conducted by the Addiction Research Center Alternative Georgia, in partnership with the Georgian National Center for Disease Control and Public Health, and the Georgian Harm Reduction Network, the primary provider of low-threshold harm-reduction services to PWID in the country. A critical aspect of the study is the successful partnership with PSP Pharma LLC, a large pharmaceutical network, which is collaborating with the project as part of its corporate social responsibility practices. Each of five harm-reduction sites in Tbilisi was assigned to manage two SSVMs and to supply consumables such as needles and syringes, alcohol pads, sterile water, and naloxone for distribution. The Addiction Research Center Alternative Georgia provides training, oversees the process, and provides the needed technical assistance to harm-reduction site personnel. Process and outcome data of interest (e.g., number of customers and their characteristics, number of sterile equipment kits distributed) are collected from all harm-reduction sites. Outcome data are collected through customer and provider surveys, administrative records, and SSVM software logs. Developing the smart syringe vending machine prototype Formative data collection The first year of the project was devoted to assessing needs, preferences, barriers, and facilitators for the SSVMs. Data were collected through customer and provider surveys, focus groups, and individual interviews. Mode of operation, specifications for sterile equipment and other consumables, locations for SSVMs, and means for interacting with machines were all based on analyses of formative data. Acceptability of SVMs in this group was extremely high, with the most highly endorsed features being uninterrupted free access to sterile injection equipment as well as privacy and anonymity. Local adaptation of smart syringe vending machines There are several unique, innovative features of SSVMs that are tailored to the needs and preferences of local PWID and the overall sociocultural context. SSVMs were installed near pharmacies and serve both the general population (with general health products for purchase) and PWID (with sterile equipment and other prevention consumables for free). Because of this, SSVMs are seen as a part of the usual pharmacy business and are not perceived as machines exclusively serving people who use drugs (PWUD); thus, their use is normalized (Figure 1).

Figure 1. SVM with (on the left) and without (on the right) a prevention poster to hide HIV prevention products

To further normalize SSVMs, the visible upper two shelves are stocked with general health products for purchase, whereas the lower three shelves that have PWID sterile equipment are covered by the HIV/HCV prevention poster so that the products behind them cannot be seen externally. The main menu on an LCD touchscreen displays a price list for general health products for sale. The ‘hidden’ interactive menu for the PWID customers is only displayed when a special plastic card is used in a specific area on the side of the machine, indicated by a sticker. Once the plastic card has been inserted, the PWID menu indicates the types of kits available in the machine. The customer can select the preferred kit by touching the screen. The machines have several types of kits: for stimulant users, opioid users, and an overdose prevention kit that includes naloxone as well as male and female condoms, pregnancy kits, and informational materials on HIV prevention and harm-reduction services available in the city. New clients in the syringe exchange program are offered the opportunity to use regular facility services—testing, counseling, and referral. Smart syringe vending machine software technology. A software infrastructure for the SSVMs was developed that comprises two main parts: the client software and the server. The client software runs on each SSVM, where it handles cash and plastic card operations and communicates each event with the server via the Internet. It handles the study website including online surveys (administered through the SSVM touch screen) and administration portals. It also receives requests, updates, and information from the SSVM and logs it all in an encrypted database, accessible only to the study team and the implementing harm-reduction site coordinators. This software tracks each SSVM plastic card and manages the permission for different card categories. The server keeps track of card expiration, survey due dates, remaining products, and money in each vending machine. The client software can communicate messages to the PWID customers on the LCD display (e.g., “Requested product is not available,” “You have exceeded your daily limit for our products,” “The plastic card is expired. Please contact the organization that gave it to you”). Communication capabilities with PWID consumers and research participants Online survey The SSVM designers developed an online portal for consumers that includes information about locations of all SSVMs, a short video describing how to use an SSVM, contact information for services in the area, harm-reduction information such as overdose prevention, first aid during an overdose, and how to use naloxone, and a link to a research survey. All PWID who have SSVM plastic cards are offered the opportunity to participate in the study. Study participants can log in to the portal using their SSVM plastic card ID. The online survey is brief, but detailed enough (covering sociodemographic details, drug use history, utilization of support services, barriers, and facilitators). The request for SSVM users to take part in the survey is displayed on an LCD screen during the first window period (one month), and then it appears during each participant’s follow-up period (six months). To motivate research participants to take part in this survey, the researchers offer a monthly lottery draw for those who complete the survey. The prize is a shopping voucher with a reasonable value (the equivalent of $40). Results Preliminary feasibility findings The first two SSVMs were installed in July 2019, and all 10 SSVMs were operational in Tbilisi by October 2020. Machines are relatively evenly distributed across Tbilisi districts and are located in the city’s major residential areas. Preliminary data suggest that they have served their purpose well. As of March 2021, 1,605 SSVM usage cards had been distributed to PWID, and more than 800 were used on a regular basis. In total, 33,521 HIV prevention kits that included 372,216 syringes of various sizes were dispensed. More than half of the kits (52%) were dispensed during nonworking hours (weekends, holidays, night-time). Each kit includes several needles and syringes of different sizes and other consumables used for injections. For example, the kit for opioid users includes four 1-ml ‘insulin’ syringes, one 2-ml syringe, sterile water, alcohol pads, a tourniquet, an aluminum spoon, and citric acid. Use during the COVID-19 lockdown There was a remarkable increase in the use of SSVMs during the COVID-19–related lockdown and social distancing requirements in March-May 2020 (see Figure 2 for details). Operations of fixed harm-reduction sites that distribute sterile injection equipment to PWID were affected—for example, access was decreased because of lack of transportation, limited working hours, and less distribution of sterile equipment.

Figure 2. Monthly number of HIV prevention kits distributed through SSVMs in Tbilisi

Note: Circled dates indicate when two SSVMs were added/activated; because of COVID-19–related delays in international cargo shipments, in August–September sterile kits to be distributed were out of stock. Conclusion The innovative SSVMs integrate service delivery and research data collection features and provide an infrastructure for testing new research ideas and interventions. For example, SSVMs might be used to distribute HIV/HCV self-tests, pre-exposure prophylaxis medications, antiretroviral treatment, medically assisted treatment for opioid use disorders, and other health interventions that might be difficult to obtain for stigmatized or hidden HIV risk groups. SSVM access can be expanded to cover diverse target populations, including men who have sex with men or commercial sex workers. Further reading: Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., VanVelzen, E. Hutchinson, S. J. (2014). Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology, 43, 235–248. doi:10.1093/ije/dyt243. Bemoni Public Unio, and Curatio International Foundation. (2016). Population size estimation of people who inject drugs in Georgia, 2015. Retrieved from http://curatiofoundation.org/population-sizeestimation-of-people-who-inject-drugs-in-georgia-2015/. Cama, E., Brener, L., & Bryant, J. (2014). Characteristics and attendance patterns of a fixed-site NSP and nearby SVM: The benefits of 24-hour access to sterile injecting equipment. Drugs: Education, Prevention & Policy, 21, 476–481. doi:10.3109/09687637.2014.956051. Chkhartishvili, N., Chokoshvili, O., Bolokadze, N., Tsintsadze, M., Sharvadze, L., Gabunia, P. Tsertsvadze, T. (2017). Late presentation of HIV infection in the country of Georgia: 2012-2015. PLoS One, 12, e0186835–e0186835. doi:10.1371/journal.pone.018683 Curatio International Foundation and Bemoni Public Union. (2018). HIV risk and prevention behaviors among people who inject drugs in seven cities of Georgia, 2017. Retrieved from http://curatiofoundation.org/bss-2017. Georgian National Drug Observatory. (2020). Drug situation in Georgia 2019. Retrieved from https://altgeorgia.ge/media/uploads/drug-situation-2019.pdf. Hussey, M. A., & Hughes, J. P. (2007). Design and analysis of stepped wedge cluster randomized trials. Contemporary Clinical Trials, 28, 182–191. doi:10.1016/j.cct.2006.05.007. Islam, M. M., & Conigrave, K. M. (2007a). Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): A review. Harm Reduction Journal, 4, 14. doi:10.1186/1477-7517-4-14. Islam, M. M., & Conigrave, K. M. (2007b). Syringe vending machines as a form of needle syringe programme: Advantages and disadvantages. Journal of Substance Use, 12, 203–212. doi:10.1080/14659890701249640. Kwon, J. A., Iversen, J., Maher, L., Law, M. G., & Wilson, D. P. (2009). The impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: A model-based analysis. Journal of Acquired Immune Deficiency Syndromes, 51, 462–469. doi:10.1097/QAI.0b013e3181a2539a. McDonald, D. (2009). The evaluation of a trial of syringe vending machines in Canberra, Australia. International Journal on Drug Policy, 20, 336–339. doi:10.1016/j.drugpo.2008.06.004. Mirzazadeh, A., Noori, A., Shengelia, N.,&Chikovani, I. (2019). HIV continues to spread among men who have sex with men in Georgia; time for action. PLoS One, 14, e0214785. doi:10.1371/journal.pone.0214785. Otiashvili, D., Kirtadze, I., Vardanashvili, I., Tabatadze, M., & Ober, A.J. (2019). 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. Harm Reduction Journal, 16, 21. doi:10.1186/s12954-019-0292-8. UNAIDS. (2019a). Global HIV & AIDS statistics—2019 fact sheet. Global HIV statistics. Retrieved from https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf. UNAIDS. (2019b). People who inject drugs. AIDS Info. Retrieved from https://aidsinfo.unaids.org/. UNODC. (2019). World drug report 2018. Retrieved from https://www.unodc.org/wdr2018/index.html. Wilson, D., Kwon, A., Anderson, J., & Thein, R. (2009). Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia. Retrieved from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/illicit-pubs-needle-return-2-toc. Wodak, A., & Cooney, A. (2006). Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Substance Use & Misuse, 41, 777–813. doi:10.1080/1082608060066957.