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

Sexual and gender minority health in the Middle East and North Africa Region: A scoping review

Background

Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems. Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa.

Objectives

We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.

Design

We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

Data sources

We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid). The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority). Each was operationalized using multiple search terms and, where available, controlled vocabulary terms.

Review Methods

Research articles were identified and assessed for inclusion using an explicit strategy. Relevant information was extracted and synthesized to present a descriptive summary of existing evidence.

Results

Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5). Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32). Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%). Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study.

Conclusion

Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence. More research is needed from countries outside of Lebanon, Pakistan, and Iran, including community-based participatory approaches and multi-level intervention development. Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

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

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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.

Drug use and risk behaviour profile, and the prevalence of HIV, hepatitis C and hepatitis B among people with methamphetamine use in Iran

BACKGROUND

Stimulants substances use, particularly methamphetamine use, is increasing globally, including in Iran. This study assessed the drug use and risk behaviour profile, and prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among a large population using methamphetamine as their primary drug in Iran.

METHODS

This cross-sectional study was conducted in eight provinces of Iran. Individuals using methamphetamine for ≥3 months during the past three years, with no life-time history of injecting opioid drugs were enrolled. Drug use and risk behaviour data were collected through interviews. Blood samples were tested for HIV antibodies (HIV Ab), HCV antibodies (HCV Ab), and HBV surface antigen (HBs Ag).

RESULT

Among 567 participated, 84% were men and mean age was 36 years. Smoking with pipe was the most common method of methamphetamine use (53%), while 13% had a history of injecting methamphetamine, among whom 30% shared needles or syringes. Among those having sex during intoxication phase (n = 270), 48% never used condom. The prevalence of HIV Ab, HCV Ab and HBs Ag was 6.7% (95%CI: 4.7-9.1), 19.4% (95%CI: 16.2-22.9) and 1.4% (95%CI: 0.6-2.7), respectively. Age ≥ 30 years (adjusted OR [aOR]: 2.10, 95%CI: 1.18-3.76), lower education (high school vs. tertiary education, aOR: 13.95, 95%CI: 1.90-102.60), and injecting methamphetamine (aOR: 1.92, 95%CI 1.10-3.35) were significantly associated with HCV exposure. No factor was found associated with HIV infection. Among those reporting no potential injecting or sexual risk factors, 19.8% and 6.8% have HCV Ab positive and HIV Ab positive, respectively.

CONCLUSION

High prevalence of injecting and sexual risk behaviours, HIV infection and HCV exposure were found among individuals using methamphetamine as their primary drug, demonstrating them as an emerging population at risk of HIV and HCV in Iran. Targeted screening and harm reduction programs for this population are required.

HIV, HBV and HCV Coinfection Prevalence in Iran--A Systematic Review and Meta-Analysis

BACKGROUND

worldwide, hepatitis C and B virus infections (HCV and HCV), are the two most common coinfections with human immunodeficiency virus (HIV) and has become a major threat to the survival of HIV-infected persons. The review aimed to estimate the prevalence of HIV, HBV, HCV, HIV/HCV and HIV/HBV and triple coinfections in different subpopulations in Iran.

METHOD

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of reports on prevalence of HIV, HBV, HCV and HIV coinfections in different subpopulations in Iran. We systematically reviewed the literature to identify eligible studies from January 1996 to March 2012 in English or Persian/Farsi databases. We extracted the prevalence of HIV antibodies (diagnosed by Elisa confirmed with Western Blot test), HCV antibodies and HBsAg (with confirmatory laboratory test) as the main primary outcome. We reported the prevalence of the three infections and coinfections as point and 95% confidence intervals.

FINDINGS

HIV prevalence varied from %0.00 (95% CI: 0.00-0.003) in the general population to %17.25 (95% CI: 2.94-31.57) in people who inject drugs (PWID). HBV prevalence ranged from % 0.00 (95% CI: 0.00-7.87) in health care workers to % 30.9 (95% CI: 27.88-33.92) in PWID. HCV prevalence ranged from %0.19 (95% CI: 0.00-0.66) in health care workers to %51.46 (95% CI: 34.30-68.62) in PWID. The coinfection of HIV/HBV and also HIV/HCV in the general population and in health care workers was zero, while the most common coinfections were HIV/HCV (10.95%), HIV/HBV (1.88%) and triple infections (1.25%) in PWID.

CONCLUSIONS

We found that PWID are severely and disproportionately affected by HIV and the other two infections, HCV and HBV. Screenings of such coinfections need to be reinforced to prevent new infections and also reduce further transmission in their community and to others.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND

Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran.

METHODS

We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection.

RESULTS

A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market).

CONCLUSION

Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Evidence for risk reduction among amphetamine-injecting men who have sex with men; results from national HIV behavioral surveillance surveys in the Seattle area 2008-2012

In the Seattle area men who have sex with men and also inject amphetamines (amphetamine-injecting MSM/IDU) are disproportionately likely to be infected with HIV. To characterize their distinctive characteristics, we combined data from two Seattle-area surveys of men who have sex with men (MSM) and two surveys of injection drug users (IDU). Amphetamine-injecting MSM/IDU were compared with: male IDU, MSM and other MSM/IDU. Amphetamine-injecting MSM/IDU were older than MSM but younger than IDU, more likely to be white than either group, and had an educational level higher than IDU but below MSM. They had the highest HIV prevalence (56 vs. 4-19 %). However, reported HIV cases among them fell from 92 in 1990 to 25 in 2012. They were most likely to report ten or more sex partners (49 vs. 4-26 %), an STD diagnosis (22 vs. 1-7 %) and be tested for HIV (odds ratio 1.00 vs. 0.34-0.52), and least likely to share needles (odds ratio 1.00 vs. 6.80-10.50). While sexual risk remains high, these data suggest measurable and effective risk reduction with respect to sharing injection equipment and HIV testing among Seattle-area amphetamine-injecting MSM/IDU.

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.

Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis

BACKGROUND

Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.

METHODS AND FINDINGS

This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.

CONCLUSIONS

This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa. Please see later in the article for the Editors' Summary.