The prevalence of human immunodeficiency virus and sexually transmitted infections among female sex workers in Shiraz, South of Iran: by respondent-driven sampling

Drug use patterns and related factors among female sex workers in Iran in 2019-2020: results from Integrated Bio-Behavioral Surveillance-III (IBBS-III)

INTRODUCTION

Drug use is highly prevalent among female sex workers (FSWs). Some forms of drug use, such as injecting drug users (IDU), put them at greater risks for HIV and blood born disease (BBD). In this study, the pattern of drug use and its related factors among Iranian FSWs were investigated.

MATERIALS AND METHODS

This cross-sectional study was performed based on the data of the integrated bio-behavioral surveillance-III (IBBS-III) on FSWs in 8 cities of Iran using the respondent-driven sampling (RDS) method conducting in 2019-2020. Of the 1515 FSWs participating in the IBBS-III study, 1,480 answered questions about drug use. To calculate the prevalence of drug use lifetime and in the past month, weighted analysis was used. Univariate and multivariate logistic regression was used to investigate the factors related to drug use.

RESULTS

The prevalence of lifetime drug use and the prevalence of current drug use (single and poly drug use) among FSWs were estimated to be 29.3% and 18.86%, respectively. According to multivariate regression analysis, the odds ratio (odds) of lifetime drug use showed a statistically significant association with lower education (AOR = 1.18; 95% CI: 1.07-1.3), being a direct sex worker (AOR = 1.77; 95% CI: 1.21-2.61), working in team houses or hangouts (AOR = 1.51; 95% CI: 1.10-2.06), a history of intentional abortion (AOR = 1.41; 95% CI: 1.07-1.87), condom use in the last sex (AOR = 1.61; 95% CI: 1.19-2.17), a history of imprisonment (AOR = 3.05; 95% CI: 2.25-4.14), HIV positive tests (AOR = 8.24; 95% CI: 1.66-40.9), alcohol use (AOR = 1.69; 95% CI: 1.29-2.29), and finding sexual clients in places such as parties, shopping malls, streets, and hotels, or by friends (AOR = 1.46; 95% CI: 1.01-2.12).

CONCLUSION

Given that drug use among FSWs is about 14 times higher than that of the Iranian general population, it is imperative that drug reduction programs be integrated into service packages. Specifically, prevention programs should be prioritized for occasional drug users within this population as they are at a greater risk of developing drug use issues compared to the general population.

HIV prevalence and associated factors among female sex workers in Iran: a bio-behavioral survey in 2020

Despite the overall decline in human immunodeficiency virus (HIV) prevalence, it remains unacceptably high in key populations. This study aimed to estimate prevalence of HIV infection and high-risk behaviors among female sex workers (FSWs). This study was a cross-sectional survey of FSWs conducted between December 2019 and August 2020 in eight geographically diverse cities in Iran. After providing informed consent, participants completed a bio-behavioral questionnaire and after completion of the interview, rapid diagnostic tests (RDT) and dried blood spots (DBS) were collected to determine HIV and syphilis status as per national guidelines, if the women consented. All analyzes were based on RDS adjustment. Weighting was done according to Giles'SS estimator. Among the 1515 FSWs, the overall prevalence of HIV and syphilis were 1.6% (95% CI: 0.8-2.3) and zero, respectively. The highest HIV prevalence was observed in Shiraz (5.1%) and Khorramabad city (1.6%). In addition, HIV-positive FSWs had a higher mean age at first sexual contact than HIV-negative FSWs (21.4 ± 5.6 vs. 17.2 ± 4.2 years). Injection drug use and a history of arrest or incarceration were associated with an increased odds of HIV infection (OR = 6.25; 95% CI: 1.90-20.55 and OR = 4.57; 95% CI: 1.64-12.72, respectively). Based on the results, strategies to improve early HIV diagnosis, harm reduction, and use of testing and treatment strategies are needed to reduce and control HIV infections.

Condomless Sex With Partners and Clients Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis

ABSTRACT

Condomless sex is the most proximal risk for HIV acquisition among female sex workers (FSWs). We performed a systematic review and meta-analysis to summarize the evidence for the prevalence of condomless sex among FSWs in Iran. A random-effect meta-analysis model was used to pool the prevalence estimates and their 95% confidence intervals (CIs). The pooled prevalence of condomless sex at last sex with a paying client and a nonpaying partner was 34.23% (95% CI: 27.83-40.93) and 48.34 (95% CI: 38.43-58.32), respectively. Last-month inconsistent condom use was 49.01% (95% CI: 21.64-76.71) with paying clients and 60.21% (95% CI: 31.27-85.73) with nonpaying partners. The pooled prevalence of lifetime condom nonuse with any partners/clients was 15.26% (95% CI: 10.68-20.49). These findings indicate that a substantial proportion of FSWs engage in high-risk sexual practices. Community-led programs should be stimulated to improve consistent condom use among FSWs.

Gonorrhoea: a systematic review of prevalence reporting globally

BACKGROUND

The World Health Organization (WHO) recommends periodic gonorrhoea prevalence assessments in the general population or proxies thereof (including pregnant women, women attending family planning clinics, military recruits, and men undergoing employment physicals for example) and in population groups at increased risk, including men-who-have-sex-with-men (MSM) and sex workers.

METHOD

We evaluated reported prevalence data, including estimates from proxy general population samples to reflect the WHO recommendations. We describe the outcomes from the general population country-by-country and extend previous reviews to include MSM, sex workers, and extragenital infections.

RESULT AND CONCLUSION

In our systematic search, 2015 titles were reviewed (January 2010-April 2019) and 174 full-text publications were included. National, population-based prevalence data were identified in only four countries (the United States of America, the United Kingdom, Peru, New Caledonia) and local population-based estimates were reported in areas within five countries (China, South Africa, Brazil, Benin, and Malawi). The remaining studies identified only reported test positivity from non-probability, proxy general population samples. Due to the diversity of the reviewed studies, detailed comparison across studies was not possible. In MSM, data were identified from 64 studies in 25 countries. Rectal infection rates were generally higher than urogenital or pharyngeal infection rates, where extragenital testing was conducted. Data on sex workers were identified from 41 studies in 23 countries; rates in female sex workers were high. Current prevalence monitoring was shown to be highly suboptimal worldwide. Serial prevalence monitoring of critical epidemiological variables, and guidelines to optimize prevalence study conduct and reporting beyond antenatal settings are recommended.

Injection and non-injection drug use among female sex workers in Iran: A systematic review and meta-analysis

BACKGROUND

Illicit drug use is a prevalent risk behavior among female sex workers (FSWs) as it increases the vulnerability of this marginalized population to negative health outcomes, including HIV infection. This systematic review and meta-analysis aimed to estimate the prevalence of injection and non-injection drug use among FSWs in Iran.

METHODS

Systematic searches of PubMed, Embase, Web of Science, Scopus, and PsycINFO (for English records), along with Iranian databases including IranMedex, Iran Psych Magiran, Scientific Information Database, and Irandoc (for Farsi records) were conducted for studies published from inception through to July 2020. We included quantitative studies on injection and non-injection drug use among FSWs. The pooled prevalence and 95% confidence intervals (CI) of recent and lifetime drug injection and non-injection were estimated using random-effects meta-analysis.

RESULTS

Of 458 screened records, 19 met the inclusion criteria. The pooled prevalence of recent non-injection drug use and injection drug use was 56.94% (95% CI: 44.68, 68.78) and 5.67% (95% CI: 2.09, 10.73), respectively. Opium (33.00%, 95% CI: 24.53, 42.05) and crystal methamphetamine (20.68%, 95% CI: 13.59, 28.79) were the most prevalent recent non-injection drugs used. Additionally, the pooled prevalence of lifetime non-injection drug use was 76.08% (95% CI: 66.81, 84.27) and injection drug use was 10.72% (95% CI: 7.02, 15.07).

CONCLUSIONS

This systematic review shows that drug use, both injection and non-injection, is prevalent among FSWs in Iran. These findings highlight the importance of evidence-based harm reduction and treatment programs to reduce the burdens of drug use and its associated potential consequences among these underserved women.

Lifetime and past-month substance use and injection among street-based female sex workers in Iran

BACKGROUND

Street-based female sex workers (FSWs) are highly at risk of HIV and other harms associated with sex work. We assessed the prevalence of non-injection and injection drug use and their associated factors among street-based FSWs in Iran.

METHODS

We recruited 898 FSWs from 414 venues across 19 major cities in Iran between October 2016 and March 2017. Correlates of lifetime and past-month non-injection and injection drug use were assessed through multivariable logistic regression models. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported.

RESULTS

Lifetime and past-month non-injection drug use were reported by 60.3% (95% CI 51, 84) and 47.2% (95% CI 38, 67) of FSWs, respectively. The prevalence of lifetime and past-month injection drug use were 8.6% (95% CI 6.9, 10.7) and 3.7% (95% CI 2.6, 5.2), respectively. Recent non-injection drug use was associated with divorced marital status (AOR 2.00, 95% CI 1.07, 3.74), temporary marriage (AOR 4.31 [1.79, 10.40]), had > 30 clients per month (AOR 2.76 [1.29, 5.90]), ever alcohol use (AOR 3.03 [1.92, 6.79]), and history of incarceration (AOR 7.65 [3.89, 15.30]). Similarly, lifetime injection drug use was associated with ever alcohol use (AOR 2.74 [1.20-6.20]), ever incarceration (AOR 5.06 [2.48-10.28]), and ever group sex (AOR 2.44 [1.21-4.92]).

CONCLUSIONS

Non-injection and injection drug use are prevalent among street-based FSWs in Iran. Further prevention programs are needed to address and reduce harms associated with drug use among this vulnerable population in Iran.

The effects of human immunodeficiency virus, human papillomavirus, herpes simplex virus-1 and -2, human herpesvirus-6 and -8, cytomegalovirus, and hepatitis B and C virus on female fertility and pregnancy

Female infertility may be defined as a woman of reproductive age being unable to become pregnant after a year of regular unprotected sexual intercourse. Social, genetic, endocrine, physiological, and psychological factors as well as lifestyle habits (i.e., smoking and alcohol consumption), either alone or in combination with male factors, are major causes. However, approximately 15-30% of cases of female infertility remain unexplained. Numerous investigations have also indicated that microbiomes play an important role in human reproduction. All parts of the female reproductive system may be influenced by infectious and pathological agents, especially viruses, and these may interfere with reproductive function and so are risk factors for infertility, although in many cases an exact role is unclear. We present an overview of the impact of common viral infections on female reproduction, searching Medline, PubMed, Scopus, and Google scholar databases for potentially relevant studies of viruses known to have a potential effect. Human immunodeficiency virus (HIV), herpes simplex virus (HSV) and human herpesvirus (HHV) increase infertility rates whilst human papillomavirus (HPV), cytomegalovirus (CMV), and hepatitis B and C virus (HBV, HCV) infections mostly lead to higher abortion and miscarriage rates. Moreover, HPV infection is linked to increased tubal infertility, endometriosis, and pelvic inflammatory disease. HPV was the most frequently observed infection and with lower pregnancy rate and foetal death in women undergoing IVF treatments. Assisted reproductive treatment could be a safe and effective approach for HIV and HBV infected women.

HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis

Given the high burden of HIV and other sexually transmitted infections (STIs) among female sex workers (FSW) and their potential role in bridging HIV/STIs into the general population, estimating the prevalence of HIV/STIs among FSW is essential for future research and policy developments. This systematic review and meta-analysis synthesize the available HIV/STIs data among FSW in Iran. We searched MEDLINE, PsycINFO, CINAHL, Embase, Web of Science, Google Scholar, and Iranian databases from inception through to January 2018. Inclusion criteria were original quantitative studies that measured HIV/STIs prevalence among FSW. Pooled prevalence estimates were calculated using random-effects meta-analyses. Out of a total of 299 screened studies, 12 were included with total study participants of 4328 FSW. Heterogeneity was present but meta-regression analyses revealed no significant association between HIV prevalence and year of publication, city, and age. Pooled HIV prevalence was 2.23% (95% confidence interval [CI] 0.82, 3.64). We estimated the prevalence of other STIs as 0.77% (95% CI 0.01, 1.53) for hepatitis B, 6.18% (95% CI 1.32, 11.04) for hepatitis C, 0.33% (95% CI 0.00, 0.66) for syphilis, 1.47% (95% CI 0.22, 2.71) for gonorrhea, 9.80% (95% CI 4.70, 14.91) for chlamydia, and 6.18% (95% CI 4.92, 7.43) for trichomonas vaginalis. Based on the existing evidence, HIV and STIs prevalence among FSW are relatively low in Iran. Strategies for timely diagnosis and treatment of HIV and other STIs among FSW and their sexual and injecting partners are needed to reduce the burden of HIV/STIs among these vulnerable populations in Iran.

Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regression

BACKGROUND

The epidemiology of Chlamydia trachomatis in the Middle East and north Africa is poorly understood. We aimed to provide a comprehensive epidemiological assessment of C trachomatis infection in the Middle East and north Africa.

METHODS

We did a systematic review of C trachomatis infection as well as a meta-analysis and meta-regression of C trachomatis prevalence. We searched PubMed and Embase, as well as regional and national databases up to March 13, 2019, using broad search terms with no language or year restrictions. Any document or report including biological measures for C trachomatis prevalence or incidence was eligible for inclusion. We extracted all measures of current (genital or rectal), recent, and ever infection with C trachomatis. We estimated pooled average prevalence in different populations using random-effects meta-analysis. Factors associated with prevalence and sources of between-study heterogeneity were determined using meta-regression.

FINDINGS

We identified a total of 1531 citations, of which 255 reports contributed to 552 C trachomatis prevalence measures from 20 countries. No incidence measures were identified. Pooled prevalence of current genital infection was 3·0% (95% CI 2·3-3·8) in general populations, 2·8% (1·0-5·2) in intermediate-risk populations, 13·2% (7·2-20·7) in female sex workers, 11·3% (9·0-13·7) in infertility clinic attendees, 12·4% (7·9-17·7) in women with miscarriage, 12·4% (9·4-15·7) in symptomatic women, and 17·4% (12·5-22·8) in symptomatic men. Pooled prevalence of current rectal infection was 7·7% (4·2-12·0) in men who have sex with men. Substantial between-study heterogeneity was found. Multivariable meta-regression explained 29·0% of variation. Population type was most strongly associated with prevalence. Additional associations were found with assay type, sample size, country, and sex, but not with sampling methodology or response rate (about 90% of studies used convenience sampling and >75% had unclear response rate). There was no evidence for temporal variation in prevalence between 1982 and 2018.

INTERPRETATION

C trachomatis prevalence in the Middle East and north Africa is similar to other regions, but higher than expected given its sexually conservative norms. High prevalence in infertility clinic attendees and in women with miscarriage suggests a potential role for C trachomatis in poor reproductive health outcomes in this region.

FUNDING

National Priorities Research Program from the Qatar National Research Fund (a member of Qatar Foundation).

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.

Knowledge and Awareness Regarding Hepatitis B, Hepatitis C, and Human Immunodeficiency Viruses Among College Students: A Report From Iran

Globally, high-risk illnesses including Hepatitis B, Hepatitis C, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) are major health problems causing considerable impact on health systems. Knowledge and awareness are very important factors for controlling these illnesses in society. Regarding the transmission routes of these viruses, young people are at the highest risk of infection. Therefore, our objectives were to determine the college students' awareness of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV/AIDS with regard to basic information, transmission, and prevention. A total of 810 students from 7 universities, from September to March 2017, were included in the study. All participants were categorized into three groups (medical, biology, and other fields). The subjects were evaluated by a standardized questionnaire and results analyzed in SPSS software using the χ² test. In total, 43% of respondents were male and the majority of them were 20 to 25 years old. Our results showed the suitable level of awareness about HBV and remarkable about HIV. In contrast, insufficient level of awareness was indicated about HCV. Given the low levels of awareness or knowledge about HCV, it can be suggested that educational programs for this important disease are necessary especially for university students. On the other hand, high awareness of participants about HBV and HIV/AIDS might be the results of the proper functioning of educational programs for students in Iran.

Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study

OBJECTIVE

The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran.

METHODS

We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds.

RESULTS

HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus.

CONCLUSIONS

HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.

Epidemiology of Treponema pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 among female sex workers in the Middle East and North Africa: systematic review and meta-analytics

BACKGROUND

The epidemiology of sexually transmitted infections (STIs) and the role of commercial heterosexual sex networks in driving STI transmission in the Middle East and North Africa (MENA) region remain largely unknown.

OBJECTIVE

To characterize the epidemiology of Treponema pallidum (syphilis), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 (HSV-2) among female sex workers (FSWs) in MENA using an in-depth quantitative assessment.

METHODS

A systematic review on ten international, regional, and country-level databases was conducted, and reported following PRISMA guidelines. Pooled prevalences of current and/or ever infection for each STI were estimated using random-effects meta-analyses. Sources of between-study heterogeneity were investigated through random-effects meta-regressions.

RESULTS

One T. pallidum incidence study and 144 STI prevalence studies were identified for 45 812 FSWs in 13 MENA countries. The pooled prevalence of current infection was 12.7% (95% confidence interval (CI) = 8.5%-17.7%) for T. pallidum, 14.4% (95% CI = 8.2%-22.0%) for C. trachomatis, 5.7% (95% CI = 3.5%-8.4%) for N. gonorrhoeae, and 7.1% (95% CI = 4.3%-10.5%) for T. vaginalis. The pooled prevalence of ever infection (seropositivity using antibody testing) was 12.8% (95% CI = 9.4%-16.6%) for T. pallidum, 80.3% (95% CI = 53.2%-97.6%) for C. trachomatis, and 23.7% (95% CI = 10.2%-40.4%) for HSV-2. The multivariable meta-regression for T. pallidum infection demonstrated strong subregional differences, with the Horn of Africa and North Africa showing, respectively 6-fold (adjusted odds ratio (AOR): 6.4; 95% CI = 2.5-16.7) and 5-fold (AOR = 5.0; 95% CI = 2.5-10.6) higher odds of infection than Eastern MENA. There was also strong evidence for declining T. pallidum odds of infection at 7% per year (AOR = 0.93; 95% CI = 0.88-0.98). Study-specific factors including diagnostic method, sample size, sampling methodology, and response rate, were not associated with syphilis infection. The multivariable model explained 48.5% of the variation in T. pallidum prevalence.

CONCLUSIONS

STI infection levels among FSWs in MENA are considerable, supporting a key role for commercial heterosexual sex networks in transmission dynamics, and highlighting the health needs of this neglected and vulnerable population. Syphilis prevalence in FSWs appears to have been declining for at least three decades. Gaps in evidence persist for multiple countries.

Hepatitis C Virus among Female Sex Workers: A Cross-Sectional Study Conducted along Rivers and Highways in the Amazon Region

Background: Previous studies found a high prevalence of pathogens among female sex workers (FSWs) in the Amazon region, and established their parenteral and sexual transmission. This study estimated the prevalence of hepatitis C virus (HCV) infection and associated risk factors, and the frequency of HCV genotypes and resistance-associated substitutions (RASs) in this vulnerable group. Methods: Distinct sampling methods were used to access 412 FSWs in cities and riverside communities in the Amazon region from 2015 to 2018. Three methods for HCV diagnosis were used to determine infection status. HCV genotypes and RASs were identified by sequencing and nucleotide fragment analysis. An association between HCV infection and exposure factors was determined by bivariate and multivariate analysis. Results: In total, 44 (10.7%) FSWs were exposed to HCV, and 32 (7.8%) of them had active infection. Nine socioeconomic characteristics and risky sexual behaviors were associated with HCV exposure, particularly unprotected sex and condom exemption for the clients who paid extra money. Genotype 1 (81.3%) and 3 (18.7%) were detected. The frequency of FSWs with RASs was 23.1% (6/26) for grazoprevir related to the occurrence of substitutions Y56F and S122G. Conclusions: HCV infection among FSWs is highly prevalent and dominated by genotype I. Urgent preventive and treatment measures are required to reduce HCV infection in FSWs and the general population.

Sex under Influence of Drugs: A Nationwide Survey among Iranian Female Sex Workers

Background

Due to the high level of sexual relationships, prostitute women are faced with many dangers, including acquired immune deficiency syndrome (AIDS), sexually transmitted infections (STIs), fertility problems, drug use, etc. In this regard, addict prostitute women are exposed to more risks because drug use is considered as an outstanding factor in those associated with transmission of AIDS and being in an insecure sexual relationship. The purpose of this study was to find out the variables influential on the level of drug use, before or during sexual relationship.

Methods

In 2010, 625 prostitute women were selected by multistage sampling from 21 centers out of 12 provinces. Then, we used a standard questionnaire for gathering data by a face-to-face interview. The multilevel ordinal logistic regression in survey model was used to find out the relationship between variables and the level of drug use before or during sexual relationship.

Findings

The number of monetary customers at the last working day [adjusted odds ratio (AOR): 1.87, 95% confidence interval (CI): 1.50-2.32] and having sexual relationship during the past month with monetary customers (AOR: 4.77, 95% CI: 2.61-8.70) were significantly related to the level of drug use before or during sexual relationship in the past month.

Conclusion

Since the level of drug use before or during sexual relationship was higher in women who had more daily sexual relationships, these women are exposed to the consequences of drug use; thus, identifying the status of this group of women is important to plan for future injuries.

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.

METHODS

A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.

RESULTS

We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2-2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3-13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0-34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1-1.8%) in FSWs and 0.4% (95% CI = 0.1-0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).

CONCLUSIONS

HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."

Drug use patterns and associated factors among female sex workers in Iran

OBJECTIVE

This study examines the prevalence of drug and poly-drug use and their associated factors among female sex workers (FSW) in Iran.

METHODS

We analyzed data from a bio-behavioral surveillance survey of 1347 FSW across 13 major cities in Iran in 2015. Two outcome measures were defined: i) past-month "any drug use", a binary variable defined as none or any; and ii) a three-category past-month "poly-drug use" variable defined as none, only one drug, and more than one drug. Correlates of these two study outcomes were assessed using multivariable logistic regression and multinomial logistic regression, respectively. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported.

RESULTS

We found that 24.9% (95% CI: 16.1, 36.4) and 13.5% (95% CI: 8.1, 21.5) of FSW reported past-month any drug use and poly-drug use, respectively. Longer sex work career (AOR 2.44 [95% CI: 1.28, 4.63]), unstable housing (AOR 2.56 [1.17, 5.64]), past-year experience of sexual violence (AOR 1.61 [1.15, 2.27]), and incarceration (AOR 2.02 [1.23, 3.32]) were positively associated with any drug use. Similarly, FSW who were unstably housed (AOR 3.4 [1.06, 10.95]), reported past-year experience of sexual violence (AOR 2.06 [95% CI: 1.24, 3.41]) and incarceration (AOR 2.82 [1.60, 4.97]) were positively associated with past-month poly-drug use.

CONCLUSION

Drug use is frequent among Iranian FSW, particularly among those who experienced sexual violence, unstable housing or incarceration. Programs to reduce harms associated with drug and poly-drug use should target FSW as a priority population.

Gonorrhea and syphilis co-infection and related risk factors in HIV patients from Shiraz, South of Iran

Background:

Neisseria gonorrhea and Treponema pallidum as an obligate human pathogen are two common causes of sexually transmitted diseases (STDs). The present study aimed to determine the prevalence of N. gonorrhoeae and T. pallidum among human immunodeficiency virus (HIV) patients in the southwest Iran.

Methods:

This retrospective study was performed from 2004 to 2013, on HIV patients who were tested for detection of gonorrhea and syphilis infection at Shiraz HIV/AIDS Research Center. ELISA technique was used for preliminary detection of HIV and confirmed by a Western Blotting test. Gonorrhea was routinely diagnosed using direct Gram-staining and culturing on selective agar. Syphilis was routinely diagnosed by RPR test.

Results:

Of the 806 HIV patients, 39 (2.6%) cases had co-infection with gonorrhea. Compared with mono-HIV infected patients, gonorrhea was significantly more likely among the males (69.4% vs. 92.3%, P=0.002). History of addiction and prison seems to be a significant risk factor for gonorrhea infection (P<0.05). Also, the mean of CD4+lymphocyte was higher among gonorrhea infected patients (368±238 vs. 415±328). Logistic regression analysis showed that sexual contact increased risk of gonococcal infection about 4 fold (OR: 4, CI: 1.7-9.39, P=0.001). None of the HIV patients had syphilis co-infection.

Conclusions:

As a preliminary survey, our findings provided unique information on the prevalence of gonorrhea and syphilis co-infections among HIV patients. Moreover, we introduced the main risk factors associated with gonorrhea co-infection in HIV patients in our region including gender, history of addiction and prison, CD4+lymphocyte count, and transmission routes for effective management of STDs.

Symptom-Based Versus Laboratory-Based Diagnosis of Five Sexually Transmitted Infections in Female Sex Workers in Iran

Among 1337 Iranian adult female sex workers in 2015, we assessed the diagnostic value of 4 self-reported sexually transmitted infection (STIs) symptoms for detecting laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, human papillomavirus (HPV), and syphilis. While 37.7% reported vaginal discharge (VD), 25.9% reported pain or burning (P/B), 3.0% reported genital ulcers (GU), and 1.4% reported genital warts (GW), the prevalence of laboratory-confirmed syphilis, gonorrhea, chlamydia, trichomoniasis, and HPV was 0.4, 1.3, 6.0, 11.9, and 41.9%, respectively. The sensitivity of VD was 40.3% for detecting tricomoniasis, 37.5% for chlamydia, and 37.5% for gonorrhea. The sensitivity of P/B ranged from 12.5% for gonorrhea to 25.2% for trichomoniasis. The sensitivity of GU and GW was very low for 5 STIs. The sensitivity of all symptoms combined was also lower than 50%. Among asymptomatic participants, 41.2% tested positive for HPV, 11.8% for trichomoniasis, and less than 6.6% for other STIs. Symptom-based case management and surveillance of STIs can lead to misclassification of a large proportion of cases.

Prevalence of HAV Ab, HEV (IgG), HSV2 IgG, and Syphilis Among Sheltered Homeless Adults in Tehran, 2012

Background: This study investigated the prevalence for hepatitis A virus (HAV), hepatitis E virus (HEV), herpes simplex virus type 2 (HSV2) and syphilis among homeless in the city of Tehran.

Methods: In this cross-sectional study, 596 homeless were recruited in Tehran. A researcher-designed questionnaire was used to study demographic data. Using enzyme-linked immunoassay, and rapid plasma reagin (RPR) test, we evaluated the seroprevalence of HAV anti-body, HEV IgG, herpes, HSV2 IgG, and syphilis among sheltered homeless in Tehran. The associations between the participant’s characteristics and infections were evaluated using logistic regression and chi-square.

Results: A total of 569 homeless, 78 women (13.7%) and 491 men (86.3%) were enrolled into the study from June to August 2012. Their age mean was 42 years and meantime of being homeless was 24 months. Seroprevalence of syphilis, HEV IgG, HSV2 IgG and HAV Ab was 0.55%, 24.37%, 16.48%, and 94.34%, respectively. History of drug abuse was reported in 77.70%; 46.01% of them were using a drug during the study and 26.87% of them had history of intravenous drug abuse. Among people who had intravenous drug abuse, 48.25% had history of syringe sharing.

Conclusion: The prevalence of HAV, HEV and HSV2 were higher than the general population while low prevalence of syphilis was seen among homeless peoples who are at high risk of sexually transmitted infection (STD). Our findings highlighted that significant healthcare needs of sheltered homeless people in Tehran are unmet and much more attention needs to be paid for the health of homeless people.

Prevalence of Sexually Transmitted Infections and Their Risk Factors among Female Sex Workers in Isfahan, Iran: A Cross-Sectional Study

OBJECTIVES

Female sex workers (FSWs) are at high risk of sexually transmitted infections (STIs) and form a core group to facilitate STI spreading. We aimed to estimate the prevalence of STIs among FSWs who attended Female Harm Reduction Center of Isfahan, Iran, and to determine the association between risky behaviors and STIs.

STUDY DESIGN

In a cross-sectional study, 99 FSWs were recruited and interviewed about demographic characteristics and risky behaviors. A trained midwife examined FSWs for genital ulcer, abnormal vaginal discharge, and cervicitis. Urine and genital specimens were collected and real-time polymerase chain reaction was performed to diagnose Neisseria gonorrhoeae, human papilloma virus (HPV), and Trichomonas Vaginalis. Data were analyzed via χ² test and logistic regression in StataCorp software (version 11) with 95% confidence interval.

RESULTS

Totally, 84.9% of FSWs reported STI symptoms, while 12.1% of them were infected with N gonorrhoeae, HPV, or T vaginalis. Human papilloma virus and gonorrhea prevalence rates were 5.7% and 8% in FSWs with STI-associated symptoms. Sexually transmitted infections showed significant association with duration of prostitution (odds ratio [OR]_HPV = 1.009 [95% confidence interval [95% CI: 1.004-1.01]; OR_gonorrhea = 1.01 [95% CI: 1.00-1.01]) and condom usage (OR_HPV = 0.11 [95% CI: 0.012-0.98]; OR_gonorrhea = 0.04 [95% CI: 0.005-0.33]).

CONCLUSION

Due to the literature gap on the Iranian FSWs' sexual health and the intense stigma around this subject, in Iran, our results would be useful for developing an efficient intervention program. The prevalence of STIs in Isfahan FSWs can be controlled with programs such as consistent condom use and STI treatment. In addition, as just one-tenth of FSWs with an STI symptom were positive for an STI, symptomatic diagnosis of STIs might be insufficient.

Consistent Condom Use with Paying and Nonpaying Partners among Female Sex Workers in Iran: Findings of a National Biobehavioral Survey

OBJECTIVES

Little is known about the dynamics of condom use among female sex workers (FSWs) in Iran. We investigated the correlates of consistent condom use (CCU) among FSWs, using data from a national biobehavioral surveillance survey in 2010.

METHODS

A total of 872 FSWs were recruited using a facility-based sampling strategy from 21 sites in 13 cities in Iran. Data were collected through face-to-face interviews using a standardized questionnaire.

RESULTS

Overall, 33.6% and 17.3% of FSWs reported CCU with paying and nonpaying sex partners, respectively. Consistent condom use with paying partners was significantly associated with temporary marriage, accessing family planning services and history of working in brothels. Conversely, temporary marriage or married status, condom rupture/slippage, and HIV seropositivity remained independently significantly associated with CCU with nonpaying sex partners.

CONCLUSION

Our findings indicated the urgent need for scaling up condom promotion interventions catered toward FSWs and their sex partners to practice safe sex consistently.

Injection drug use among female sex workers in Iran: Findings from a nationwide bio-behavioural survey

BACKGROUND

Globally, one in three women who inject drugs is involved in sex work which increases their vulnerability to sexually transmitted infections including HIV. This study was conducted to improve our understanding of injection drug use practices among Iranian female sex workers (FSWs) and shed light on the high-risk profile of FSWs who inject drugs (FSW-IDUs).

METHODS

This survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 13 cities in Iran. Data were collected through face-to-face interviews and lifetime injection drug use was assessed through the responses to the question "Have you ever injected any illicit drugs?". Independent variables included a range of socio-demographic and risk characteristics. Logistic regression models were applied to investigate the correlates of lifetime history of injection drug use.

RESULTS

Median (Q1, Q3) age of the participants was 30 (25, 37) and a total of 127 (14.6%, 95% confidence interval (CI): 12.3-17.1) had ever injected drugs. In the multivariable logistic regression model, older age (adjusted odds ratio (AOR)=AOR_{25-34 vs. <18}=3.37, 95% CI: 1.64, 7.70; AOR_{≥35 vs. <18}=2.80, 95% CI: 1.11, 7.10), longer duration (>5 years) of involvement in sex work (AOR=1.06, 95% CI: 1.02, 1.10), and history of drinking alcohol (AOR=4.42, 95% CI: 2.67, 7.32) were positively associated with lifetime history of drug injection and younger age at sex work debut (AOR=0.52, 95% CI: 0.28, 0.96) was negatively associated with lifetime history of illicit drug injection among FSWs.

CONCLUSION

The prevalence of injection drug use among FSWs in Iran is concerning. Given the potential of this sub-population in bridging HIV into the general population, gender-sensitive and peer-led harm reduction programs should be further scaled up to meet the special needs of this vulnerable population.

HIV-1 genetic diversity and transmitted drug resistance frequency among Iranian treatment-naive, sexually infected individuals

In recent years, the patterns of human immunodeficiency virus 1 (HIV-1) transmission in Iran have been changing gradually from drug injection to unprotected sexual contact. This study sought to investigate the phylogenetic trends and characteristics of transmitted drug resistance (TDR) mutations of HIV-1 in a population that is mainly infected through homo/heterosexual contacts. Sixty newly diagnosed antiretroviral-naive individuals with HIV infection living in Tehran were recruited to this survey, and among them, 42 subjects were established to be infected through sexual intercourse. Following amplification and sequencing of the main part of the HIV-1 pol region, phylogenetic and drug-resistance mutation (DRM) analysis was successfully performed on these 42 patients. Phylogenetic analysis showed that the majority of the subjects were infected with subtype CRF35_AD (88%), followed by subtype B, with 7.1%, and subtype CRF01_AE, with 4.7%. A total of 7.1% of the subjects were found to be infected with HIV-1 variants with surveillance drug-resistant mutations (SDRMs) according to the last world health organisation (WHO) algorithm. All of the identified SDRMs belonged to the non-nucleoside reverse transcriptase inhibitors (NNRTIs) class, including K103 N and V106A, which were found in three patients. Two minor HIV protease-inhibitor-related mutations (L10I and G73S) were detected in two patients, but these mutations are not included in the WHO SDRMs list. The dominance of HIV-1 subtype CRF35_AD was observed among subjects of this study who were infected through sexual contact. The moderate prevalence of SDRMs (7.1%) in this population emphasises the fact that the risk of treatment failure in HIV-infected individuals might increase in the future, and preventive measures should be considered by health authorities.

Effect of self-care training program based on Orem's model on the behaviors leading to sexually transmitted disease in vulnerable women

Background:

Vulnerable women are prone to sexually transmitted diseases due to their high-risk behaviors. The present study aimed to investigate the effect of self-care training program based on Orem's model on the behaviors leading to sexually transmitted diseases in vulnerable women.

Materials and Methods:

This field trial was initially conducted on 100 women covered under health services and welfare organization in Isfahan city, who were selected by rationing ssampling. For needs assessment, they filled the self-care needs assessment questionnaire in three domains of knowledge, attitude, and practice. Then, at the stage of intervention (self-care training), 64 subjects were selected through convenient sampling and were assigned to experimental and control groups by random allocation. Data were analyzed by descriptive and analytical statistical tests through SPSS 18.

Results:

Results showed that mean scores of knowledge (P < 0.001), attitude (P < 0.001), practice (P = 0.04), and behavior change (P = 0.01) were significantly higher immediately after and 3 months after intervention, compared to before intervention, but there was no significant difference in mean scores between immediately after and 3 months after intervention.

Conclusions:

With regard to these results, it can be concluded that if the educational programs are planned based on clients’ real needs assessment, the learners follow the educational materials, related to their problems, more seriously and it results in a notable behavior change in them.

Population-based survey on STI-associated symptoms and health-seeking behaviours among Iranian adults

BACKGROUND

Qualified decision-making for the improved management of sexually transmitted infections (STIs) requires various sources of information. We aimed to estimate the STI-associated symptom prevalence and care-seeking patterns in the general population of Iran.

METHODS

In 2014, using a street-based survey with a standard gender-specific questionnaire on STI-associated symptoms and willingness to seek treatment, we interviewed 9166 Iranian participants, who were selected from among the 18-60-year-old population using multistage sampling. Data were analysed via generalised estimating equation and survey analysis, taking into account a 95% confidence coefficient.

RESULTS

About 67.3% of participants, mean age 33 years, were 'assumed sexually active' and were therefore eligible for inclusion. Approximately 39.9% (95% CI 28.4% to 51.4%) of women and 17.6% (95% CI 13.9% to 21.6%) of men reported at least one STI-associated symptom in the current week. The occurrence of symptoms decreased with an increase in age in both genders (p<0.05). About 21.2% (95% CI 13.3% to 29.1%) of women and 7.1% (95% CI 5.4% to 7.8%) of men treated symptoms themselves after symptoms first appeared. Of the women and men with symptoms, 37.4% (95% CI 24.8% to 50.0%) and 46.8% (95% CI 39.7% to 51.4%), respectively, sought care. Most women visited a gynaecologist and midwife; men tended to visit a general practitioner and urologist after their symptoms appeared.

CONCLUSIONS

The prevalence of STI-associated symptoms in Iranian adults is considerable. The results emphasise the need for appropriate and timely STI care and more attention to sexual health promotion to mitigate onward and future infections. Attention to the care-seeking pattern is fundamental to policymaking and planning.

Drug Use and High-Risk Sexual Behaviors of Women at a Drop-In Center in Mazandaran Province, Iran, 2014

BACKGROUND

Female drug users are more likely to transmit human immunodeficiency virus (HIV) to their sexual partners. Little is known about HIV, sexually transmitted diseases (STDs), cervicitis, and drug abuse among female sex workers in Iran.

OBJECTIVES

Therefore, this study was conducted at a drop-in center (DIC) in Iran to investigate the prevalence of HIV associated risk factors, the prevalence of drug use, high-risk sexual behaviors, and the relationship between the associated factors in women.

PATIENTS AND METHODS

This quantitative cross-sectional study was conducted on 190 female sex workers (SW) in a DIC in Sari, Mazandaran, Northern Iran, in January and February 2014. The study sample was selected through census sampling. In the end, 190 female SWs referring to the DIC participated in our study. There was no limitation in sampling. The self-administered questionnaire was completed via an interview.

RESULTS

The results showed that 39% of the female SWs were less than 30 years old and 64% had elementary school education. In addition, 59% of the participants took some type of illegal drugs and 1.1% of them were reportedly injecting drug users. Moreover, 43% of them had substance dependent husbands, and 39% were reportedly regular condom users. They had 1 - 10 sexual partners on average per week. The overall prevalence of HIV infection was 4%. A significant relationship was found between the type of drugs used and factors such as having a substance dependent husband, use of condom during the last sexual contact, regular condom use, and the number of sexual acts per week. A significant correlation exists between using psychiatric drugs and factors like regular condom use, education, cervicitis, and the number of sexual conducts per week.

CONCLUSIONS

Female sex workers often engage in sex for financial reasons and are at high risk of drug abuse, HIV, and cervicitis. In addition, the rate of cervicitis among females with high-risk sexual behavior is considerable in Mazandaran, Iran. Therefore, the state authorities should provide sex workers with health care services and help them acquire a good job to support their life.

HIV prevalence and related risk behaviours among female sex workers in Iran: results of the national biobehavioural survey, 2010

OBJECTIVES

To determine the prevalence of HIV and related behavioural risks among Iranian female sex workers (FSW) via the first national biobehavioural surveillance survey.

METHODS

In 2010, 1005 FSW were approached and 872 recruited using facility-based sampling from 21 sites in 14 cities in Iran. We collected dried blood samples and conducted face-to-face interviews using a standardised questionnaire. Data were weighted based on the response rate and adjusted for the clustering effect of the sampling site. Adjustment was performed by weighting based on the sampling fraction of each site using a prior estimate of its total size of the FSW population.

RESULTS

The prevalence of HIV infection (95% CI) was 4.5% (2.4 to 8.3) overall, 4.8% (2.2 to 9.8) among those who had reported a history of drug use and 11.2% (5.4 to 21.5) among those who had a history of injection drug use. The frequencies of condom use in the last sexual act with paying clients and non-paying partners were 57.1% and 36.3%, respectively. Any drug use was reported by 73.8% of participants, and among this subgroup, 20.5% had a history of injection drug use.

CONCLUSIONS

The prevalence of HIV was considerable among FSW particularly those who had a history of drug injection. A combination of prevention efforts addressing unsafe sex and injection are needed to prevent further transmission of HIV infection.