Setting

The study was conducted in collaboration with two organizations that are part of the Georgian Harm Reduction Network (GHRN). GHRN is a national umbrella association that brings together 26 member organizations across the country. Of these, 14 organizations specifically implement needle and syringe programs (NSPs) and provide a comprehensive package of harm reduction services, including sterile injecting equipment, condoms, HIV, HCV, HBV and syphilis testing, counseling, education, case management and linkage to health and social services. The remaining member organizations focus on other key populations and thematic areas, such as advocacy, community mobilization, and broader health and human rights initiatives.

For this study, two GHRN-affiliated organizations were selected – one located in Tbilisi, the capital of Georgia, and another in the Samegrelo region of western Georgia. These sites were chosen because both areas have among the highest HIV prevalence rates in the country. In addition, the Tbilisi site reflects an urban context, while the Samegrelo site represents a regional setting; including both locations allowed us to explore potential urban–regional differences in barriers and facilitators to condom use.

Participants and recruitment

Participants were purposively selected with the assistance of social workers from two GHRN-affiliated organizations in Tbilisi and Samegrelo. The recruitment started on 25 June 2025 and continued until 20 August 2025. Inclusion criteria required that individuals of both sex be aged 18 years or older, have engaged in sexual activity within the past six months, have injected drugs within the past six months, and provide written informed consent. Individuals who did not meet these criteria or declined participation were excluded. Recruitment continued until the target sample size of ten participants was reached, with five participants recruited from Tbilisi and five from Samegrelo, while ensuring that thematic saturation was achieved.

Data collection

A semi-structured interview guide, developed based on the COM-B framework, was used to explore barriers and facilitators to condom use among PWID (see S1 File for the interview guide). The guide was organized into sections addressing physical and psychological capability (e.g., knowledge, skills, and perceptions related to condom use), physical and social opportunity (e.g., availability, affordability, partner influence, and cultural norms), and automatic and reflective motivation (e.g., impulsivity, past experiences, risk perception, and protective intentions). Open-ended questions were followed by probes to elicit detailed narratives and examples. The guide was pilot tested with two participants to evaluate clarity, sequencing, and comprehensiveness; no substantive changes were required, and these pilot interviews were included in the analysis.

A total of 10 in-depth interviews were conducted remotely via Zoom. Each interview lasted 45–60 minutes. All interviews were conducted by one researcher with prior experience conducting qualitative research with vulnerable populations. At the start of each interview, the researcher emphasized confidentiality and voluntary participation and used a non-judgmental approach to encourage open discussion. Efforts were made to build rapport and create a comfortable environment so that participants could speak freely about sensitive topics. With participants’ written informed consent, all sessions were audio-recorded and transcribed verbatim to ensure accuracy and capture participants’ own wording. To compensate for their time, participants received 70 GEL (approximately USD 25).

Data analysis

We used thematic analysis to examine patterns related to barriers and facilitators of condom use among PWID, following the six-phase approach described by Kiger and Varpio: (1) familiarization with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report [30]. Verbatim transcripts were read repeatedly and annotated; two research team members independently manually coded an initial subset to develop a shared codebook, met to reconcile differences by discussion and refined the final codebook (see S2 File for the codebook). Codes and themes were organized deductively under the COM-B domains (Capability, Opportunity, Motivation), while allowing inductive subthemes to emerge within each domain.

Thematic saturation was reached during analysis, as no substantially new themes emerged in the later interviews. Although the total sample included ten participants, qualitative research suggests that thematic saturation in interview-based studies is often achieved with relatively small samples when the study scope is focused and participants share similar experiences [31]. In this study, participants were recruited from NSPs and shared similar experiences related to injection drug use, sexual behaviors and engagement with harm reduction services, which facilitated the identification of recurring themes. In addition, participants described behaviors they observed among peers in their communities, providing insights beyond their own experiences.

Ethical considerations

Ethical approval for the study was obtained from the Institutional Review Board (IRB) of the Georgian National Centre for Disease Control and Public Health (# 2025−004). Potential participants were first approached by social workers from partner organizations, who explained the aims and objectives of the study and obtained written informed consent. Prior to each interview, the interviewer also obtained verbal consent for audio-recording. All research activities commenced only after IRB approval was secured.

Capability

Reduced physical pleasure emerged as a significant Physical Capability barrier to condom use. All participants reported that either they themselves or their peers perceived sex with condom as less enjoyable. While most respondents emphasized reduced pleasure as a strong deterrent, one participant noted that the difference was relatively small in his own experience, and another suggested that the impact on pleasure is highly individual.

“The reason is always the same — reduced pleasure. You know, “You can’t get a good grip with gloves on [you can’t get the same feeling with a condom]” and things like that. That’s just how it is.” – 45-year-old PWID, male, Tbilisi

“Yes, it’s also true that people feel reduced pleasure with a condom… many don’t use them for this reason… people sometimes say sex is better without [a condom] … but in my opinion, the difference is not that big. From my personal experience, I don’t see a significant difference…” – 49-year-old PWID, male, Tbilisi

“I’ve heard some people say they feel discomfort or can’t reach full pleasure with condoms… of course, sex without a condom feels different than with one… Still, yes, the pleasure without a condom is less… Among the people around me, there are some who say, “Why should I have sex like that if I can’t enjoy it?” So they don’t care about using condoms.” – 49-year-old PWID, male, Zugdidi

Lack of awareness and knowledge was identified as a Psychological Capability barrier to condom use, primarily when participants described the experiences of other members of their PWID communities. Most emphasized that some peers might have limited understanding of the risks of unprotected sex, particularly underestimating the possibility of HIV, hepatitis, or other STIs transmission. Some also noted insufficient awareness of the benefits of condom use or a lack of clarity about when condoms should be used, for example with different partner types. Only one participant mentioned that some PWID might not be aware that condoms are distributed through harm reduction centers. In all these cases, lack of knowledge was perceived as a factor that could act as a barrier to condom use.

“There are also those who don’t fully understand the risks of transmitting HIV, HCV, HBV, or other STIs… I’d say PWID know about the benefits roughly 50/50.” – 42-year-old PWID, female, Tbilisi

“I can’t say that I fully understand [the risks of not using a condom]… I think members of my community don’t understand these risks and don’t know about them — there’s a lack of knowledge in this regard… Accordingly, my community members also don’t know the benefits [of regular condom use]… Logically, you’d think they should have this knowledge, but from what I see around me and what we discuss, only a handful of people both use condoms and know the harm that comes from not using them, as well as the benefits of using them… There is lack of knowledge about in which situation to use condom as well, I mean the partner type.” – 28-year-old PWID, female, Tbilisi

On the contrary, awareness and knowledge of the risks and benefits of consistent condom use, as well as where to obtain condoms, emerged as an important Psychological Capability facilitator to condom use among PWID. To a large extent, participants demonstrated good knowledge in these areas, though not always complete. Nearly all participants articulated awareness of the risks of unprotected sex, such as the transmission of HIV, hepatitis, and other STIs. Nearly all likewise emphasized the benefits of condom use, most often citing protection from infections and, in some cases, prevention of unintended pregnancy. All participants reported knowing where to access condoms, most commonly mentioning pharmacies and harm reduction centers as a source.

“I think the majority are more aware of the risks… I know that there are many infections you can get from unprotected sex — it’s definitely possible.” – 42-year-old PWID, male, Tbilisi

“The risks are too serious — I know how things are transmitted, I’m fully aware, and I never have sex without a condom…” – 49-year-old PWID, male, Zugdidi

“Yes, I know that infections won’t be transmitted [when using condom]. Also, for example, if I’m healthy and my spouse is a user and I don’t want to have a child, I would use a condom and be protected…” – 49-year-old PWID, male, Tbilisi

“Yes, I think PWID know where to get condoms, mainly from pharmacies. We also know that they are distributed at harm reduction centers.” – 27-year-old PWID, male, Zugdidi

Opportunity

Limited access and availability was considered as a Physical Opportunity barrier to condom use in two directions. Some participants from the region talked about geographic barrier, such as distance to pharmacies or harm reduction centers, particularly when sexual encounters occurred in villages, forests, or other locations far from outlets. Some respondents both from the capital and the region, noted that pharmacy and store working hours might pose difficulties, as most of them are often closed at night when condoms are needed.

Some participants identified supply-related issues at harm reduction centers as a Physical Opportunity barrier, talking about experiences of stock-outs or supply interruptions and dissatisfaction with the quality of condoms provided.

Finally, few participants from the region identified affordability as a Physical Opportunity barrier, explaining that limited financial resources sometimes prevented them from purchasing condoms, particularly when they had multiple partners.

“For a while, they [at harm reduction center] stopped providing them [condoms], so I was buying them, and then they brought them in again, although the quality was poor.” – 28-years-old PWID, female, Tbilisi

“Yes, a few years ago I had a situation where I wanted to use a condom but couldn’t get one — it was nighttime, the pharmacies were closed, and so I ended up having unprotected sex. I’ve also heard of similar cases from others, for the same reason.” – 40-years-old PWID, male, Zugdidi

“Yes, I’ve had 1–2 cases where I wanted to use a condom but couldn’t find one, because I was in a village where they weren’t available… If you have to buy condoms, it can mean spending a lot of money, especially if you have many partners... unfortunately, in Georgia, money for buying condoms is a problem. I don’t have spare cash for that either” – 49-years-old PWID, male, Zugdidi

With regard to Physical Opportunity facilitators, easy access and availability of condoms was widely emphasized. All participants reported that condoms could be easily obtained at pharmacies or stores, and also available through harm reduction centers. Most highlighted the proximity of these outlets as an important enabler, while some participants specifically mentioned the advantage of 24/7 pharmacies. In addition, some participants referred to the visibility of condoms in pharmacies, and another three described the free access provided through harm reduction centers as a significant facilitator.

A further Physical Opportunity facilitator described by few participants was the opportunity for engagement created by harm reduction centers. They explained that visiting these centers not only allowed them to obtain condoms for free but also fostered regular interaction with services, which in turn reinforced consistent access and use.

“Now [condoms] are very widely and easily available — in pharmacies, in stores. I also know they’re distributed at harm reduction centers… When I used to get syringes and other supplies from there [harm reduction center], they would give us condoms too. So, if I happened to be there, I would grab it, sure — but I wouldn’t go there specifically just for that.” – 45-years-old PWID, male, Tbilisi

“It makes me laugh to think they [PWID] couldn’t get one [condom]… They’re [condoms] sold everywhere — in stores, pharmacies… If you’re struggling and can’t afford to buy them, you can go there [harm reduction center] and they’ll give them to you…” – 49-years-old PWID, male, Tbilisi

“I live nearby, and it only takes me 10 minutes to get here [to the harm reduction center]. I also have a pharmacy close by… here [at harm reduction center] everything is free… Since I started coming here [at harm reduction center] and became a beneficiary, I come here for everything.” – 43-years-old PWID, male, Zugdidi

“I live in the city center, where 24-hour pharmacies and stores are available.” – 28-years-old PWID, female, Tbilisi

Partner influence was frequently reported as a Social Opportunity barrier to condom use. Most participants described experiences of partner influence, most often in the form of emotional pressure and coercion, including accounts of being persuaded during intimate encounters and pressure escalating under the influence of alcohol. Some participants further referred to transactional pressure, where condomless sex was encouraged through offers of money or drugs. Others described influence in the form of persuasion and suggestion, such as partners presenting condomless sex as more pleasurable, expressing personal preference, or framing it as a mutual agreement.

Another Social Opportunity barrier identified was cultural and social norms, mentioned by some participants. They highlighted embarrassment or shame when buying condoms, particularly in smaller communities where participants feared being judged at pharmacies. One of them also pointed to stigma and taboos, describing old-fashioned mentalities and silence around sexual health, while another noted about the gender norms, citing the expectation that condom use was the man’s responsibility. Finally, broader cultural attitudes were described, such as the absence of a strong “culture of self-protection” within the community or presence of normative belief about having sex in a “real Georgian way”.

“I’ve also heard of women being pressured — they [men] start with alcohol, then request sex without condom, then turn more aggressive… there are situations where, if there are drugs, someone might say, “I can spend time with you, we can get high together,” as a kind of offer.” – 42-years-old PWID, male, Tbilisi

“Yes, I had situation when I had condomless sex, and my partner justified it by saying that the feeling and pleasure are different without a condom. But he presented it all so nicely that I didn’t feel pressured — he persuaded me… In my opinion, it’s due to mentality — an old-fashioned mindset — they feel embarrassed to buy condoms or even to take them from harm reduction center… From a woman’s perspective, the perception and expectation are probably that it’s the man’s responsibility to put on a condom, and they shouldn’t have to remind him — so they often place that responsibility entirely on the man.” – 28-years-old PWID, female, Tbilisi

“They don’t have the culture of first protecting themselves and then thinking that if they have something, which they might not even know, they shouldn’t transmit it to others... - 49-years-old PWID, male, Tbilisi

Several Social Opportunity facilitators were identified, although most were mentioned by single participants. The absence of pressure was the most common theme, with nearly all participants stating that they had never been pressured by a partner not to use a condom, nor had they heard of such cases within their communities.

Another Social Opportunity facilitator was partner support for condom use, described in different ways. One participants emphasized that sex workers insist on condom use. Another described situations of successful negotiation, where women resisted male pressure and ultimately prevented condomless sex. In addition, few participants highlighted partner preparedness and responsibility, noting cases in which partners provided condoms or refused sex without them.

Information sharing and access also emerged as a Social Opportunity facilitator for condom use. One participant described peer-to-peer knowledge transfer, in which he actively reminded his peers to use condoms and seek services at harm reduction centers. Another referred to the digital and media environment, noting that platforms such as TikTok and the internet contribute to broader awareness of condom benefits.

Finally, few participant described norms and cultural framing as a Social Opportunity facilitator. One compared repeated exposure to messages about condoms to Coca-Cola advertisements, arguing that constant reminders reinforce the behavior. Another framed condom use as a positive cultural habit, comparing it to an everyday routine such as brushing one’s teeth.

“Well, I’ve never had a situation like that [wanting to use condom but the partner refusing]. And I haven’t heard of it from others either… When you mentioned commercial partners — they themselves tell you that you have to use one [condom]. Otherwise, I know many people around me who, if they [sex workers] weren’t insisted on, wouldn’t use it [condom].” – 45-years-old PWID, male, Tbilisi

“There were 1–2 times when I didn’t have a condom myself, but my partner did. I’ve been with people who protected themselves too — even if I had said I wanted sex without a condom, they wouldn’t have agreed.” – 49-years-old PWID, male, Zugdidi

“It’s the 21st century, and with the internet, TikTok, and everything else, you get this information [on benefits of condom use] from everywhere.” – 40-years-old PWID, male, Zugdidi

“It’s like Coca-Cola — you know it does not need advertising, right? But we keep hearing those ads, and it’s a psychological thing — it gets into your head, and you always want it. It works the same way here: the more you hear about it [condom], the more you think about it.” – 42-years-old PWID, male, Tbilisi

Motivation

Being under the influence of alcohol or drugs emerged as an important Automatic Motivation barrier to condom use. All participants described situations where being under the influence of alcohol or drugs reduced their ability to consider protective behaviors. Participants explained that intoxication often led to diminished attention to health, impaired memory, and impulsive decision-making, with many emphasizing that alcohol and drugs such as stimulants were particularly linked to risky sexual encounters.

In addition, some participants described impulsivity and situational factors as Automatic Motivation barriers. These included being caught up in the “heat of the moment”, sometimes tied to younger age and feeling too lazy to obtain a condom when one was not immediately available.

“There are drugs that make you lose control — I’m not talking about opiates like heroin — but, for example, when people are on ecstasy, MDMA, or magic mushrooms, in such cases they might not use condoms…” – 42-year-old PWID, female, Tbilisi

“Of course, when you’re under the influence of drugs or alcohol, condom use is the last thing on your mind. Personally, I don’t think about it at all in those moments. Naturally, it’s hard to focus on your health at such times [when under the influence of drugs/alcohol].” – 45-year-old PWID, male, Tbilisi

“As for others, not from drugs, but when drunk, yes — they’ve had sex without a condom, and later remembered it. They experienced burning sensations afterward and had to see a doctor. I’ve had one risky sexual encounter myself, when I was very drunk — I didn’t even think about using a condom, even though I had one in the car.” – 49-year-old PWID, male, Zugdidi

“We were already so caught up in the moment that I definitely didn’t think about it [using condom].” – 42-year-old PWID, male, Tbilisi

“Unfortunately, yes, I’ve had such an experience [wanted to use a condom but couldn’t get one]… I didn’t have a condom, and I was too lazy to go out and get one.” – 42-year-old PWID, male, Tbilisi

Low risk perception emerged as a significant Reflective Motivation barrier. All participants reported low risk perception with regular partners, often explaining that condom use was unnecessary with a spouse or trusted partner whom they believed to be “clean”. This pattern was consistently framed as a conscious decision based on trust and familiarity. Only one participant described a perceived low risk with a casual partner, framing it as a similar barrier to condom use. There were additional singular cases where participants justified condom non-use because they considered themselves healthy, or minimized risk by reasoning that a single unprotected encounter would not have consequences.

Another Reflective Motivation barrier to condom use concerned low attitude towards protection identified by most participants. This was expressed through apathy or lack of motivation to protect themselves or a partner, and in some cases through hopelessness or fatalism, described as “giving up” or believing “it does not matter what’s going to kill me.” Others emphasized a general disinterest in condom use, observing that many in their community did not value their health highly, failed to prioritize protective behaviors, or simply “did not care.”

Some participants from the capital described lack of preparedness as a Reflective Motivation barrier to condom use. They talked about situations where unprotected sex occurred in remote or spontaneous settings, such as in forests or recreational areas, where condoms were not readily available. However, these accounts reflected a lack of preparedness rather than structural inaccessibility, since condoms were otherwise widely accessible in urban areas. In these cases, the barrier arose from not planning ahead and failing to carry condoms.

“With a regular partner, I know she’s mine and clean, so I might not use one... For example, if a couple goes up to Mtatsminda [central park in Tbilisi], they’ve been drinking and they get to that point [of having sex], and neither of them have a condom, they won’t be able to find one there. Naturally, they’ll end up having sex without it [condom]…” – 42-year-old PWID, male, Tbilisi

“It also depends on the partner. For example, I don’t use them with my regular partner… When you know who your partner is and she is your regular partner, then using a condom isn’t necessary… if it’s someone I trust and know well, I may not use a condom.” – 43-year-old PWID, male, Zugdidi

“Motivation is probably individual. When you know you’re healthy, you see less risk and may be less likely to use condoms… As for condom use, many people in our community don’t even have the desire to live a healthier life… …I was like that too, and I think most of us drug users are the same — we’ve given up, with the attitude of “it does not matter what’s going to kill me. Yes, that’s exactly what I’m saying… they’ve given up… At exactly those times, it depends on the type of person — some may dismiss it and not use one [condom]. This group of people simply doesn’t care…” – 49-year-old PWID, male, Tbilisi

“Some think, “It’s just this one time, nothing will happen to me,” there are such cases also.” – 42-year-old PWID, female, Tbilisi

The most prominent theme within the Reflective Motivation facilitators was high motivation for self and partner protection, reported by nearly all participants. Respondents consistently emphasized their deliberate commitment to protecting both themselves and their partners, often describing condom use as a conscious, routine practice regardless of partner type. Notably, only one participant explicitly underlined the increased risk his injecting drug use could pose to a regular partner, which was a driver for partner protection.

Another strong Reflective Motivation facilitator was high risk perception, described by most participants in relation to occasional or commercial partners, and by some specifically regarding the risk of infection transmission. Participants explained that perceived risks were highest with non-regular partners, commercial sex encounters, or when infection was a possibility, and these circumstances consistently motivated condom use.

Past negative experiences also emerged as a Reflective Motivation facilitator, identified by most participants. These included histories of contracting hepatitis B or C, sexually transmitted infections, or other health complications, as well as experience of unintended pregnancy. These experiences were described as important turning points that encouraged consistent condom use.

Further Reflective Motivation facilitator to condom use was fear or avoidance of negative outcomes. Most participants described fear of acquiring HIV or other infections, while some participants emphasized avoiding unintended pregnancies as an important reason for condom use.

Finally, some participants mentioned other Reflective Motivation facilitators. Two of them referred to a moral or ethical responsibility to protect partners, particularly when aware of their own infection status. Singular accounts described strong will and proactive preparedness as additional facilitators to consistent condom use.

“But otherwise [apart from regular partner], in 99% of cases, it’s risky. With commercial partners, the risks are even higher… with casual partners or commercial partners, you must use one [condom] 100%...”- 49-year-old PWID, male, Zugdidi

“I can’t and won’t approach a woman without a condom. After all, I’m a drug user, and something might be wrong with me without me even knowing it — and I don’t want to transmit it to my partner.” – 49-year-old PWID, male, Tbilisi

“I once had a case where I caught a “bouquet” [a slang term for multiple infections]. I thought “bouquet” only meant flowers, but when I went to the doctor, I found out I had a lot of different things. Since then, I always use a condom with casual partners…” – 42-year-old PWID, male, Tbilisi

“Both the fear of infection and of unwanted pregnancy are equally important motivators for me… Ideally, motivation shouldn’t depend on the type of partner, protection should be your responsibility, but in reality it does.” – 27-year-old PWID, male, Zugdidi