High prevalence of HIV infection associated with incarceration among community-based injecting drug users in Tehran, Iran

Prevalence of HIV, hepatitis B virus, and hepatitis C virus among incarcerated people in Iran: a systematic review and meta-analysis

OBJECTIVES

Incarcerated people are at higher risk for HIV, Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) infections. This review systematically summarized the evidence on the prevalence of these infections among incarcerated people in Iran.

STUDY DESIGN

A systematic review and meta-analysis.

METHODS

We searched Embase, PubMed, Web of Science, Scopus, PsychInfo, Iranian databases, including IranMedex, Magiran, Scientific Information Database (SID), and IranDoc. A grey literature review was conducted to find unpublished reports from the Ministry of Health and experts throughout the country. Included studies reported data on the prevalence of HIV, HBV, or HCV infections. A random-effects meta-analysis was performed to estimate the pooled prevalence. A meta-regression analysis was also conducted.

RESULTS

Of 1461 screened records, 23 records were eligible (total participants = 199,855). The pooled prevalence of HIV (17 studies), HBV (6 studies), and HCV (10 studies) was 2.77% (95% CI: 1.96, 3.70), 2.89% (95% CI: 2.28, 3.56), and 21.57% (95% CI: 13.62, 30.76), respectively. Meta-regression analyses showed that HIV (P-value = 0.05) and HCV (P-value = 0.02) were reduced over time using survey year as the interested variable in the model. Also, lifetime history of drug injection had a significant association with the HIV infection (P-value = 0.03).

CONCLUSION

The findings suggest that the prevalences of these infections are relatively considerable among Iranian incarcerated people. These findings support developing interventions to reduce the risk of the acquisition and circulation of these infections among incarcerated people, and continued harm reduction programs among most at-risk incarcerated people, as well as HCV treatment.

Risk factors associated with human immunodeficiency virus infection in blood donors in Iran: A case-control study

BACKGROUND

Despite setting the stringent criteria for the selection of safe donors, some human immunodeficiency virus (HIV)-positive volunteers manage to give blood. Considering the window period of screening tests, this could endanger the safety of blood supply.

MATERIALS AND METHODS

A frequency match case-control study was conducted on HIV-positive and negative blood donors in Iran from 2007 to 2008. Overall, 61 HIV-positive and 224 HIV-negative blood donors were selected as cases and controls, respectively. Two groups were matched for confounding factors. An identical questionnaire was used to assess risk factors. Univariate regression analysis for calculating crude odds ratio (OR) and 95% confidence interval (CI) was used for detecting eligibility of risk factors to enter the final model. The exposures with P < 0.1 were entered in the logistic regression model. Adjusted ORs with P < 0.05 and 95% CIs were reported for statistically significant variables.

RESULTS

Significant effects were detected for the following variables: education, job, tattoo, intravenous (IV) drug abuse, imprisonment, and risky sexual behavior. However, based on multiple analyses, education, IV drug abuse, imprisonment, and risky sexual behavior remain significant.

CONCLUSION

The majority of our findings are in parallel with the other studies performed in other countries. To increase blood safety, special attention should be paid to illiterate, first-time blood donors who are in the 25-40 age range. In addition, having the history of IV drug abuse, imprisonment and risky sexual behaviors put the blood donors more at risk of infecting HIV.

Prevalence of HIV infection and high-risk behaviors in truck and bus drivers in Kurdistan province

BACKGROUND

Truck, bus, transit drivers, and men with mobile jobs are at high risk for HIV/AIDS. The purpose of this study was to investigate the prevalence of HIV and risky behaviors among truck and bus drivers in Kurdistan province.

METHODS

This cross-sectional study was conducted on 601 bus and truck drivers in Kurdistan province during 2018-2019. Data on high-risk behaviors were collected using a standard questionnaire. ELISA test was used to detect HIV in the study participants. Data were analyzed using Chi-square, Mann-Whitney U tests, and logistic regression modeling in Stata-14 software.

RESULTS

The mean and standard deviation of the age of study participants was 44.04 ± 11.44 years. HIV rapid test was positive in two subjects; in other words, the prevalence of HIV in the study population was 0.33%. Ninety-two (15.3%) individuals reported a history of drug use, with one (1.1%) having a history of injecting drugs. One hundred and thirty-one (21.8%) of them had a history of high-risk sexual behavior outside of marriage.

CONCLUSION

According to the results of the present study, the prevalence of high-risk behaviors in bus and truck drivers is high. It seems necessary to direct the drivers' attention to self-care while considering disciplinary intervention programs to prevent the use of drugs, cigarettes, alcohol along with high-risk sexual behaviors to maintain the health of drivers and passengers.

HIV in Iran: onset, responses, and future directions

Iran, a country in the Middle East and North Africa (MENA) region, has been actively involved in the fight against HIV/AIDS over the past three decades. The unique features of the HIV epidemic in Iran are reflected by the modes of transmission and its recent changes to improve management and prevention programs. In this review, we recount the initial onset and subsequent spread of HIV infection in Iran, beginning with the first case diagnosed to the ongoing responses and most recent achievements in controlling this epidemic. Although in the MENA region, Iran is one of the pioneers in implementing pertinent policies including harm reduction services to decrease HIV incidence, drug injection still continues to be the major risk of infection. In line with other nations, the programs in Iran aim at the UNAIDS 90-90-90 targets (UNAIDS 90-90-90 global targets to end the AIDS epidemic by 2020: by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression) and to eliminate mother-to-child HIV transmission. In this article, we discuss the strengths and shortcomings of the current HIV programs and offer suggestions to provide a better perspective to track and respond to the HIV epidemic. More generally, our account of the national religious and cultural circumstances as well as obstacles to the approaches chosen can provide insights for decision-makers in other countries and institutions with comparable settings and infrastructures.

Epidemiology of HIV in Iran

:

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

HIV prevalence among people who inject drugs (PWID) and related factors in Iran: a systematic review, meta-analysis and trend analysis

AIMS

In Iran, injecting drug use has been the major route of human immunodeficiency virus (HIV) transmission. In order to control the HIV epidemic, a harm reduction program was initiated and has been expanded in recent years. The aim of this study was to provide an updated estimate of HIV prevalence among people who inject drugs (PWID) in Iran, investigate prevalence differences over time and assess prevalence correlates.

DESIGN

A comprehensive systematic review was undertaken in the international, regional and national bibliographic databases in November 2018 and extensive contacts with authors were made. For studies conducted before 2005, we used data from a previous published systematic review.

SETTING

All studies conducted in Iran were included. Recruitment settings included anywhere except studies conducted in infectious diseases wards or HIV counseling centers.

PARTICIPANTS

PWID with any definition utilized in the studies. Thirty-six studies were included, which were conducted in 24 of 31 provinces with a sample size of 22 160 PWID.

MEASUREMENTS

We included studies that had performed HIV testing and had a confirmed diagnosis of HIV through repeating the enzyme-linked immunosorbent assay (ELISA) or Western immunoblot assay (WB). Pooled prevalence of HIV was calculated for the total sample and for different subgroups, by available socio-demographic and behavioral factors. For assessing the trend of HIV prevalence over time, a linear meta-regression model was fitted separately for before 2007 and during 2007 and afterwards.

FINDINGS

The pooled prevalences of HIV before 2007 and in 2007 and afterwards were 14.3% [95% confidence interval (CI) = 9.8-18.9] and 9.7% (95% CI = 7.6-11.9), respectively. HIV prevalence increased until 2005-06 and then slowly declined until 2009-10, which was not significant. Prevalence of HIV was significantly higher in PWID above age 25 years, and in those with history of imprisonment and history of needle/syringe-sharing. HIV prevalence was higher in men than in women, but the difference was insignificant.

CONCLUSION

The prevalence of HIV among people who inject drugs in Iran decreased after 2006 which could, at least in part, be attributed to the development of extensive harm reduction programs in the country.

Tattooing among Iranian prisoners: results of the two national biobehavioral surveillance surveys in 2015-2016

BACKGROUND

Tattooing is among identified risk factor for blood-borne diseases.

OBJECTIVE

This study aims to determine the prevalence of tattooing during lifetime and in prisons and its related factors among Iranian prisoners.

METHODS

This is a cross-sectional study. The required data was obtained from hepatitis B and C surveillance surveys in prisons in 2015-2016 that was collected through face-to-face interview. 12,800 prisoners were selected by multi-stage random sampling from 55 prisons of 19 provinces in Iran. Weighted prevalence and associated factors (using Chi-Square test and multivariate logistic regression) were determined by Stata/SE 14.0 survey package.

RESULTS

Out of 12,800 prisioners, 11,988 participated in the study (93.6% participation rate). The prevalence of tattooing in lifetime and in prisons was 44.7% and 31.1% respectively. The prevalence of tattooing during lifetime was significantly associated with age<35 years, being single, illiteracy, history of imprisonment, drug use, piercing during lifetime, extramarital sex and history of STI; the prevalence of tattooing in prison had a significant association with history of imprisonment, drug use, piercing in prison, and history of extramarital sex (p<0.05).

STUDY LIMITATIONS

Information and selection bias was one of the study limitations.

CONCLUSION

The results of this study showed that the prevalence of tattooing during lifetime and in prison among prisoners was significantly high especially in high-risk groups such as drug users and sexually active subjects. Given the role of tattooing, drug injection and sex in the transmission of blood-borne diseases, harm reduction programs are recommended to reduce these high-risk behaviors in prisons.

Epidemiologic and clinical findings of children with acquired immunodeficiency syndrome in four provinces of Iran

INTRODUCTION

The human immunodeficiency virus (HIV) is still a remarkable challenge throughout the world, especially in developing countries. Despite the fact that HIV in children is becoming one of the most challenging diseases, it seems that pediatric AIDS in Iran is an unknown disease and there is a lack of studies about it. The aim of this study was to describe the characteristics of HIV-positive children who referred to the hospitals of Tehran, Kermanshah, Kurdistan, and Qom provinces of Iran.

MATERIALS AND METHODS

This study was a retrospective investigation of medical records among 61 children with a diagnosis of HIV who were admitted to the children's hospitals in the four provinces of Iran during a 3-year period (2013-2016).

RESULTS

The frequency of HIV in the center of Iran (Tehran and Qom provinces) was higher (N = 37, 61%). Most of the infected patients were between 5 and 15 years old, 52% were male, and 93% had a history of HIV in their family. Median age at diagnosis of HIV was 2 years. Most of the hospitalized patients were discharged and only two patients (3%) died due to HIV infection. The vast majority of patients (93%) were infected through maternal transmission and a low percentage (29%) were diagnosed before 1 year of age. All of them were in the third stage of the disease. All patients had a positive HIV PCR test. HIV EIA was positive in the majority of cases (98%). A history of addiction in the family was demonstrated in 22 cases (36%). Weight loss (N = 51, 84%), prolonged fever (N = 50, 81%), and respiratory infection (N = 26, 47%) were the most common symptoms.

CONCLUSION

This study demonstrated a high frequency of pediatric HIV among children aged 5-15 years in four provinces of Iran. Novel strategies to prevent and eliminate mother-to-child transmission of HIV, diagnostic facilities, and treatment of infected mothers during pregnancy in our country are highly recommended.

The prevalence of syphilis in HIV-seropositive patients: a retrospective study at the regional hospital in Agadir, Morocco

Introduction

HIV and syphilis are major public health problems in Morocco. The region of Souss-Massa, south-west of the country, hold more than 24% of HIV seropositive cases registered in Morocco during 2009. The aim of this study is to evaluate the seroprevalence of syphilis among HIV seropositive patients in the region of Souss-Massa, south-west of Morocco.

Methods

To evaluate the seroprevalence of syphilis and neurosyphilis among HIV seropositive patients, we retrospectively investigated the medical records of HIV-infected patients attending the regional hospital located in the city of Agadir, during the period comprised between 2011 and 2016.

Results

The population studied involved 1381 males (49.18%) and 1427 females (50.82%) HIV seropositive patients. Among them, 481 patients were seropositive for syphilis and three cases were diagnosed with neurosyphilis. The sex ratio distribution was 243 male (52.71%) and 218 female (47.29%). The prevalence of syphilis among the studied population was estimated to 16.42% with a slight dominance in male (17.63%) compared to female (15.28%). By contrast, neurosyphilis was only detected in male patients, with a prevalence estimated to 0.11%.

Conclusion

Even if the prevalence of HIV and syphilis is stable in the region of Souss-Massa, the prevalence of syphilis among HIV seropositive patients remained high and correlated positively with that of HIV infection. We did not find a significant difference between the genders, in relation to the prevalence of HIV and syphilis. We concluded that it was essential to continue monitoring the population, in order to improve the prevention and the access to the medical care in the south-west of Morocco.

Assessment of adherence to therapy and exploring of barriers and facilitators in HIV positive patients in Tabriz-Iran: a mixed method study protocol

BACKGROUND

Adherence to therapy is a key predictor of the success of human immunodeficiency virus (HIV) treatment. There is limited information available from Iran about that and there is a need for more knowledge about factors influencing treatment adherence. The aim of this study is to examine adherence levels and to explore patients' views about barriers and facilitators to HIV treatment adherence.

METHODS

This mixed-method study with the sequential explanatory design has two phases. The first phase (quantitative phase) is a cross- sectional study to assess the in Tabriz, the sixth large city of Iran. A convenience sampling method will be used to select 150 HIV positive patients who visit health centers in Tabriz. The second phase is a qualitative study designed to explore the HIV positive patients' views of barriers and facilitators that can affect their adherence to therapy. In this phase, purposive sampling and in-depth individual interviews will be conducted for data collection. The conventional content analysis approach will be employed for data analysis. In addition to literature review and nominal group technique, the findings of the qualitative and quantitative phases, will be used to recommend some strategies to support adherence to therapy in HIV positive patients.

DISCUSSION

This is the first study looking into adherence to therapy and exploring of factors influencing in HIV positive patients which will be performed via a mixed-method approach, aiming to develop health practices improvement strategies. It is worth noting that there is no strategic guideline in Iran's health system for improvement of treatment adherence in HIV positive patients. Health professionals and policy makers can be aware of factors influencing HIV treatment adherence. Therefore, it is hoped that the strategy proposed in the current study can lead to improvements their ability to treatment adherence.

Are non-injecting opioid users at risk of transition to injecting drug use? A multi-site study from India

BACKGROUND

Most people who inject drugs (PWID) start their drug use careers by using non-injecting opioid drugs. A variety of interconnected factors may influence the risk of transition from non-injecting to injecting drug use (IDU). However, such factors have not been studied well in India. As almost all non-injecting opioid users (NIOU) are at potential risk of switching to IDU in future, it is important to understand the phenomenon of transition.

METHOD

In this multi-site, cross-sectional observational study, we compared injecting and non-injecting opioid users on the pattern of progression of drug use and their knowledge, attitude and belief about IDU/HIV. Data were collected from people who use drugs coming in contact with Non-Governmental Organizations providing drug treatment or HIV prevention services, in ten cities of six states located in North/North-West India. Following informed consent, a total of 1987 male participants (n = 1234 PWID and n = 753 NIOU) were interviewed using a semi-structured questionnaire. Factors associated with risk of transition were analyzed using logistic regression analysis.

RESULT

The age of onset of heroin and other opiates as well as other substances was not different between two groups. Among PWID, a majority (n = 713; 57.77%) reported using opioids through non-injecting route before switching to injecting route. The mean duration between first use of non-injecting opioid and first use of injecting opioid was 1.80 ± 3.32 years (range 0-26 years). Awareness and exposure to the act of injecting were amongst factors associated with perceived risk of transition to injecting (p < 0.01). On a univariate logistic regression analysis, less education was associated with increased likelihood while being employed was associated with less likelihood of being offered injection (p < 0.001).

CONCLUSION

Though, NIOU are almost indistinguishable from PWID in many respects, there may be certain factors putting them at risk of transition to injecting route. As the majority of PWID start their injecting career by non-injecting route, interventions targeted atrisk NIOU (as suggested by our study) could interrupt the HIV transmission.

HIV and the criminalisation of drug use among people who inject drugs: a systematic review

BACKGROUND

Mounting evidence suggests that laws and policies prohibiting illegal drug use could have a central role in shaping health outcomes among people who inject drugs (PWID). To date, no systematic review has characterised the influence of laws and legal frameworks prohibiting drug use on HIV prevention and treatment.

METHODS

Consistent with PRISMA guidelines, we did a systematic review of peer-reviewed scientific evidence describing the association between criminalisation of drug use and HIV prevention and treatment-related outcomes among PWID. We searched MEDLINE, Embase, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and other sources. To be included in our review, a study had to meet the following eligibility criteria: be published in a peer-reviewed journal or presented as a peer-reviewed abstract at a scientific conference; examine, through any study design, the association between an a-priori set of indicators related to the criminalisation of drugs and HIV prevention or treatment among PWID; provide sufficient details on the methods followed to allow critical assessment of quality; be published or presented between Jan 1, 2006, and Dec 31, 2014; and be published in the English language.

FINDINGS

We identified 106 eligible studies comprising 29 longitudinal, 49 cross-sectional, 22 qualitative, two mixed methods, four mathematical modelling studies, and no randomised controlled trials. 120 criminalisation indicators were identified (range 1-3 per study) and 150 HIV indicators were identified (1-5 per study). The most common criminalisation indicators were incarceration (n=38) and street-level policing (n=39), while the most frequent HIV prevention and treatment indicators were syringe sharing (n=35) and prevalence of HIV infection among PWID (n=28). Among the 106 studies included in this review, 85 (80%) suggested that drug criminalisation has a negative effect on HIV prevention and treatment, 10 (9%) suggested no association, five (5%) suggested a beneficial effect, one (1%) suggested both beneficial and negative effects, and five (5%) suggested both null and negative effects.

INTERPRETATION

These data confirm that criminalisation of drug use has a negative effect on HIV prevention and treatment. Our results provide an objective evidence base to support numerous international policy initiatives to reform legal and policy frameworks criminalising drug use.

FUNDING

Canadian Institutes of Health Research and US National Institutes of Health.

Number of HIV-infected cases in Iran: True or just an iceberg

Background:

The number of HIV cases in Iran is increasing. Knowledge of the changing epidemiology of HIV is fundamental for service planning and prevention activities. This study aims to estimate the number of HIV-infected cases by the capture and recapture method for size estimation.

Materials and Methods:

From 2002 to 2009, we used three different centers – hospitals, the Voluntary Counseling and Testing (VCT) center, and a central prison in Fars Province for data retrieval. The overlaps between these centers were investigated to determine the true estimate of HIV cases. Finally, interactions were analyzed by a linear logarithm model with STATA version 9 software.

Results:

We observed 5167 HIV cases. The number of males was ten times more than that of females. The most frequent age range was between 15 and 44 years. The majority of cases (n = 3347) were retrieved from the VCT center. The least number of infected persons were located in the prison and hospitals. The estimated number of cases in Fars Province was 14,925 from 2002 to 2009. The best model consisted of three sources.

Conclusion:

Covering the system of medicine deputy for registering the number of infected cases with HIV is poor in Iran. Improvements in making arrangements for enhancing the quality of data related to HIV-infected cases are essential for solving this problem and must be on the agenda for medical policymaking.

Status of HIV and hepatitis C virus infections among prisoners in the Middle East and North Africa: review and synthesis

INTRODUCTION

The status of HIV and hepatitis C virus (HCV) infections among incarcerated populations in the Middle East and North Africa (MENA) and the links between prisons and the HIV epidemic are poorly understood. This review synthesized available HIV and HCV data in prisons in MENA and highlighted opportunities for action.

METHODS

The review was based on data generated through the systematic searches of the MENA HIV/AIDS Epidemiology Synthesis Project (2003 to December 15, 2015) and the MENA HCV Epidemiology Synthesis Project (2011 to December 15, 2015). Sources of data included peer-reviewed publications and country-level reports and databases.

RESULTS AND DISCUSSION

We estimated a population of 496,000 prisoners in MENA, with drug-related offences being a major cause for incarceration. Twenty countries had data on HIV among incarcerated populations with a median prevalence of 0.6% in Afghanistan, 6.1% in Djibouti, 0.01% in Egypt, 2.5% in Iran, 0% in Iraq, 0.1% in Jordan, 0.05% in Kuwait, 0.7% in Lebanon, 18.0% in Libya, 0.7% in Morocco, 0.3% in Oman, 1.1% in Pakistan, 0% in Palestine, 1.2% in Saudi Arabia, 0% in Somalia, 5.3% in Sudan and South Sudan, 0.04% in Syria, 0.05% in Tunisia, and 3.5% in Yemen. Seven countries had data on HCV, with a median prevalence of 1.7% in Afghanistan, 23.6% in Egypt, 28.1% in Lebanon, 15.6% in Pakistan, and 37.8% in Iran. Syria and Libya had only one HCV prevalence measure each at 1.5% and 23.7%, respectively. There was strong evidence for injecting drug use and the use of non-sterile injecting-equipment in prisons. Incarceration and injecting drugs, use of non-sterile injecting-equipment, and tattooing in prisons were found to be independent risk factors for HIV or HCV infections. High levels of sexual risk behaviour, tattooing and use of non-sterile razors among prisoners were documented.

CONCLUSIONS

Prisons play an important role in HIV and HCV dynamics in MENA and have facilitated the emergence of large HIV epidemics in at least two countries, Iran and Pakistan. There is evidence for substantial but variable HIV and HCV prevalence, as well as risk behaviour including injecting drug use and unprotected sex among prisoners across countries. These findings highlight the need for comprehensive harm-reduction strategies in prisons.

Drug use treatment and harm reduction programs in Iran: A unique model of health in the most populated Persian Gulf country

Because of the proximity of Persian Iran to Afghanistan, the main opium producer in the world, drug use especially opium use has a long history in Iran. Opium and its residues are the traditional drugs while heroin, heroin Kerack, norgesic, temgesic, and methamphetamine use and injection have emerged more recently. In recent decades, heroin smoking and injection have presented challenges to the Persian health policy makers to accept and develop the internationally-approved programs of drug use treatment and harm reduction. The current paper summarizes the overall picture of main drugs used and the history of establishing the nationwide movement of drug use treatment and harm reduction programs after the 1979 revolution until the end of 2014. The paper concludes that Persian Iran has a well-developed healthcare system in the provision of drug use treatment and harm reduction programs in the south-west of Asia especially the Persian Gulf region. These therapeutic and harm reduction-related programs are required to be strengthened by opium supply reduction and eradicating drug production in Afghanistan. The provision of prevention programs, drug education via mass-media, employment and inexpensive leisure activities are required in Iran. In addition, conducting household surveys of the prevalence of drug use and evaluating the clinical effectiveness and treatment outcomes of the provided drug treatment and harm reduction programs are required. National and regional collaborations are rigorously suggested to manage supply reduction along the borders and implement demand reduction inside the borders.

Methadone maintenance treatment program in prisons from the perspective of medical and non-medical prison staff: a qualitative study in Iran

BACKGROUND

As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran.

METHODS

On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons.

RESULTS

This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants' views "reduction of illegal drug use and high-risk injection", "reduction of potentially high-risk behaviors" and "making positive attitudes" were the main advantages of MMT in prisons, while issues such as "inaccurate implementation", "lack of skilled manpower" and "poor care after release from prison" were among the main shortcomings of MMT program.

CONCLUSION

MMT program in Iran's prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.

High HIV prevalence in a respondent-driven sampling survey of injection drug users in Tehran, Iran

Iran is facing unprecedented dual drug use and HIV epidemics. We conducted a cross-sectional survey to obtain HIV prevalence and risk behavior data from injection drug users (IDU) in Tehran. We used respondent-driven sampling (RDS) to recruit IDU through successive waves starting with 24 "seeds," conducted anonymous face-to-face interviews and HIV testing and counseling, and used RDSAT to adjust data. During 44 weeks, 1,726 study referral coupons resulted in 645 (37 %) IDU referrals, of whom 548 (85 %) were enrolled. From those enrolled, 84 % were incarcerated, 47 % employed, 55 % single, 27 % under 30 years of age, and 26 % homeless. The adjusted HIV prevalence was 26.6 % (95 % confidence interval 21.3-32.1), and was higher among certain IDU subgroups (e.g., those who sharing injection paraphernalia). Our estimates of HIV prevalence were higher than some other estimates; however, repeated surveys using similar methodology are needed to monitor the trend of HIV epidemic over time.

HIV among people who inject drugs in the Middle East and North Africa: systematic review and data synthesis

BACKGROUND

It is perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA.

METHODS AND FINDINGS

This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting (1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or (2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or (3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases. We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%-28% in the last injection), the low levels of condom use (20%-54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%-30% and 2%-10% in the last year, respectively), and of selling sex (5%-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics.

CONCLUSIONS

Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

Risk and vulnerability of key populations to HIV infection in Iran; knowledge, attitude and practises of female sex workers, prison inmates and people who inject drugs

Background In this study data of three national surveys conducted among female sex workers (FSW), prison inmates and people who inject drugs (PWID) were presented and compared in relation to knowledge, attitude, and practises.

METHODS

The surveys were conducted in 2009 and 2010 and included 2546 PWID, 872 FSW and 5530 prison inmates. Knowledge, attitude and practises towards HIV were measured through similar questions for each category.

RESULTS

Over 90% of all participants had ever heard of HIV/AIDS, although only approximately half of them perceived themselves at risk of contracting HIV. More than 80% were able to correctly identify the ways of preventing the sexual transmission of HIV; while more than two-thirds did not use condom in their last sexual contact. Approximately 20% of prisoners and FSW had a history of injecting drugs. Among all participants who have injected drugs, prisoners had the highest unsafe injecting behaviour at the last injection (61%), followed by FSW (11%) and PWID (3%).

CONCLUSIONS

Despite major efforts to control the HIV epidemic in Iran, the level of risk and vulnerability among prisoners, FSW and PWID is still high. The level of comprehensive knowledge about HIV/AIDS is relatively good; however, their risk perception of contracting HIV is low and high-risk behaviours are prevalent. Therefore, HIV prevention programs should be redesigned in a more comprehensive way to identify the best venues to reach the largest number of people at a higher risk of contracting HIV and decrease their risk overlaps and vulnerability factors.

Outcome assessment of a triangular clinic as a harm reduction intervention in Rajaee-Shahr Prison, Iran

Background

Transmission of the human immunodeficiency virus (HIV) among incarcerated injection drug users (IDU) is a health epidemic in the Islamic Republic of Iran. Triangular clinics (TCs) were established in prisons as a harm reduction measure to decrease the risk of HIV transmission and other blood-borne infections. The objective of this study was to assess the immediate outcomes of one TC among male IDUs in Iran’s Rajaee-Shahr prison.

Methods

This study was conducted in two stages between 2003 and 2005. In the preparatory stage, focus group data was collected to update the prison’s TC education and medical interventions and construct the self-report questionnaire. In stage two, 150 male IDUs were recruited in a closed cohort study design to assess the immediate outcome of the TC. Participants were measured at baseline and followed up to six months to measure their drug use, attitude toward and knowledge of high risk behaviours, serological conversion for HIV, HBV and HCV, and engagement in risky behaviors. The TC outcomes were determined through random urine analysis testing, a self-administered questionnaire and behaviour report cards, and viral infection testing.

Results

The findings of the urine analyses indicated a minimal yet consistent decrease in drug use over the six months. The pre and post- self-administered questionnaire data relayed a modest change in IDU risky behaviours associated with sexual practices; this was greater in comparison to the knowledge and attitude measures. It was determined that age may have a detrimental effect as may viral infections (HIV and HBV) on knowledge, attitude and behavior change. Both education and employment may have a protective effect. Data collected from the self-report behaviour cards similarly showed a modest reduction in high risk practices. At the six month follow-up, only one case became HIV positive, 9 HCV and 17 HBV.

Conclusions

Considering that HIV is concentrated among Iranian prisoners who inject drugs at a high level, the results of this study indicate that TCs are a possible effective intervention. However, many prisoners continued with risky behaviors even if they were participating in harm reduction measures, such as methadone maintenance therapy.

Correlates of shared methamphetamine injection among methamphetamine-injecting treatment seekers: the first report from Iran

Shared methamphetamine injection is an emerging route of drug use among Iranian methamphetamine injectors. It is a primary vector for blood-borne infections. The aim of the current study is to determine the prevalence and correlates of shared methamphetamine injection in a sample of Iranian methamphetamine injecting treatment seekers in the south of Tehran. We surveyed male and female methamphetamine injectors at three drop-in centres and 18 drug-use community treatment programmes. Participants reported socio-demographic characteristics, drug use, high-risk behaviours, current status of viral infections and service use for drug treatment. Bivariate and multivariate logistic regression models were used to test associations between participants' characteristics and shared methamphetamine injection. Overall, 209 clients were recruited; 90.9% were male; 52.6% reported current methamphetamine injection without any shared injection behaviour and 47.4% reported current shared methamphetamine injection. Shared methamphetamine injection was found to be primarily associated with living with sex partners (AOR 1.25, 95% CI 1.13-1.98), reporting ≥3 years of dependence on methamphetamine injection (AOR 1.61, 95% CI 1.27-2.12), injection with pre-filled syringes in the past 12 months (AOR 1.96, 95% CI 1.47-2.42), homosexual sex without condom use in the past 12 months (AOR 1.85, 95% CI 1.21-2.25), the paucity of NA group participation in the past 12 months (AOR 0.67, 95% CI 0.41-0.99), the paucity of attending psychotherapeutic sessions in the past 12 months (AOR 0.44, 95% CI 0.28-0.96) and positive hepatitis C status (AOR 1.98, 95% CI 1.67-2.83). Deeper exploration of the relationship between shared methamphetamine injection and sexual risk among Iranian methamphetamine injectors would benefit HIV/sexually transmitted infection prevention efforts. In addition, existing psychosocial interventions for methamphetamine-injecting population may need to be adapted to better meet the risks of shared methamphetamine injectors.

HIV trend among Iranian prisoners in 1990s and 2000s; analysis of aggregated data from HIV sentinel sero-surveys

BACKGROUND

Using the aggregated data of all sentinel sero-surveys (1991 to 2007), this study aimed to report the HIV trend among Iranian prisoners.

METHOD

Overall, we analysed the aggregated data from 397 HIV sero-surveys conducted in 72 prisons (included 155,771 prisoners) from 1991 through 2007.

RESULTS

The overall HIV prevalence was 2.8% (95% CI: 1.8%-4.3%). In 1998, HIV prevalence dramatically increased to 4.5% (95% CI: 1.1%-16.8%), which later became stable at level of 2.8%. Prisons were so heterogeneous regarding HIV prevalence (0% to 13.2%).

CONCLUSION

Since the outbreak, the ministry of health has acknowledged prisoners as one of the high-risk groups for HIV, increased the number of sentinel surveys and on-site harm reduction services to better monitor and response to the HIV epidemic. The downward trend of HIV prevalence after 2005 suggests the effectiveness of such interventions which need to be continued.

Viral hepatitis and HIV infection among injection drug users in a central Iranian City

OBJECTIVE

This study aimed to determine the prevalence of serological markers for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and occult HBV infection among injection drug users (IDUs) with isolated anti-hepatitis B core (anti-HBc).

METHODS

A total of 153 male IDUs were tested for anti-hepatitis B surface (anti-HBs), hepatitis B surface antigen (HBsAg), anti-HBc, anti-HCV, and anti-HIV. The presence of HBV-DNA was determined in plasma samples of individuals with isolated anti-HBc (HBsAg negative, anti-HBs negative, and anti-HBc positive) by polymerase chain reaction (PCR).

RESULTS

The prevalence of markers for viral hepatitis and HIV infections was 59.5% for anti-HCV, 44.4% for anti-HBs, 22.9% for anti-HBc, 7.2% for HBsAg, and 5.9% for anti-HIV. Several markers for coinfection, including HBV-HCV (5.9%), HCV-HIV (5.2%), HBV-HIV (2.0%), and HBV-HCV-HIV (1.3%), were present. Of the 7.2% of IDUs with isolated anti-HBc, all were anti-HCV positive and 18.2% were anti-HIV positive; however, no cases had detectable HBV-DNA as a marker of occult infection.

CONCLUSIONS

Markers for HCV, HBV, HIV, and combinations of these infections were common among IDUs in a city of central Iran. Isolated anti-HBc was associated with HCV but not with occult HBV infection in this sample. The 10-fold higher prevalence of HCV than HIV infection may be a harbinger of increasing HIV among IDUs in this area.

Evidence of HIV epidemics among non-injecting drug users in Iran: a systematic review

AIMS

In Iran, injecting drug users have been recognized as a high-risk group for HIV/AIDS for years. However, evidence of HIV epidemics in non-injecting drug users (non-IDUs) has also been found in recent years. The aim of this systematic review was to determine the prevalence of HIV in non-IDUs in Iran.

METHODS

International and regional databanks, including Pubmed, ISI, CINAHL, ASCI and IMEMR, as well as domestic databanks such as IranPsych, IranMedex SID and research reports were searched, and extensive personal contacts were made. All studies with HIV testing conducted between 1998 and 2007, which included non-IDU subjects, were gathered and their qualities were assessed. HIV prevalence was pooled for each gender and stratified to several categories. The prevalence of HIV in non-IDUs and IDUs was compared using pooled odds ratios in a fixed meta-analysis model.

RESULTS

Overall, 10 studies with 2275 non-IDU samples were included. Six of the studies were conducted in prison settings, two in treatment centres, one in a community setting and one in a shelter setting. Four studies were performed in Tehran, the capital city of Iran. The pooled HIV prevalence was 5.4% [95% confidence interval (CI) 3.7-7.4] after 2005, which was significantly higher than the prevalence before 2005 [1.6% (95% CI 1.0-2.3)]. IDUs were 4.36 (95% CI 2.63-7.24) times more likely to be infected with HIV than non-IDUs.

CONCLUSION

Iran is facing a major HIV epidemic among non-injecting illicit drug users, which necessitates an urgent preventive response.

A comparative study of characteristics and risky behaviors among the Iranian opium and opium dross addicts

BACKGROUND

Iran ranks first per capita in the use of opiates, but we have little information about possible differences regarding the 2 most commonly used illicit drugs, namely opium and its dross (residue).

DESIGN

This is a cross-sectional study.

SETTING

A cross-sectional study about drug abuse and drug dependence in Iran was conducted from April 2006 to August 2008 in the prisons of 28 Iranian provinces, in the treatment centers, and in the streets.

PARTICIPANTS

To pursue the objectives of this research, participants included 2979 opiate addicts including opium users (n = 2636) and dross users (n = 343), who were not significantly different by gender (P = 0.269) or age (P = 0.452).

MEASUREMENTS

An anonymous questionnaire was completed through an interview that gathered sociodemographic characteristics and information about some high-risk behaviors.

RESULT

: By the end of the study, we concluded that dross addicts, in comparison with opium addicts, were mostly immigrants from rural areas to urban areas (P = 0.031 χ test, 95% confidence interval [CI]), mostly uneducated, illiterate, or semiliterate (P = 0.04 χ test, 95% CI), had illegal occupations (P = 0.048 χ test, 95% CI), were cigarette smokers (P < 0.000 χ test, 95% CI), and had experienced drug injections (P = 0.032 χ test, 95% CI) and drug overdose (P = 0.007 χ test, 95% CI). They also had a history of hospital admission within the preceding year because of drug overdose (P < 0.000) and a record of being arrested and jailed in the past year (P = 0.028 χ test, 95% CI).

CONCLUSION

These results indicated the need for more intensive and effective care for the opioid addicts in Iran.

Predictors and consequences of incarceration among a sample of young Thai methamphetamine users

INTRODUCTION AND AIMS

Our study examined the incidence of arrest and incarceration, investigated predictors of incarceration and explored the persistence of depression, alcohol use and drug use after incarceration among young methamphetamine users from Thailand.

DESIGN AND METHODS

Participants were aged 18-25 years old and were a part of a 12 month randomised social network trial that aimed to reduce sexual risk and methamphetamine use. Estimates of the incidence of arrest and incarceration over 12 months were calculated. A matched case-control study (n = 73 cases; n = 223 controls) was performed to examine incarceration risk factors using conditional logistic regression. Persistence of drug-risk behaviours were explored after incarceration.

RESULTS

Study participants (n = 950) were 72% male, with a median age of 19 years and a median of 9 years of schooling. Frequent drug and alcohol use were reported at baseline. In total, 35% of the sample reported ever having been arrested and 22% reported ever having been incarcerated at baseline. During the 12 month follow up, 16% of the sample was arrested. In univariate analyses, risk factors for incarceration included frequent drug and alcohol use, being less educated, and a history of arrest and incarceration. A high prevalence of drug and alcohol use and involvement in the drug economy persisted after arrest.

DISCUSSION AND CONCLUSIONS

The study indicates a high prevalence of recidivism among this young sample, with continued involvement in drug-risk behaviours after incarceration. Appropriate interventions are needed to address root causes of arrest, largely related to substance use.

Potential for sexual transmission of HIV infection from male injecting-drug users who have sex with men in Tehran, Iran

BACKGROUND

Iran faced an HIV epidemic among injecting-drug users (IDUs) and has responded to this threat. Meanwhile, there is growing concern over the possibility of bridging HIV infection from IDUs to other populations, including men who have sex with men (MSM).

METHODS

Cross-sectional biobehavioral surveys were conducted among 370 injecting-drug users recruited from drug treatment centers, a drop-in center, as well as streets in drug-populated areas in Tehran, Iran, between 2003 and 2004.

RESULTS

Data from these surveys showed that about 12% of male, sexually experienced IDUs have had same-gender sex, and HIV prevalence is high (19%), but condom use during the last sexual encounter was low (20%). A multivariate analysis showed that IDUs who had sex with men (MSM IDUs), compared to other sexually experienced IDUs, are younger (AOR, 0.89; 95% CI, 0.81-0.98), more likely to have used a shared needle/syringe for drug injection (AOR, 4.29; 95% CI, 1.82-10.12), and have had more than 5 sexual partners in their lifetime (AOR, 2.71; 95% CI, 1.14-6.44).

CONCLUSIONS

These results show that MSM IDUs exhibit more drug-related and sexual risk behaviors that may serve as a bridge for sexual transmission of HIV to other populations, including the broader MSM community, in Tehran. This report intends to encourage health authorities in Iran to take serious action to prevent sexual transmission of HIV from MSM IDUs to their sexual networks.

Prevalence of HIV, hepatitis B and hepatitis C and associated risk behaviours amongst injecting drug users in three Afghan cities

BACKGROUND

HIV amongst injecting drug users (IDUs) has been described in Kabul but little data exists for other Afghan cities. We assessed HIV, hepatitis B virus (HBV), and C virus (HCV) prevalence and associated risk behaviours amongst IDUs in Hirat, Jalalabad, and Mazar-i-Sharif, Afghanistan.

METHODS

Consented participants reporting injecting drugs within the previous 6 months completed interviewer-administered questionnaires and testing for HIV, hepatitis C antibody (HCV Ab), and hepatitis B surface antigen (HBsAg). Logistic regression was used to determine characteristics associated with each infection.

RESULTS

Of 623 participants, most (98.7%) were male. Prevalence of HIV, HCV, and HBV was 1.8% (95% CI: 0.88-3.2), 36.0% (95% CI: 33-41), and 5.8% (95% CI: 3.9-7.6), respectively. All HIV cases and highest HCV prevalence were detected in Hirat; HBV prevalence was highest in Jalalabad. Amongst male IDUs, 62.9% had been imprisoned, of whom 17.2% (n=66) injected in prison. High risk behaviours were common; 30.2% reported needle sharing in the last 6 months, 23.1% reported sex with another male, and 50.4% reported paying females for sex. Behaviours varied significantly by site; generally, Hirat participants reported fewer sexual risk behaviours. Sex with other males was negatively associated with both HBV and HCV in multivariate logistic regression analysis; no injecting behaviours were associated with both HBV and HCV.

CONCLUSIONS

Whilst HIV prevalence is low, HCV prevalence and high risk behaviours were common in these populations. Regional variations should be considered in programming to prevent transmission of HIV and viral hepatitis amongst IDUs in Afghanistan.

Epidemiologic links between drug use and HIV epidemics: an international perspective

Injecting use of heroin has been the highest risk substance use behavior for HIV since the beginning of the pandemic. These risks extend beyond individual levels to networks of drugs users and to wider social contexts that have been referred to collectively as the risk environment. Investigations of individual, network, and risk environment level associations with heroin availability, use, and subsequent spread among injecting drug users (IDUs) have been conducted in multiple settings, but much less is known about the world's center of illicit opium production and heroin exports-Afghanistan. Recent outbreaks of injecting drug use and of HIV infection attributed to IDUs in several African countries suggest that heroin use is expanding into new regions. This article explores the epidemiology of HIV among drug users in several risk environments, the epidemiology of heroin and its associations with HIV outbreaks among IDUs in Central Asia and the Commonwealth of Independent States, and the drug use and IDUs outbreaks now emerging in Africa. The dearth of targeted, evidence-and human rights-based responses to these epidemics is explored as a structural driver of HIV spread in these settings.

Toward a comprehensive approach to HIV prevention for people who use drugs

Comprehensive HIV prevention interventions are increasingly recognized as critical in the global effort to reduce HIV transmission among people who use injection drugs. Scientific evidence clearly shows that a variety of biomedical, behavioral, and structural interventions can prevent and reduce injection drug user-driven HIV epidemics, yet social and structural barriers to their implementation remain. This review discusses the scientific evidence on the effectiveness of individual programs for reducing HIV incidence among people who use injection drugs and how, by integrating individual programs as complements within a comprehensive HIV prevention approach, it is possible to achieve, and to sustain, greater results than those of individual programs alone. The article concludes with a discussion of a critical research priority; namely, to improve the implementation of comprehensive HIV prevention interventions in settings of prevalent injection drug use and to overcome the often complex barriers that impede them. Such an effort will require more than research alone, however. It will also require the ongoing commitment of policymakers, public health officials, and the affected communities themselves to use comprehensive HIV treatment and prevention as the most effective strategy to reduce new HIV infections.

Opium trade, insurgency, and HIV/AIDS in Afghanistan: relationships and regional consequences

Global health and conflict studies share key linkages that have important research and policy implications but for which data are currently lacking. This analytical review examines the ongoing conflict in Afghanistan, using it as a basis to develop a conceptual framework that integrates security and public health concepts. The analysis draws on recent peer-reviewed and gray literature to assess the interrelationship among 3 variable clusters and their impact on the emergence of the HIV epidemic in Afghanistan. The evidence suggests that there is a complex indirect relationship linking illicit opium trade, the ongoing insurgency, and forced and spontaneous migration to the emergence of an injection drug use-driven HIV epidemic in Afghanistan. These findings demonstrate a clear need for an integrated cross-disciplinary and regional approach to the emerging threat of HIV/AIDS in Afghanistan, to inform more balanced and effective policy making in this and other regions of strategic global import.

HSV-2 serology can be predictive of HIV epidemic potential and hidden sexual risk behavior in the Middle East and North Africa

BACKGROUND

HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA.

METHODS

We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA.

RESULTS

We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is present.

CONCLUSIONS

HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden sexual risk behaviors in a region where quality behavioral data are limited.

Needle and syringe sharing practices among injecting drug users in Tehran: a comparison of two neighborhoods, one with and one without a needle and syringe program

This study was conducted to compare needle and syringe sharing practices among injecting drug users (IDUs) in two neighborhoods, one with and one without a needle and syringe program (NSP). In 2005, 419 street-based IDUs were interviewed at specific locations in two neighborhoods where IDUs are known to congregate. We compared self-reported needle and syringe access and use between IDUs from a neighborhood with an active NSP to IDUs from a neighborhood without such an intervention. A significantly smaller proportion of IDUs from the former neighborhood reported having used a shared needle/syringe over a 1-month period (21.0%) compared to IDUs from the latter neighborhood (39.9%; adjusted odds ratio, 0.24; 95% confidence interval, 0.13-0.45). These findings indicate that access to an NSP may reduce needle and syringe sharing practices. Therefore, these programs should be intensified in settings with concentrated HIV epidemics among IDUs in Iran.

HIV and risk environment for injecting drug users: the past, present, and future

We systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. We then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. We estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting IDUs' access to HIV prevention and treatment could substantially curtail HIV epidemics.

Epidemiology of HIV infection in the Middle East and North Africa

OBJECTIVE

The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.

METHODS

A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.

RESULTS

Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.

CONCLUSION

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Patterns of drug use and HIV-related risk behaviors among incarcerated people in a prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.

Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran

BACKGROUND

Research evidence indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions including methadone maintenance treatment (MMT) have been introduced into prisons in Iran.

METHODS

This report reviews and presents some important information extracted from published articles, and available documents on HIV sentinel surveillance and provision of MMT inside correctional settings in Iran.

RESULTS

Biological surveillance data in 2005 showed that on average about 3% of prisoners in the country tested positive for HIV infection. MTT that constitutes a main component of the Prison Organisation's HIV prevention package is becoming increasingly accessible to opioid-dependent prisoners. Between 2002 and 2008, the number of opioid-dependent prisoners receiving MMT increased steadily from 100 to more than 25000.

CONCLUSION

Experiences in Iran suggest that access to MMT would be helpful for reducing illicit drug injection in a prison setting and can be considered as a major intervention for preventing the transmission of blood-borne infections among prisoners.

Surveillance of HIV drug resistance transmission in Iran: experience gained from a pilot study

We performed a pilot surveillance study on transmitted HIV drug resistance (TDR) in Iran, with specimens collected and stored as dried blood spots (DBS). The protease region and relevant positions in the reverse transcriptase region of the pol gene were sequenced to detect mutations known to be associated with resistance to drugs in standard first-line regimens. Seventy-three specimens were collected, with 39 (53%) specimens yielding sequence from both protease and at least part of RT. Specimens were almost exclusively HIV-1 subtype CRF 35_A1D based on pol sequencing. Mutations were restricted to RT, with D67DG and V75AV each seen in a single specimen. An atypical protease inhibitor mutation, I47M, appeared at a resistance-associated position in protease from a single specimen. These preliminary data showed that the rate of transmitted drug resistance in Iran, within the areas sampled, was 5.1% (2/39). However, the small sample size makes this figure only an approximation. Due to the sampling strategy and resulting small sample size, we were unable to accurately calculate TDR rates for individual areas using the WHO HIV drug resistance threshold survey method. Increasing the sample size and improving the yield from DBS would improve the accuracy of drug resistance surveillance and facilitate wider application of this methodology in Iran.

Methamphetamine use and rates of incarceration among street-involved youth in a Canadian setting: a cross-sectional analysis

Background

Given concerns over rising use of methamphetamine, especially among street-involved youth, and the links between exposure to the correctional system and the production of drug-related harm, we sought to assess the relationship between ever using methamphetamine and reporting ever being incarcerated in the At-Risk Youth Survey (ARYS) in Vancouver, Canada.

Methods

The relationship between ever being imprisoned and ever using methamphetamine was estimated using a multivariate logistic regression analysis while also considering potentially confounding secondary demographic, social and behavioural variables.

Results

Of the 478 youth recruited into ARYS between September 2005 and October 2006, 385 (80.5%) reported ever being incarcerated overnight or longer. In the multivariate model, methamphetamine use was independently associated with ever being incarcerated (Adjusted Odds Ratio: 1.79, 95% Confidence Interval [CI]: 1.03 – 3.13).

Conclusion

Incarceration was very common in this cohort and strongly linked with ever using methamphetamine. This finding is of concern and, along with the previously identified risks of drug-related harm associated with incarceration, supports the development of novel public policy, such as community-based drug treatment, to address the use of methamphetamine among street youth.

HIV, hepatitis C virus, and hepatitis B virus co-infections among injecting drug users in Tehran, Iran

OBJECTIVES

To assess the prevalence of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and co-infections among injecting drug users (IDUs) in Tehran.

METHODS

A sample of 899 IDUs (861 male and 38 female) was recruited in Tehran from treatment and harm reduction facilities and from drug user hangouts in public areas in equal proportions. ELISA testing for HIV, HCV antibody (HCV-Ab), hepatitis B surface antigen (HBsAg), and hepatitis B core antibody (HBcAb) was carried out. Positive HIV tests were rechecked by Western blot.

RESULTS

The prevalence of HIV was 10.7%, HCV infection was 34.5%, and past or current HBV infection was 50.7%. Infection with all three viruses was seen in 6.5% (95% confidence interval 4.9-8.2) of participants. HIV/HCV, HIV/HBV, and HBV/HCV co-infections were seen in 8.7%, 7.8%, and 21.0% of participants, respectively. The rate of HCV infection among HIV-positive cases was significantly higher than in HIV-negative IDUs (80.6% vs. 28.7%, p<0.0001). There was no significant association between these infections and co-infections with gender and source of sampling.

CONCLUSION

In general, co-infection with these three blood-borne viruses is common among IDUs. Since co-infection increases the morbidity and mortality of all infections, the observed level of co-infection in the high number of IDUs in Iran necessitates a serious comprehensive response.

Incidence of HIV and sexually transmitted infections and risk factors for acquisition among young methamphetamine users in northern Thailand

BACKGROUND

Southeast Asia is experiencing an epidemic of methamphetamine use, a drug associated with risky sexual behaviors, putting a large segment of the population at increased risk for sexually transmitted infections (STIs) and HIV and in need of prevention efforts. Incidence estimates of STIs are rare in Southeast Asia, especially among newer risk groups.

STUDY DESIGN

We enrolled methamphetamine users aged 18 to 25 years in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every 3 months, and biologic specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs.

RESULTS

Overall, 12.7% of 519 participants acquired at least 1 STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration and having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having 2 or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition.

CONCLUSIONS

Although HIV incidence is low in this population, incidence of other STIs is high compared with previous studies of young Thai adults. Risk factors for acquisition emphasize the need for new prevention strategies targeted toward current populations at risk.

A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran, Iran

BACKGROUND

This study aimed to investigate the context in which methadone maintenance treatment (MMT) is provided for opioid-dependent prisoners, and to identify barriers against further scale-up of MMT in Ghezel Hesar prison in Tehran.

METHODS

This was a cross-sectional qualitative study using field observations, focus group discussions, and individual interviews. In total, 30 prisoners and 15 prison staff and health policymakers participated in this study in November 2006.

RESULTS

The rate of drug injecting in the prison unit was unanimously reported to have decreased drastically since introducing the MMT program. In addition to the health benefits to MMT recipients, interview data indicates that MMT has had positive effects on socio-economic status of prisoners' families. Nevertheless, several impediments to the provision of MMT services and to its further expansion were also identified, including staff shortages, some degree of methadone diversion, widespread concerns over the possible side effects of methadone, and the stigma attached to methadone treatment.

CONCLUSION

MMT constitutes one of the main components of the Iran Prison Organization's comprehensive HIV prevention package and is becoming increasingly accessible to opioid-dependent prisoners in Iran. Our findings indicate that the MMT program in Ghezel Hesar prison has been helpful for many opioid-dependent prisoners to reduce their risk of drug-related harm and to ease social and financial burden over their families. Meanwhile, existing barriers against provision of MMT should be properly addressed before further scale up of the program.

Prevalence of infections, HIV risk behaviors and factors associated with HIV infection among male injecting drug users attending a needle/syringe exchange program in Dhaka, Bangladesh

Injecting drug users (IDU) in Bangladesh are at the early stages of an HIV epidemic. To understand the dynamics of the HIV epidemic, male IDU (n = 561) were recruited from the needle/syringe exchange program in Dhaka in 2002, who underwent a risk-behavior survey and were tested for HIV, syphilis, hepatitis C, and hepatitis B. Correlates of HIV infection were determined by conducting bivariate and multiple regression analyses. The median age of the IDU was 35 years, 39.6% had no formal education, approximately half were married and/or living with their regular sex partner and 26% were currently homeless. The median age at first injection was 29 years. HIV was detected in 5.9% of the IDU and homelessness was the only factor independently associated with HIV (OR = 5.5). Urgent measures must be undertaken to prevent escalation of the HIV epidemic. The study's limitations are noted.