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

Characterizing people who inject drugs with no history of opioid agonist therapy uptake in Iran: Results from a national bio-behavioural surveillance survey in 2020

Injection drug use is the primary driver of the human immunodeficiency virus HIV epidemic in Iran. We characterized people who inject drugs (PWID) living in Iran who had never received opioid agonist therapy (OAT) and examined barriers to OAT uptake. We recruited 2,684 PWID with a history of drug injection in the previous 12 months using a respondent-driven sampling approach from 11 geographically dispersed cities in Iran. The primary outcome was no lifetime uptake history of OAT medications. The lifetime prevalence of no history of OAT uptake among PWID was 31.3%, with significant heterogeneities across different cities. In the multivariable analysis, younger age, high school education or above, no prior incarceration history, and shorter length of injecting career was significantly and positively associated with no history of OAT uptake. Individual-level barriers, financial barriers, and system-level barriers were the main barriers to receiving OAT. PWID continue to face preventable barriers to accessing OAT, which calls for revisiting the OAT provision in Iran.

Patterns of Health-related Quality of Life in Men Who Inject Drugs: A Survey in Southeast Iran

OBJECTIVES

Understanding patterns of quality of life in people who inject drugs (PWID) can help healthcare providers plan and manage their health problems in a more focused manner. Therefore, the current study aimed to identify patterns of health-related quality of life in PWID in southeast Iran.

METHODS

This cross-sectional study was conducted in southeast Iran on men who had injected drugs at least once during the last year. We used convenience sampling in 2 drop-in centers and venue-based sampling at 85 venues. Demographic characteristics, high-risk behaviors, and health-related quality of life were evaluated using the 5-level EQ-5D version (EQ-5D-5L) questionnaire. Latent profile analysis was used to identify patterns of quality of life.

RESULTS

This study enrolled 398 PWID, who had a mean age of 34.1±11.4 years. About 47.9% reported a prison history in the last 10 years, 59.2% had injected drugs in the last month, and 31.6% had a history of sharing syringes. About 46.3% reported having 2 or more sexual partners in the last 6 months, and 14.7% had a history of sex with men. Out of the 5 EQ-5D-5L profiles, the fifth profile had the most people (36.6%). Most variations in quality of life were related to pain and discomfort.

CONCLUSIONS

We showed that the pain and discomfort dimension of EQ-5D-5L had more variation in PWID. This finding will be useful for allocating appropriate interventions and resources to promote health-related quality of life in this population.

Odds of HIV among incarcerated drug users: a systematic review and meta-analysis of Asian countries

Background

HIV makes up a large portion of infectious diseases globally. People injecting drugs in prisons are at high risk for contracting HIV infection. Prisons house ~10.2 million people globally, making them a high-risk setting for HIV transmission. This systematic review summarizes the available data on the odds of developing HIV infection among imprisoned people who inject drugs (PWIDs) in Asian regions.

Methods

The authors electronically assessed published studies from January, 2000 to December, 2022, including studies that investigated the odds of HIV in imprisoned PWIDs. We extensively searched PubMed, ERIC, and Cochrane Central and Google Scholar with no constraints in language or time. All the observational studies evaluating the chances of HIV in Asian prisoners with an exposure group of PWIDs and a control group of non-injecting-drug users were included in our analysis.

Results

The databases search yielded 254 potential studies, 10 observational studies of which having a total of 17 333 participants were included. A low or moderate risk of bias was reported in all the studies except one case-control. The pooled analysis showed a significant association between PWIDs and the chances of contracting HIV infection (Odds ratio=6.40; 95% CI=3.89-10.52; P<0.00001; I2=53%).

Conclusion

This study found a vital correlation between injecting-drug usage during imprisonment and HIV transmission speed. The results of this meta-analysis support the need to prevent HIV and conducting treatment programs in high-risk settings like prisons.

Life-time HIV testing among people who inject drugs in Iran: results from the National Rapid Assessment and Response survey

Background

HIV testing is recommended for people who inject drugs (PWID). The aim of this study was to determine the prevalence of lifetime HIV testing among PWID and to better understand the predictors for HIV testing in a convenience sample across Iran.

Materials and methods

This study is a secondary analysis of Iran's National Rapid Assessment and Response survey conducted between October 2016 and March 2017. Analysis includes the 999 people who reported injecting drugs across the capital cities of 21 provinces. Data were collected by using the venue-based application of the Time Location Sampling (TLS) frame. Chi-square tests were used to examine the difference between HIV testing across different quantitative variables. Logistic regression was used to determine the predictors of life-time HIV testing. Analysis was performed using STATA V.12 software with a significance level of 95%.

Results

Most participants were male (n = 902, 93.50%), and over half (n = 555, 59.17%) were older than 35 years old. About one-third, (n = 326, 38%) of people interviewed were single and another one-third (n = 251, 29%) reported being divorced. Over two-thirds of participants (n = 678, 69.78%) in this study reported lifetime HIV testing. The results from a multiple variable logistic regression showed people with a university education were more likely to have been previously tested for HIV than illiterate people (OR = 18.87, 95%CI 2.85-124.6, value of p = 0.002). Those individuals who reported ever receiving methadone treatment were 2.8 times more likely to have been tested for HIV than individuals without methadone treatment experience (OR = 2.89, 95%CI 1.53-5.42, value of p < 0.001). Needle syringe sharing in last month, was negatively associated with life-time HIV testing (OR = 0.29, 95%CI 0.17-0.48, value of p < 0.001).

Conclusion

Despite Iran's wide availability and access to counseling services for HIV testing in key populations, the proportion of PWID being tested for HIV could be improved. Developing effective strategies to increase people's understanding and awareness of the importance of and need for HIV prevention and familiarity with HIV testing sites is an essential step in increasing HIV testing for this population. Studies on more recent HIV testing are required to better assess and understand the frequency of HIV testing among PWID in Iran.

Prevalence of Tuberculosis among People Who Use Drugs in Iran: A Systematic Review and Meta-analysis

Background

Drug use, especially injecting drug use, is associated with a higher risk of tuberculosis (TB). This study aimed to systematically review the prevalence of TB among people who use drugs (PWUD) in Iran.

Methods

A systematic search was conducted in international and national databases. All studies that provided data on the prevalence of TB among PWUD based on screening tests and diagnosis from 1990 up to August 2019 were assessed. Meta-analysis was performed on the prevalence of active TB among people who inject drugs (PWID).

Findings

Overall, nine studies were included. The studies were carried out from 1994 to 2012 in seven out of the 31 provinces of Iran. Seven studies provided data on the prevalence of TB diagnosis among 1087 PWID. The pooled prevalence of TB diagnosis was 10.1% (95% CI: 4.5, 15.8) in studies carried out in hospitals and 0.54% (95% CI: 0.04, 1.04) in other settings.

Conclusion

The present review suggests an approximately 40 times higher prevalence of TB among PWID compared to the general population. However, most of the included studies were conducted on a subpopulation of drug users, and caution should be exercised when generalizing the findings.

An application of social marketing for promoting HIV testing in Iran

BACKGROUND

It has been estimated that 60,000 Iranians have been infected with HIV/AIDS and only 36% of them are aware of their status. This study aimed to design, implement and evaluate a social marketing campaign to promote HIV testing in Boyer-Ahmad County, Kohgiluyeh, and Boyer-Ahmad Province, southwest of Iran.

MATERIALS AND METHODS

This study was a quasi-experimental pretest-posttest without a control group, developed based on a social marketing assessment and response tool. To design the intervention formative research was conducted, comprised of four focus group discussion sessions with 42 participants of the target community along with seven in-depth semi-structured personal interviews with health care providers involved in the HIV/AIDS Program. Data analysis was done manually using content analysis and the main content was formulated for the campaign. Afterward, the slogan and messages of the campaign were developed. The campaign's materials including banners, posters, pamphlets, referral forms, and short messages were designed, pretested, and revised. Ultimately, the campaign was conducted for one month in October 2019. To determine the effectiveness of the campaign, the rate of referrals to the Center for Behavioral Health Counseling Services (CBHCS), for three months before and after the campaign, was compared.

RESULTS

Qualitative findings identified that the majority of the interviewees mentioned that the main reasons for the low rate of referrals to get tested for HIV were lack of awareness and information about HIV/AIDS and its diagnosis as well as the free and confidential tests available from the CBHCS. Moreover, the stigma associated with HIV/AIDS was another important reason for low referrals for testing. The rate of referrals for HIV testing in the three months leading up to the campaign was 18, 32, and 23 people, and three months after the campaign was 64, 81, and 44 individuals; respectively. The results of the multivariate analysis demonstrated that the campaign had increased the rates of referrals for HIV testing through its significant influence on females, and individuals with academic degrees.

CONCLUSION

It can be concluded that the social marketing campaign was successful in persuading people to get tested for HIV.

An Evolving HIV Epidemic in the Middle East and North Africa (MENA) Region: A Scoping Review

Human immunodeficiency virus (HIV) in the Middle East and North Africa (MENA) region is severely understudied despite the region's increase in new HIV infections since 2010. A key population that is particularly affected, due to the lack of adequate knowledge and proper interventional implementation, includes people who inject drugs (PWID). Furthermore, the paucity of HIV data (prevalence and trends) worsens an already critical situation in this region. A scoping review was conducted to address the scarcity of information and to synthesize the available data on HIV prevalence rates within the key population of PWID throughout the MENA region. Information was sourced from major public health databases and world health reports. Of the 1864 articles screened, 40 studies discussed the various factors contributing to the under-reporting of HIV data in the MENA region among PWID. High and overlapping risk behaviors were cited as the most prevalent reason why HIV trends were incomprehensible and hard to characterize among PWID, followed by lack of service utilization, lack of intervention-based programs, cultural norms, lack of advanced HIV surveillance systems, and protracted humanitarian emergencies. Overall, the lack of reported information limits any adequate response to the growing and unknown HIV trends throughout the region.

Duration of delayed diagnosis in HIV/AIDS patients in Iran: a CD4 depletion model analysis

Objective

Delayed diagnosis of HIV can lead to an inappropriate response to antiretroviral therapy (ART), rapid progression of the disease, and death. It can also carry harmful effects on public health due to the increment of transmission. This study aimed to estimate the duration of delayed diagnosis (DDD) in HIV patients in Iran.

Methods

This hybrid cross-sectional cohort study was conducted on the national HIV surveillance system database (HSSD). Linear mixed effect models with random intercept, random slope, and both were used to estimate the parameters required for the CD4 depletion model to determine the best-fitted model for DDD, stratified by the route of transmission, gender, and age group.

Results

The DDD was estimated in 11,373 patients including 4,762 (41.87%) injection drug users (IDUs), 512 (4.5%) men who had sexual contact with men (MSM), 3,762 (33.08%) patients with heterosexual contacts, and 2,337 (20.55%) patients who were infected through other routes of HIV transmission. The total mean DDD was 8.41 ± 5.97 years. The mean DDD was 7.24 ± 0.08 and 9.43 ± 6.83 years in male and female IDUs, respectively. In the heterosexual contact group, DDD was obtained as 8.60 ± 6.43 years in male patients and 9.49 ± 7.17 years in female patients. It was also estimated as 9.37 ± 7.30 years in the MSM group. Furthermore, patients infected through other transmission routes were found with a DDD of 7.90 ± 6.74 years for male patients and a DDD of 7.87 ± 5.87 years for female patients.

Conclusion

A simple CD4 depletion model analysis is represented, which incorporates a pre-estimation step to determine the best-fitted linear mixed model for calculating the parameters required for the CD4 depletion model. Considering such a noticeably high HIV diagnostic delay, especially in older adults, MSM, and heterosexual contact groups, regular periodic screening is required to reduce the DDD.

Pattern of contributing behaviors and their determinants among people living with HIV in Iran: A 30-year nationwide study

Introduction

A major shift in the routes of HIV transmission seams to be taking place in Iran. Our study aimed to investigate the 30-year trend of major HIV related behaviors in Iran.

Methods

The national HIV/AIDS registry database (from September 1986 to July 2016 with data on 32,168 people newly diagnosed with HIV) was used to study the 30 years trend and demographic determinants of major HIV related behaviors.

Results

The highest rate of drug injection (DI) among people living with HIV (PLHIV) was reported during 1996 to 1999 (p-for trend < 0.001) while the highest rate of sexual activity by minorities or hard to reach groups was during 2004 to 2011 (p-for trend < 0.001). Among males, drug injection was directly associated with being single (OR_{single/married} = 1.34), being unemployed (OR_{unemployed/employed} = 1.94) and having lower level of education (OR_{<highschool/≥highschool} = 2.21). Regarding females, drug injection was associated with being housewife (OR_{housewife/employed} = 1.35) and lower level of education (OR_{<highschool/≥highschool} = 1.85). In females, condomless sexual contact was more common among those younger (OR_20-29/<20 = 6.15), and married (OR_{married/single} = 7.76). However, among males those being single (OR_{married/single} = 0.82), being more educated (OR_{≥highschool/<highschool} = 1.24), and being unemployed (OR_{unemployed/employed} = 1.53) reported more sexual activity by minoritised or hard to reach groups.

Discussion

The pattern of major HIV related behaviors among Iranian males and females have been rapidly changing and people living with HIV (PLHIV) are being diagnosed at a younger age. Health education to younger individuals is an essential HIV controlling strategy among Iranian population. Implementation of surveys in hidden and hard-to-reach populations is also recommended.

Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran

BACKGROUND

Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.

METHODS

Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020. We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings. Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.

RESULTS

Of 2388 respondents, 69.6 % reported public injecting in the previous year. Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting. Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.

CONCLUSION

These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran. Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran. Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.

Spouse and Child Abuse Associated With Illicit Drug Use in Iran: A Systematic Review and Meta-Analysis

BACKGROUND

There is a high prevalence of substance use disorders, especially among men, in Iran and is associated with a high burden on families. We aimed to systematically review the association between illicit drug use and spouse and child abuse in Iran.

METHOD

Comprehensive terms were used to search three international databases (ISI, Medline, and Scopus) and a national database of Scientific Information Database up to September 2019. The retrieved citations were screened based on the eligibility criteria and then data were extracted, and the risk of bias was assessed by two independent investigators. Data were analyzed using random-effects model to estimate pooled odds ratios (ORs) and the heterogeneity of studies.

RESULTS

The search yielded 18 articles that met the inclusion criteria. Illicit substance use in husbands was associated with increased odds of current violence (OR = 3.50; 95% CI [2.09, 5.86]), current physical violence (OR = 5.41; 95% CI [3.50, 8.35]), current psychological violence (OR = 6.20; 95% CI [3.74, 10.30]), and current sexual violence (OR = 7.23; 95% CI [4.06, 12.87]) against spouse. In studies on child abuse, the odds of current physical child abuse by parents who used an illicit substance was 3.88 times (95% CI [1.50, 10.01]) higher than parents who did not use any illicit substance.

CONCLUSION

The results of the current study showed that illicit substance use is associated with an increased risk of spouse and child abuse. This is an important social and health consequence of drug use and should be addressed in all drug control plans.

Availability of HIV surveillance data in key populations in the countries of the World Health Organization Eastern Mediterranean Region

OBJECTIVES

To present an assessment of key components and results of HIV surveillance activities relevant for understanding HIV epidemics in the countries of the World Health Organization (WHO) Eastern Mediterranean Region among key populations (KPs), which include men who have sex with men (MSM), sex workers, people who inject drugs and transgender people.

METHODS

We examined HIV surveillance data submitted by the National AIDS Programmes of all 22 countries of the WHO Eastern Mediterranean Region via an online database hosted by the WHO since 2011. We also examined journal articles available on PubMed and technical reports on surveillance activities.

RESULTS

Recent (i.e., since 2017) estimates of HIV indicators from integrated bio-behavioral surveys (IBBS) were available from only four countries (Lebanon, Morocco, Somalia, and Tunisia) and population size estimates from two (Afghanistan and Morocco). IBBS indicated an increase in HIV prevalence among KPs in Pakistan, among people who inject drugs and female sex workers in Tunisia, and among MSM in Lebanon. Information on size estimations of KPs was available from 11 countries, and population size estimation data since 2017 had been collected in only Afghanistan and Morocco.

CONCLUSION

Although some countries have been able to progressively expand HIV strategic information systems, there were still few or no HIV data on KPs in almost a third of the countries.

Factors Associated with HIV Risk and Vulnerability Among Injecting Drug Users in Afghanistan: A Narrative Review

The number of human immunodeficiency virus (HIV) cases in Afghanistan is increasing mainly associated with injecting drug use (IDU). This study aimed to explore the risk and vulnerability factors associated with HIV infection among injecting drug users (IDUs) in Afghanistan in order to contribute to improving the response and reversing the concentrated HIV epidemic among this group. A narrative review of the literature was conducted to reach the objective. The modified social ecological model was used as conceptual framework for analysis of the HIV risk and vulnerability factors among IDUs at five levels. At the “individual level”, the injecting risk behaviors among IDUs such as sharing the injecting equipment and their sexual risk behaviors like unprotected sexual contact with multiple partners identified as immediate factors that put them at risk of HIV infection. At the “network level”, lack of HIV knowledge and low uptake of the harm reduction services were identified as the factors that increase their vulnerability. At the “community level”, massive drug production and easy access to illicit drugs, armed conflicts, massive internal and external migration, unemployment and poverty, high stigma and discrimination against IDUs, unsafe injecting locations such as under the bridges; and at the “public policy level”, punitive drug laws, and weak national political response to HIV and IDU were identified as determinants that add to the IDUs vulnerability to HIV. At the “stage of epidemic level”, the concentrated HIV epidemic among IDUs in the country poses a potential risk to uninfected IDUs and beyond. In conclusion, the IDUs in Afghanistan are highly at risk and vulnerable to HIV. An informed and multisectoral response is required to control the epidemic. A rapid expansion of the harm reduction interventions is urgently needed.

HIV Prevalence and Related Behaviors Among People Who Inject Drugs in Iran from 2010 to 2020

Injection drug use has been the leading route of HIV transmission in Iran. We assessed HIV prevalence, risk behaviors, and uptake of prevention services among people who inject drugs (PWID) in Iran between 2010 and 2020. We also examined the individual and environmental determinants of HIV among PWID. PWID were recruited in major cities across the country in three national bio--behavioral surveillance surveys in 2010, 2014, and 2020. Participants were tested for HIV and interviewed using a behavioral questionnaire. Between 2010 and 2020, the prevalence of HIV (15.1% to 3.5%), receptive needle sharing (25.2% to 3.9%) and unprotected sex (79.4% to 65.2%) decreased. Moreover, uptake of free needle/syringe increased (57.4% to 87.9%), while uptake of free condoms remained relatively stable across the surveys (34.3% to 32.6%). Multivariable analysis for the 2020 survey showed that a history of homelessness, incarceration, and a longer injection career significantly increased the odds of HIV seropositivity. During the past decade, HIV prevalence and drug- and sexual-related risk behaviors decreased among Iranian PWID. However, individual and structural determinants continue to drive HIV among this population. HIV prevention, diagnosis, and treatment among marginalized PWID with a history of homelessness or incarceration and those who inject drugs for a longer period, should be further prioritized in HIV care planning and resource allocation in Iran.

Mapping and population size estimates of people who inject drugs in Afghanistan in 2019: Synthesis of multiple methods

INTRODUCTION

Mapping and population size estimates of people who inject drugs (PWID) provide information needed for monitoring coverage of programs and planning interventions. The objectives of this study were to provide the locations and numbers of PWID in eight cities in Afghanistan and extrapolate estimates for the country as a whole.

METHODS

Multiple population size estimation methods were used, including key informant interviews for mapping and enumeration with reverse tracking, unique object and service multipliers, capture-recapture, and wisdom of the crowds. The results of the several methods were synthesized using the Anchored Multiplier-a Bayesian approach to produce point estimates and 95% credible intervals (CI). Using the prevalence of PWID in the eight cities and their correlation with proxy indicators, we extrapolated the PWID population size for all of Afghanistan.

RESULTS

Key informants and field mapping identified 374 hotspots across the eight cities from December 29, 2018 to March 20, 2019. Synthesizing results of the multiple methods, the number of male PWID in the eight study cities was estimated to be 11,506 (95% CI 8,449-15,093), corresponding to 0.69% (95% CI 0.50-0.90) of the adult male population age 15-64 years. The total number of women who injected drugs was estimated at 484 (95% CI 356-633), corresponding to 0.03% (95% CI 0.02-0.04) of the adult female population. Extrapolating by proxy indicators, the total number of PWID in Afghanistan was estimated to be 54,782 (95% CI 40,250-71,837), men and 2,457 (95% CI 1,823-3,210) women. The total number of PWID in Afghanistan was estimated to be 57,207 (95% CI 42,049-75,005), which corresponds to 0.37% (95% CI 0.27-0.48) of the adult population age 15 to 64 years.

DISCUSSION

This study provided estimates for the number of PWID in Afghanistan. These estimates can be used for advocating and planning services for this vulnerable at-risk population.

Increased prevalence of transfusion-transmitted diseases among people with tattoos: A systematic review and meta-analysis

Whether having a tattoo increases the risk of transfusion-transmitted diseases (TTDs) is controversial. Although a few studies have suggested a strong association between having tattoos and TTDs, other studies have not shown the significance of the association. In addition, previous studies mainly focused only on hepatitis C viral infections. The objective of our study was to identify the prevalence and risk of TTDs in people with tattoos as compared with the non-tattooed population. A systematic review of the studies published before January 22, 2021, was performed using the Pubmed, Embase, and Web of Science databases. Observational studies on hepatitis C virus (HCV), hepatitis B virus (HBV), human immunodeficiency virus (HIV), and syphilis infections in people with and without tattoos were included. Studies that reported disease status without serological confirmation were excluded. A total of 121 studies were quantitatively analyzed. HCV (odds ratio [OR], 2.37; 95% confidence interval [CI], 2.04–2.76), HBV (OR, 1.55; 95% CI, 1.31–1.83), and HIV infections (OR, 3.55; 95% CI, 2.34–5.39) were more prevalent in the tattooed population. In subgroup analyses, the prevalence of HCV infection was significantly elevated in the general population, hospital patient, blood donor, intravenous (IV) drug user, and prisoner groups. IV drug users and prisoners showed high prevalence rates of HBV infection. The prevalence of HIV infection was significantly increased in the general population and prisoner groups. Having a tattoo is associated with an increased prevalence of TTDs. Our approach clarifies in-depth and supports a guideline for TTD screening in the tattooed population.

Public health risks associated with methadone in Iran: A systematic review and meta-analysis

BACKGROUND

There has been a marked growth in methadone maintenance treatment (MMT) in Iran in the past two decades with positive health outcomes. We conducted a systematic review of studies on the prevalence of non-prescribed methadone use, methadone use disorder, and methadone-related poisoning and mortality in Iran.

METHODS

We searched International and Iranian databases up to May 2020 and contacted relevant experts. The pooled proportions were estimated through random-effects model. Methadone-related adverse outcomes were evaluated over time.

RESULTS

Sixty-five studies were included. The pooled estimates of non-prescribed methadone use in the last 12-month were 2.7% (95%CI: 0.9-5.4) and 0.1% (95%CI: 0.03-0.2) in the male and female general population, respectively. Among people who use drugs, 8.4% reported daily non-prescribed use in 2018. Four heterogeneous studies in drug treatment centers reported the existence of treatment-seeking for methadone use disorder. Methadone was responsible for 10.4% (95%CI: 4.5-18.3) of cases of acute poisoning in adults and 16.0% (95%CI: 9.3-24.1) in children. Methadone was reported as a cause of death in 53.5% of substance-related deaths referred to the Legal Medicine Organization while being the only cause in 35.8% of all cases.

CONCLUSION

Non-prescribed use of methadone in the general population is much less than opiates and some other available prescription opioids, like tramadol. However, notwithstanding the large and successful MMT program in Iran, increasing trends in methadone-related poisoning and deaths pose serious public health concerns. There is an urgent need to explore these fatal and non-fatal poisoning cases and implement policies to curb the harms associated with methadone use.

HIV prevalence among non-injecting people who use drugs and related factors in Iran: A systematic review and meta-analysis

ISSUES

This systematic review aimed to provide an updated estimate on the prevalence of human immunodeficiency virus (HIV) infection among non-injecting people who use drugs (PWUD) and the various subgroups and the odds of HIV infection in the injecting compared to non-injecting PWUD.

APPROACH

A comprehensive search of international, regional and national databases was performed from January 2005 to May 2020. We conducted backward citation tracking of the included studies and contacted experts for unpublished studies. Studies providing HIV prevalence among non-injecting PWUD were included. Data were also drawn from a previous systematic review, covering 10 years from 1998 to 2007, and was added to the new database. The HIV prevalence was pooled for non-injecting PWUD and other subgroups using the random-effects model.

KEY FINDINGS

Seventeen studies with a total sample of 9912 non-injecting PWUD were found. The prevalence of HIV infection was 1.9% (95% confidence interval 0.9, 3.1) for 2007 and afterward (nine studies). It was not significantly different from the estimate for the years before 2007 (0.5%; 95% confidence interval 0.0, 2.0; eight studies). No significant difference was found among gender subgroups. The overall estimate of odds of HIV infection among injecting PWUD was 5.7 (95% confidence interval 3.2, 10.0) times higher than non-injecting PWUD.

IMPLICATIONS AND CONCLUSIONS

The HIV prevalence among the non-injecting PWUD was higher than the general population in Iran. Targeting non-injection PWUD by preventive measures such as harm reduction, drug and psychoeducation, and surveillance seem to be crucial in reducing HIV prevalence in this group.

Buprenorphine abuse and health risks in Iran: A systematic review

INTRODUCTION

Buprenorphine maintenance treatment (BMT) is widely used in Iran, and its use is growing continuously. We reviewed studies on buprenorphine use, non-prescribed use, use disorder and treatment-seeking for it, buprenorphine-associated poisoning, and mortality in Iran in the current systematic review.

METHODS

An Iranian database (Scientific Information Database; SID) and three International electronic databases (PubMed, Scopus, and Web of Science) were searched for publications up to August 2020 for the relevant data. Opportunistic methods (Contact with experts and backward citation tracking) were also used for this purpose. Identified records were screened for eligibility criteria, and data of included studies were extracted. For context, the trend of BMT in the country was also examined.

RESULTS

Ten studies were found on the prevalence of non-prescribed buprenorphine use, seven were on the regular use and use disorder, and two studies on buprenorphine poisoning. The last 12-month prevalence of non-prescribed use was lower than 0.5 % in the general population, university, and high school students. The indicator was 2.5 % among persons who use drugs in a 2018 national study. The proportion of buprenorphine poisoning was 4.9 % among all illicit substance poisoning cases admitted to a hospital. The proportion of buprenorphine poisoning cases among all acute pediatric drug poisoning cases increased from 1.2 % to 2.5 % in a 3-year study.

CONCLUSION

Despite the expansion of BMT in Iran in the last decade, the adverse health consequences associated with buprenorphine are infrequent, when compared to other opioids used in Iran, suggesting the safety of BMT for future expansion.

Factors influencing engagement and utilisation of opium tincture-assisted treatment for opioid use disorder: A qualitative study in Tehran, Iran

INTRODUCTION

In response to a high burden of opioid use disorder (OUD), Iran established a network of opioid agonist treatment (OAT) centres beginning in 2002. To increase treatment diversity, particularly for patients who use opium as their drug of choice, opium tincture (OT)-assisted treatment was introduced to the network. This study aimed to explore factors influencing OT-assisted treatment selection for OUD in Tehran, Iran.

METHODS

We conducted 54 in-depth interviews with patients with OUD (n = 33), family members of patients (n = 9) and drug treatment providers (n = 12). Participants were recruited from 12 drug treatment centres across Tehran, between September and November 2019. All interviews were audio-recorded, transcribed and coded in OpenCode 4.02 software and analysed using thematic analysis.

RESULTS

Study participants more commonly reported individual-level factors as facilitators (e.g. to reduce harms associated with illicit opioid use, achieve recovery through a gradual dose reduction regimen combined with Congress 60 recovery program) and structural level factors (e.g. low adoption by OAT system and lack of familiarity of treatment providers) as barriers for utilisation of OT-assisted treatment regimens. OT was perceived to produce lower levels of physiological dependence than methadone, but the requirement for twice supervised dosing was restrictive. Low familial and community acceptance were also seen as barriers to access.

DISCUSSION AND CONCLUSIONS

This research identified a range of perceived benefits for OT-assisted treatment ranging from harm reduction to an intermediate step to achieve recovery. However, several structural-, individual-, familial- and community-level barriers impede its availability and acceptability.

Willingness to utilize supervised injection facilities among people who inject drugs in Iran: Findings from 2020 national HIV bio-behavioral surveillance survey

BACKGROUND

Supervised injection facilities (SIFs) have not yet been integrated into Iran's harm reduction programs. This study aimed to report the extent to which people who inject drugs (PWID) in Iran are willing to use SIFs.

METHODS

Participants were recruited from 11 major cities using respondent-driven sampling. Willingness to use SIFs was defined as a three-level categorical variable: low, moderate, or high.

RESULTS

Of 2,490 PWID, 52.8% and 23.8% reported high and moderate willingness to use SIFs, respectively. PWID with a history of homelessness (relative-risk ratio (RRR): 2.22, 95% CI: 1.76-2.80), incarceration (1.86 [1.48-2.35]), hepatitis C infection (1.49 [1.13-1.97]), and non-fatal overdose (2.30 [1.69-3.13]) were more likely to be willing to utilize SIFs. Willingness to use SIFs was also higher among PWID who reported recent public injecting (2.24 [1.70-2.97]), daily injection (1.82 [1.35-2.45]), stimulants injection (2.39 [1.41-4.07]), syringe sharing (3.09 [1.23-7.74]), harm reduction services utilization (2.80 [2.13-3.68]), and food insecurity (8.28 [5.43-12.63]).

CONCLUSION

The majority of PWID in Iran expressed willingness to use SIFs, in particular, those who were involved in higher-risk injection practices, dealing with structural risks, and had experienced drug-related harms. SIFs represent critical opportunities to deliver comprehensive harm reduction services to improve the health and well-being of PWID in Iran.

Proportion and reasons for loss to follow-up in a cohort study of people who inject drugs to measure HIV and HCV incidence in Kerman, Iran

Background

Understanding the reasons for loss to follow-up (LTFU) in cohort studies, especially among marginalized groups such as people who inject drugs (PWID), is needed to strengthen the rigor of efficacy trials for prevention and treatment interventions. We assessed the proportion and reasons for loss to follow-up in a recent cohort of PWID enrolled in the southeast of Iran.

Methods

Using respondent-driven sampling, we recruited 98 PWID age 18 years or older who reported injecting drugs in the past 6 months, and were negative for HIV and HCV at initial screening. Participants were followed at 6 week intervals, alternating a short six-week visit and long 12-week or quarterly visit to measure incidence of HIV and HCV. Methods to enhance retention included incentives for completing each visit, tracking people who missed the scheduled visits through their peer referral networks, engaged outreach teams to explore hotspots and residences, and photos. LTFU was defined as participants who missed their quarterly visits for two or more weeks.

Results

Mean (SD) age of participants was 39.7 years (SD 9.6). Of 98 enrolled, 50 participants (51.0%) were LTFU by missed their scheduled quarterly visits for 2 weeks or more. For those whose reasons for LTFU could be defined (46.0%, 23 of 50), main reasons were: forgetting the date of visit (43.5%, 10 of 23), being incarcerated (39.1%, 9 of 23), and moving out of the city (17.4%, 4 of 23).

Conclusion

This study highlighted the difficulty in retaining PWID in longitudinal studies. Despite having several retention strategies in place, over half of PWID were LTFU. The LTFU might be reduced by setting up more effective reminder systems, working closely with security systems, and online means to reach those who move outside the study area.

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.

Harm reduction program and hepatitis C prevalence in people who inject drugs (PWID) in Iran: an updated systematic review and cumulative meta-analysis

BACKGROUND

Prevalence of hepatitis C virus (HCV) infection among people who inject drugs (PWID) in Iran is high. Since 2005, the Iranian government has implemented a harm reduction program to control HCV. We aimed to describe the prevalence of HCV antibody (Ab) in Iranian PWID before and after the implementation of harm reduction with cumulative meta-analysis.

METHODS

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies published on the seroprevalence of HCV among PWID. We systematically reviewed the literature to identify eligible studies up to December 2018 in international and national databases. Pooled prevalence and 95% confidence intervals were calculated using Der Simonian and Laird method, taking into account conceptual heterogeneity. Subgroup analyses were performed by harm reduction implementation and studies' characteristics to assess the sources of heterogeneity. We used Cochran-Armitage test for the linear trend of the prevalence of HCV Ab among PWID.

RESULTS

We reviewed 5966 papers and reports and extracted data from 62 eligible records. The pooled HCV Ab prevalence among PWID in Iran was 46.5% (95% confidence interval [95% CI] 41.1-52.0%). Overall, the Cochran-Armitage test for trend indicated a significant decreasing trend of HCV Ab prevalence (P = 0.04). The cumulative meta-analysis showed a slight decline in the prevalence of HCV Ab between the years 2005 and 2018.

CONCLUSIONS

The HCV Ab prevalence among PWID in Iran is high, with a considerable geographical variation. The prevalence of HCV Ab among PWID in Iran slightly decreased after 2005 which could be, at least to some extent, related to the implementation of extensive harm reduction programs in the country.

Prevalence of latent tuberculosis infection and HIV among people who inject drugs in Iran

INTRODUCTION

Iran has an human immunodeficiency viruses (HIV) epidemic that is concentrated among people who inject drugs (PWID), who have higher risks of progression from latent tuberculosis infection (LTBI) to active disease. The aim of this study is to measure prevalence of LTBI, HIV infection and any risk behaviors among PWID in Iran.

METHODS

The cross-sectional study was conducted from August to December 2013 in six cities across Iran. A total of 420 PWID were recruited from drop-in centres using convenience sampling. Trained interviewers collected data on socio-demographic characteristics, drug use history and drug-related risk behaviors across the study sites. A tuberculin skin test (TST) was performed, and HIV infection was assessed by a rapid test. Multivariable modified Poisson regression and logistic regression were used for data analysis.

RESULTS

Prevalence of positive TST and HIV positivity was 35.7% and 8.6%, respectively. The prevalence of LTBI and HIV was significantly different across the cities of this study. Positive TST was independently associated with older age (APR 1.03, 95% CI 1.01, 1.05) and being HIV positive (APR 1.89, 95% CI 1.45, 2.47). HIV infection was associated with lifetime history of sharing syringes (AOR 3.28, 95% CI 1.44, 10.71) and lifetime number of imprisonment (AOR 1.09, 95% CI 1.03-1.14).

DISCUSSION AND CONCLUSIONS

Prevalence of LTBI infections among PWID is high and independently associated with HIV infection. Given that there are currently no TB services available within drop-in centres, programs which integrate TB case finding, TB preventive therapy, referral and care services for PWID are urgently needed.

Hepatitis B virus infection among people who use drugs in Iran: a systematic review, meta-analysis, and trend analysis

Background

People who use drugs (PWUD) are considered as one of the main at-risk populations for Hepatitis B virus (HBV) infection. We conducted a systematic review on the prevalence of HBV infection among PWUD in Iran.

Methods

Consistent with PRISMA guideline, international (Medline, Web of Science, Scopus, and Embase) and national (Scientific Information Database) databases were searched using a comprehensive search strategy up to September 2019. The retrieved records were reviewed, and experts were contacted for unpublished studies. Studies on Iranian PWUD reporting HBV surface Antigen (HBsAg) prevalence among people who inject drugs (PWID) and non-injecting PWUD were included. HBsAg prevalence was pooled for PWID and non-injecting PWUD and for other subgroups using random-effects model meta-analysis. The trend of HBV prevalence over time was investigated using meta-regression analysis.

Results

Overall, 35 studies reported data on HBV infection among PWID (33 studies) and non-injecting PWUD (11 studies). The pooled prevalence of HBsAg among PWID was 4.8% (95% CI 3.7–6.2). The only risk factor significantly associated with the odds of positive HBsAg in PWID was the previous history of imprisonment (OR 1.72, 95% CI 1.29–2.30, p value = 0.000). The pooled estimate of HBsAg among non-injecting PWUD was 2.9% (95% CI 2.5–3.2). Time trend analyses showed significant decrease in HBV prevalence among PWID reaching from 8.2% (95% CI 3.9–16.5) in 2004–2006 to 3.1% (95% CI 2.3–4.1) in 2016 and later (b = -0.07; p value = 0.05). No significant trend was detected for non-injecting PWUD.

Conclusion

The prevalence of HBV infection among non-injecting PWUD and even PWID was not considerably higher than the Iranian general population. This might be the result of extensive harm reduction interventions in Iran. However, it seems that there are subgroups of PWID, who do not adequately benefit from existing harm reduction interventions. Future programs should more specifically target these high-risk groups.

HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran

BACKGROUND

The HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran.

METHODS

Using data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID.

RESULTS

The majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month.

CONCLUSION

The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.

Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran

BACKGROUND

The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.

METHODS

Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.

RESULTS

In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.

CONCLUSIONS

Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

The evolution of addiction treatment and harm reduction programs in Iran: a chaotic response or a synergistic diversity?

BACKGROUNDS AND AIMS

Iran has 2.1 and 1.8% of its 15-64-year-old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a large and multi-modality addiction treatment system, spanning the time before and after the Islamic Revolution.

METHODS

Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop-in centers providing low-threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence-based residential centers. We will review the evolution of this system in four phases.

RESULTS

In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non-agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid-maintenance programs has been implemented to reduce HIV-related high-risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court-based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization.

CONCLUSION

Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.