Unlike in much of the world today, the HIV epidemic is expanding in Iran.1 More than 17,000 cases have been reported so far, although the true number of persons living with HIV is estimated to be many times higher.2 The vast majority of reported cases have occurred among injection drug users (IDU),1,2 with the next largest categories being the wives of IDU and their children. Estimates of HIV prevalence among IDU in Iran range from 1% to 30%.3-6 The situation is exacerbated by the proximity of Iran to Afghanistan, the source of the majority of the global heroin supply. Iran also has one of the highest per capita opioid use rates in the world and an increasing number of injecting opioid users.7,8
HIV is usually more prevalent in prison populations than in the surrounding communities because of the high proportion of IDU present in these institutions.5 Prison populations are also dynamic, with vast numbers young men and women moving between the prison setting and vulnerable communities. These attributes of prison populations, a high proportion of IDU and a high turnover of inmates, may contribute to the spread of HIV infection among prisoners and among their communities.5 To more effectively target HIV prevention programs, we assessed the prevalence of infection, relevant drug practices, and sexual risk behavior among male IDU upon detention in Tehran, Iran.
Methods of the survey have been described by Jahani et al.9 In brief, our study is a cross-sectional survey of male IDU detained by police during a “sweep” in Tehran, Iran in 2006. Participants agreed to estimate the prevalence of HIV and associated risk factors for infection. Records were kept separate from the jail system, and referrals for treatment and care were given through the university medical center. The study was approved by the Ethics Committee of the Tehran University Medical School.
Upon entry to the mandatory detoxification center, we offered serologic screening for HIV antibody. Samples were first screened using an enzyme-linked immunosorbent assay (Biotest AG, Dreieich, Germany). HIV-positive samples were confirmed by Western blot (Diagnostic, Berlin, Germany). A questionnaire recorded demographic information, imprisonment history, injecting drug risk behaviors, and questions regarding HIV sexual risk behaviors. Of 499 inmates approached, 459 (92.0%) consented to participate and provided a specimen.
In the center, detoxification was implemented without of use of methadone for the 3-month period. The condition was similar to mandatory drug rehabilitation throughout the 1980s and 1990s in Iran. However, since 2000, harm reduction programs have been gradually established in Iran.10
Data were entered and analyzed using STATA (8.0, College Station, TX, USA). HIV point prevalence was calculated as the number of confirmed HIV-positive individuals divided the number of test results overall and stratified by demographic characteristics, incarceration history, and drug use and sexual risk behaviors. Because of high levels of “decline to answer” and missing data for many sensitive questions, we chose to code variables as 1 = acknowledging behavior, 0 = not acknowledging behavior (i.e., “no,” “decline to answer,” and missing). Although we recognize this approach may misclassify many negative responses, it provided the advantages of conserving data for analysis and giving minimum estimates for risk behaviors. After description of the variables by proportions and 95% confidence intervals (CI), we conducted logistic regression analyses to determine associations with HIV infection. Variables associated with HIV infection in bivariate analysis at the P ≤ 0.10 level were included as potential independent predictors. The final model retained those variables associated with HIV infection at the P < 0.05 level.
Demographic characteristics and risk behaviors of detained IDU are described in Table 1. Of the 459 participants, 112 (24.4%) were HIV positive (95% CI: 20.5-28.6) (Table 1). Also, 68.6% participants did not know their previous HIV test result. At the P < 0.10 level, HIV infection was associated with age, past history of incarceration, and history of using an opioid in jail. Acknowledging having sex in jail was borderline significant. We did not detect associations between HIV infection and other demographic characteristics, type of drugs used, injection practices, history of sexually transmitted disease, or other sexual behaviors.
In multivariate analysis that included all variables associated with HIV infection at P ≤ 0.10 in bivariate analysis, history of using an opioid in jail (adjusted odds ratio 2.11, 95% CI: 1.26-3.53) and older age (adjusted odds ratio 2.79 for 25-34, 3.01 for 35-44, 4.62 for ≥ 45 yr) remained independently associated with HIV infection (P < 0.05).
Our study, like that of Zamani et al,11 with a 24.4% HIV prevalence, higher than found in some previous studies in Iran,3,6 provides compelling data that incarceration is a major contributor to the spread of HIV among IDU in Iran. Past history of incarceration accounted for the highest fraction of HIV infections detected (91 of 112), and reported history of opioid use in jail was the only risk factor significantly associated with infection. Jails may serve as amplifiers of HIV transmission by leading to the sharing of injection equipment with large numbers of persons, many of whom may already be infected with HIV acquired from previous incarceration or from the outside community. Imprisonment is a common and recurring event for most IDU. Over 60% of IDUs in a 12-city study in low- and middle-income countries reported a history of imprisonment, and in one Australian study, IDU reported an average of five imprisonments.5,12 In 10 European cities, injecting drugs while in prison was associated with HIV infection.13 In another study in Thailand, incarceration was independently associated with HIV infection.14 Our findings are therefore corroborated by many studies around the world.15-18
However, a particular concern for Iran is the incarceration of large number of noninjecting opioid users (8). Otherwise noninjecting opium users may be compelled to inject while in jail to abate withdrawal symptoms because of the difficulty of clandestine smoking and scarcity of sufficient raw opium.19 Such noninjectors may also be mixing with higher prevalence injecting populations for the first time. Of note in our data is that 80.0% of IDU reported past use of opium. In a study in Shiraz, Iran, IDU were more likely to have been to prison than noninjecting drug users (41% vs. 7%); however, 91% of all IDU and noninjection drug users ever imprisoned reported using drugs while in prison.19
The effectiveness of harm reduction programming in a prison setting has been supported through research in many countries, such as Iran.20,21 Therefore, Iran has started a number of harm reduction programs for tackling the HIV epidemic among IDUs. Methadone maintenance therapy and needle exchange programs have been established in many prisons. Likewise, condom distribution exists, but it should be expanded. There are more than 60 triangular clinics (sexually transmitted infections, HIV/AIDS, drug abuse) across Iran, but it is unclear how many of these have initiated needle exchange programs.10,21 Large numbers of participants in this study did not previously know their HIV serologic status, with testing therefore directly benefiting their health and potentially slowing secondary transmission.
We note that a major limitation of our data is the potential for severe under-reporting of risk behaviors in the jail setting because of their illegal and highly sensitive nature. Social desirability response bias may also account for the lack of association between HIV infection and needle and equipment sharing. Such limitations may be true to an even greater extent for sexual behaviors. Sex outside of marriage is illegal in Iran, and other studies have noted the strong reluctance to divulge sexual risk behavior in surveys.22 Male-male sexual behavior in particular is highly stigmatized and illegal. It is therefore notable that nearly 1 in 5 acknowledge engaging in sex with sex workers and 1 in 20 in male-male sex. Moreover, we found at least a borderline association between HIV infection and acknowledging having sex while in jail. Although sexual behaviors may be contributing to HIV transmission among IDU inside and outside jails, we believe it is very likely to be under-reported in our study. In addition to the risk of acquiring HIV through sex, the high rate of marriage among IDU in our study underscores the risk of transmission from IDU to their wives. Appropriate and accurate ways of measuring sexual behavior as well as the prevention of sexual transmission of HIV in the Iranian context is an area requiring basic research.
Other limitations to our data include limited recall, not knowing the timing of infection in relation to the reported risk behaviors and to incarceration, and the representativeness of our sample to the wider IDU population of Tehran. It may be the case, for example, that IDU from higher socio-economic status are under-represented because of the areas and nature of the police sweeps. Finally, a major limitation is that our sample did not include female IDU, a population very difficult to sample in the Middle East region.
Despite these potential limitations, our data provide a basis to advocate for enhanced HIV prevention action in Iran. The very high HIV prevalence found in our survey lends strong support to launching additional needle exchange programs, expanding methadone programs, renewing education to help establish cleaning norms before sharing of works, and promoting condom use.
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