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Introduction: People who inject drugs (PWID) are a key population at risk of HIV in Iran. We measured the prevalence and covariates of HIV-related risk behaviours among PWID in Iran. Methods: We conducted a respondent-driven bio-behavioural surveillance survey among PWID from July 2019 to March 2020 in 11 major cities. We assessed PWID's recent (i.e., last three months) HIV-related risk behaviours using a four-level categorical variable: Only unsafe injection (i.e., sharing needles/syringes or injecting equipment), only unsafe sex (i.e., unprotected sex), dual HIV risk (i.e., both unsafe injection and unprotected sex), and safe injection and sex. Data were summarized using RDS-weighted analysis. Multinomial logistic regression models were built to characterize HIV-related risk behaviours and relative risk ratio (RRR) with 95% confidence interval (CI) were reported. Results: Overall, 2562 men who inject drugs (MWID) were included in the regression analysis. The RDS-weighted prevalence of dual HIV risk was 1.3% (95% CI: 0.8, 1.9), only unsafe injection was 4.5%, and only unsafe sex was 11.8%. Compared to the safe injection and sex group, dual HIV risk was significantly and positively associated with multiple partnership (RRR = 15.06; 3.30, 68.73). Only unsafe injection was significantly associated with homelessness in the last 12 months (RRR: 3.02; 95% CI: 1.34, 6.80). Only unsafe sex was significantly associated with multiple partnership (RRR = 6.66; 4.27, 10.38), receiving free condoms (RRR = 1.71; 1.01, 2.89), receiving free needles (RRR = 2.18; 1.22, 3.90), and self-received risk for HIV (RRR = 2.51; 1.36, 4.66). Moreover, history of HIV-testing in the last three months was significantly associated with only unsafe injection (RRR = 2.71; 1.84, 3.80). Among the 90 women who injected drugs, none reported dual HIV risk behaviours. Discussion and conclusions: While the low prevalence of dual HIV risk among PWID is encouraging, unprotected sexual practices among PWID is concerning. Expanding sexual health education and care services as well as tailored interventions aimed at reducing high-risk sexual activities among PWID are warranted. Additionally, tackling potential misperceptions about risk of HIV transmission among PWID in Iran is warranted. [ABSTRACT FROM AUTHOR]

Background: Persons who inject drugs (PWID) may be unengaged with healthcare services and face an elevated risk of severe morbidity and mortality associated with COVID-19 due to chronic diseases and structural inequities. However, data on COVID-19 vaccine uptake, particularly booster vaccination, among PWID are limited. We examined COVID-19 vaccine uptake and factors associated with booster vaccination among PWID in New York City (NYC). Methods: We recruited PWID using respondent-driven sampling from October 2021 to November 2023 in a survey that included HIV and SARS-CoV-2 antibodies testing. The questionnaire included demographics, COVID-19 vaccination and attitudes, and drug use behaviors. Results: Of 436 PWID, 80% received at least one COVID-19 vaccine dose. Among individuals who received at least one COVID-19 vaccine dose, 95% were fully vaccinated. After excluding participants recruited before booster authorization for general adults started in NYC, and those who had never received an initial vaccination, 41% reported having received a COVID-19 booster vaccine dose. COVID-19 booster vaccination was significantly associated with having a high school diploma or GED (adjusted odds ratio (aOR) 1.93; 95% confidence interval (CI) 1.09, 3.48), ever received the hepatitis A/B vaccine (aOR 2.23; 95% CI 1.27, 3.96), main drug use other than heroin/speedball, fentanyl and stimulants (aOR 14.4; 95% CI 2.32, 280), number of non-fatal overdoses (aOR 0.35; 95% CI 0.16, 0.70), and mean vaccination attitude score (aOR 0.94; 95% CI 0.89, 0.98). Conclusions: We found a suboptimal level of COVID-19 booster vaccination among PWID, which was consistent with the rates observed in the general population in NYC and the U.S. Community-based interventions are needed to improve COVID-19 booster vaccination access and uptake among PWID. Attitudes towards vaccination were significant predictors of both primary and booster vaccination uptake. Outreach efforts focusing on improving attitudes towards vaccination and educational programs are essential for reducing hesitancy and increasing booster vaccination uptake among PWID. [ABSTRACT FROM AUTHOR]

Background: Most people who inject drugs (PWID) in Iran have not undergone recent HIV testing. While PWID face barriers when seeking HIV testing at health facilities, HIV self-testing (HIVST) could be a promising approach to improve HIV testing uptake. We examined the awareness and willingness to use HIVST among PWID in Iran. We also identified participants' characteristics associated with a higher willingness to use HIVST. Methods: PWID were recruited in 11 cities using a respondent-driven sampling method. Willingness to use HIVST was defined as a binary variable (very low/low willingness vs. high/very high willingness). We performed multivariable modified Poisson regression to examine associated factors and report adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Results: Of 2,252 PWID, 362 (16.2%; 95% CI 14.7, 17.8) had ever heard of HIVST; however, 1,658 (73.6%; 95% CI 71.7, 75.4) reported high/very high willingness to use HIVST. Willingness to use HIVST was higher among PWID who reported having a high/moderate HIV risk perception (aPR 1.22; 95% CI 1.09, 1.37), ever experiencing homelessness (aPR 1.15; 95% CI 1.03, 1.28), > 10 years of injecting history (aPR 1.16; 95% CI 1.00, 1.34), and high injection frequency in the last three months (aPR 1.18; 95% CI 1.05, 1.32). Conclusion: Most PWID in Iran, particularly those experiencing homelessness, have a longer injecting history, engage in more frequent injection practices, and possess a heightened perception of HIV risk would be willing to adopt HIVST. Enhancing HIVST awareness through increased access to HIVST and health education programs are needed. Additionally, conducting implementation science studies to effectively design and run HIVST programs in Iran can also increase PWID's access to HIV testing. [ABSTRACT FROM AUTHOR]

We characterized suicidal ideation and suicide attempts among incarcerated people in Iran. We recruited a multistage random sample of 5785 incarcerated people from 33 prisons across Iran. Eligible participants were those aged ≥ 18 years who had been incarcerated for at least one week at the time of the study. Lifetime suicidal ideation and suicide attempts were estimated at 38.2% and 20.5%, respectively. Of participants who reported suicide attempts, 57.6% reported attempts prior to incarceration, 31.5% while incarcerated, and 10.9% both before and during incarceration. Suicide attempt was significantly associated with a younger age, being a woman, being widowed/divorced, a longer period of incarceration, convictions for violent crimes, HIV sero-positivity, lifetime non-injection, and injection drug use. The primary reasons reported for suicide attempts were feeling empty/hopeless and living with substance use disorders. Prison health services should provide a comprehensive, integrated mental health programme, including mental health screening upon arrival and continued care during incarceration. [ABSTRACT FROM AUTHOR]

Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs. We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023. We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies. We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8–43.7) and 21.7% (14.9–29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1–42.4), and multiple induced abortion prevalence was 23.1% (12.4–35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8–54.6), and multiple induced abortion prevalence was 19.9% (11.9–29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6–42.7) overall, 42.8% (37.2–48.5) for countries where elective abortion is illegal, and 15.6% (3.9–32.7) for countries that legally allow elective abortion. Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services. [ABSTRACT FROM AUTHOR]

Background: Macrolides have shown beneficial effects in the treatment of chronic rhinosinusitis (CRS). This study aimed to compare the effect of azithromycin and clarithromycin in combination with conventional therapies for the treatment of CRS. Methods: This single-blind randomized controlled trial was conducted during 2018-2019 at the Otorhinolaryngology Clinic of Shahid Mohammadi Hospital, Bandar Abbas, Iran. Out of 102 selected patients, 90 were included in the analysis. Patients were selected through convenience sampling and randomly assigned to two equal groups. In addition to conventional therapies (nasal irrigation, betamethasone injection, oxymetazoline and fluticasone spray, guaifenesin syrup, and steam inhalation), the patients in the clarithromycin group received clarithromycin 500 mg tablets twice daily for four weeks. The other group received azithromycin 500 mg tablets daily for four weeks. Patients' symptoms were evaluated pre- and post-intervention, and the Lund-Mackay (LM) scoring system was used for the staging of CRS based on computed tomography scan findings. Data were analyzed using SPSS software, and P<0.05 was considered statistically significant. Results: Patients in both groups were comparable in terms of age and sex. Complete resolution of symptoms was significantly higher in the azithromycin group than the clarithromycin group (71.1% vs. 24.4%, P<0.001). Baseline LM scores did not differ significantly between the groups (P=0.120). However, postintervention, LM scores reduced considerably in both groups, but the change was significantly higher in the azithromycin group (P<0.001). Conclusion: In combination with conventional therapies for CRS in adults, a four-week course of treatment with azithromycin is more effective than clarithromycin. Trial Registration Number: IRCT20201209049661N1. [ABSTRACT FROM AUTHOR]

This study explored reasons for women's entry into sex work using data from the national bio-behavioral survey of female sex workers (FSWs) in Iran. We also compared FSWs' reasons for those who entered sex work as a minor (< 18) versus those as an adult (≥ 18). We recruited 1347 FSWs who reported having sex in exchange for money, goods, services, or drugs with at least two clients in the previous year in 13 large cities. Participants were asked about their main reason for entering into sex work. Overall, economic hardship was the main reason for entry into sex work (56.2%), followed by personal choice (20.2%), environmental forces (16.6%), and drug use (7.0%). While economic hardship was the main reason in all birth cohorts, it decreased from 68.3% among FSWs born before 1970 to 39.6% among those born in 1990 or later. Compared to women who began sex work as adults, women who entered sex work as minors were more likely to report environmental forces (31.5% vs. 15.2%, P < 0.001) and less likely to report economic hardship as reasons for beginning sex work (36.2% vs. 58.7%, P = 0.003). Our data suggest that the engagement of women in sex work in Iran is multi-factorial. The main factor is dependence on sex work for income which highlights the need for economic empowerment programs. Programs should also target environmental forces and provide access to social support services for those who have entered sex work as minors. [ABSTRACT FROM AUTHOR]

Background: Female sex workers (FSWs) are at a disproportionate risk of sexually transmitted infections and they may face significant barriers to HIV testing. This study aimed to examine HIV testing prevalence and its associated factors among street-based FSWs in Iran.Method: A total of 898 FSWs were recruited from 414 venues across 19 major cities in Iran between October 2016 and March 2017. Eligible FSWs were women aged 18 years of age who had at least one commercial sexual intercourse in the previous year. HIV testing was defined as having tested for HIV in the lifetime. Bivariable and multivariable logistic regression were used to examine the correlates of HIV testing. We report adjusted odds ratios (aOR) and their 95% confidence intervals (CI).Result: Overall, 57.8% (95%CI: 20.0, 88.0) of participants reported having tested for HIV, and HIV prevalence among FSWs who tested for HIV was 10.3% (95%CI: 7.5, 13.0). The multivariable model showed that unstable housing (aOR: 8.86, 95%CI: 2.68, 29.32) and drug use (aOR: 3.47, 95%CI: 1.33, 9.06) were associated with increased likelihood of HIV testing. However, FSWs with a higher level of income were less likely to be tested for HIV (aOR: 0.09, 95%CI: 0.02, 0.43).Conclusion: Almost one in ten street-based FSWs had never tested for HIV. These findings suggest the need for evidence-based strategies such as outreach support and HIV self-testing to improve HIV testing in this marginalized population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Induced abortion is an occupational hazard for female sex workers (FSWs). This study aimed to examine the prevalence and factors associated with induced abortion among FSWs in Iran. 1337 FSWs aged ≥18 years who reported selling sex to more than one male client in the past 12 months were recruited in 13 major cities in Iran between January and August 2015. Bivariable and multivariable modified Poisson regression models were constructed to examine the correlates of induced abortion. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported. Lifetime induced abortion was reported by 621 of 1335 participants (46.5%; 95% CI 43.8, 49.2). Older age (APR for ≥ 35 vs. < 25 years, 1.46; 95% CI: 1.03, 2.07), having ever been married (APR 1.58; 95% CI 1.05, 2.39), having ever worked in a brothel (APR 1.19; 95% CI 1.02, 1.38) and a lifetime history of being raped (APR 1.19; 95% CI 1.03, 1.38) were significantly associated with lifetime induced abortion (all p < 0.05). The high prevalence of induced abortion among FSWs in Iran is concerning. Evidence-informed programmes targeting FSWs in Iran would improve their knowledge and encourage contraceptive use as well as promote pregnancy prevention and post-abortion care. [ABSTRACT FROM AUTHOR]

Drug use is common among people who live in prisons (PWLP) worldwide. This systematic review and meta-analysis aimed to summarize the prevalence of drug use among PWLP in Iran. We searched PubMed, Embase, Web of Science, Scopus, PsycINFO, as well as Farsi-language databases including Iran Psych Magiran, IranMedex, Scientific Information Database (SID), and Irandoc for studies published from January 2003 to January 2021. We included studies that reported the prevalence of drug use among PWLP. We performed a random-effects meta-analysis to pool prevalence estimates. Point estimates and 95% confidence intervals (CI) are reported. Among 1107 publications and reports screened, 16 studies reported the prevalence of drug use and were included. The pooled prevalence of lifetime non-injection drug use was 73.8% (95% CI 70.9, 76.6). The pooled prevalence of lifetime injection drug use was 16.0% (12.6, 19.7). Needle/syringe sharing among those with a lifetime injection drug use history was 14.0% (6.4, 24.0). Non-injection and injection drug use was found to be prevalent among PWLP in Iran. Continued evidence-based prevention, harm reduction, and treatment programs should address drug use among this population. [ABSTRACT FROM AUTHOR]

People who inject drugs (PWID) continue to experience the highest burden of hepatitis C virus (HCV). We aimed to characterize HCV antibody prevalence, determinants of infection, and the cascade of engagement in HCV care among PWID in Iran. Participants were recruited in 11 cities of Iran using respondent-driven sampling. PWID underwent a structured interview capturing measures on socio-demographics, behaviors, and the HCV cascade of care. HCV and HIV were tested using antibody rapid tests. Multivariable logistic regression models identified characteristics associated with HCV seropositivity. HCV antibody prevalence was 26.0% among 2684 PWID enrolled. Of 699 participants who were HCV antibody positive, 88 (12.6%) were aware of past infections. HCV antibody prevalence was associated with older age (adjusted odds ratio [aOR] 2.09; 95% CI 1.18, 3.71), lower education (aOR 1.31; 95% CI 1.02, 1.69), >10 years of injecting (aOR 6.03; 95% CI 4.10, 8.85), methamphetamine injection (aOR 1.46; 95% CI 1.07, 1.99), daily injection drug use (aOR 1.26; 95% CI 1.01, 1.58), needle/syringe sharing (aOR 2.04; 95% CI 1.24, 3.34), recent incarceration (aOR 1.74; 95% CI 1.30, 2.32), and HIV seropositivity (aOR 7.93; 95% CI 4.12, 15.24). Additionally, 12.0% had ever tested for HCV, 4.0% had previously tested reactive for HCV antibody, and 3.7% had received an HCV diagnosis. Of diagnosed cases, 44.4% were linked to care, 15.2% initiated treatment, and 3.0% achieved sustained virologic response. Our data show a high prevalence of HCV antibody and low engagement in HCV care, underscoring an unmet need for HCV prevention, screening, and treatment among PWID in Iran. HCV prevention and treatment programs tailored for PWID are needed to enhance harm reduction efforts and access to HCV care in Iran. • HCV antibody prevalence was high among this national, community-recruited sample of PWID in Iran. • HCV antibody testing, RNA testing, linkage to care, and treatment were low. • HCV seropositivity was associated with older age, lower education, high-risk injection prectices, incarceration, and HIV seropositivity. • Community-based HCV prevention, screening, and treatment programs are required to address the HCV epidemic among PWID in Iran. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Evidence shows a growing trend of the HIV epidemic in the Middle East and North Africa (MENA). We aimed to project the incidence, mortality, and disability-adjusted life years (DALY) in the region from 1990 to 2019 and assess its trend by 2025, and 2030. We extracted the HIV incidence, mortality, and DALY data from the Global Burden of Disease (GBD) and UNAIDS databases. The joinpoint regression model was used to examine changes in HIV trends. The trend changes were estimated by average annual percent change (AAPC). In most countries, an increasing trend was observed in HIV incidence, mortality, and DALY. Specifically, the highest growth in the annual incidence rate was related to Egypt (AAPC = 14.4, GBD) and Iran (AAPC = 9.6, UNAIDS). Notably, Qatar (AAPC = − 5.6, GBD), Bahrain (AAPC = − 3.3, GBD), and Somalia (AAPC = − 4.2, UNAIDS) demonstrated a significant reduction in incidence. Regarding mortality rates, Djibouti (AAPC = 24.2, GBD) and Iran (AAPC = 16.2, UNAIDS) exhibited a significant increasing pattern. Furthermore, the estimated increase in incidence by 2030 was most marked in Djibouti (985%) and Iran (174%). Iran (422%) and Egypt (339%) showed a prominent rise in mortality rates. GBD data showed 16 countries had an increasing pattern in DALY in both genders. According to age and period effects, there was a significant upward trend in incidence, mortality rates, and DALY. Findings highlighted the urgent need for improved prevention and treatment services, including expanding access to HIV testing, promoting safe practices, increasing antiretroviral therapy coverage, and supporting targeted interventions for high-risk populations. [ABSTRACT FROM AUTHOR]

Evidence shows a growing trend of the HIV epidemic in the Middle East and North Africa (MENA). We aimed to project the incidence, mortality, and disability-adjusted life years (DALY) in the region from 1990 to 2019 and assess its trend by 2025, and 2030. We extracted the HIV incidence, mortality, and DALY data from the Global Burden of Disease (GBD) and UNAIDS databases. The joinpoint regression model was used to examine changes in HIV trends. The trend changes were estimated by average annual percent change (AAPC). In most countries, an increasing trend was observed in HIV incidence, mortality, and DALY. Specifically, the highest growth in the annual incidence rate was related to Egypt (AAPC = 14.4, GBD) and Iran (AAPC = 9.6, UNAIDS). Notably, Qatar (AAPC = − 5.6, GBD), Bahrain (AAPC = − 3.3, GBD), and Somalia (AAPC = − 4.2, UNAIDS) demonstrated a significant reduction in incidence. Regarding mortality rates, Djibouti (AAPC = 24.2, GBD) and Iran (AAPC = 16.2, UNAIDS) exhibited a significant increasing pattern. Furthermore, the estimated increase in incidence by 2030 was most marked in Djibouti (985%) and Iran (174%). Iran (422%) and Egypt (339%) showed a prominent rise in mortality rates. GBD data showed 16 countries had an increasing pattern in DALY in both genders. According to age and period effects, there was a significant upward trend in incidence, mortality rates, and DALY. Findings highlighted the urgent need for improved prevention and treatment services, including expanding access to HIV testing, promoting safe practices, increasing antiretroviral therapy coverage, and supporting targeted interventions for high-risk populations. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

• Homeless youth in our survey had high levels of substance use; over one third reported heroin use, nearly one third reported alcohol use, and one fourth reported methamphetamine use in the last month. • Homeless youth who were older, male, used tobacco, and were completely homeless had higher odds of substance use. • Innovative programs are needed to address substance use and competing social welfare needs of homeless youth in Iran. Homeless youth are at increased risk of substance use and its consequences worldwide. Substance use among youth who are homeless has not been as well studied, particularly in developing country settings. We therefore aimed to assess the prevalence and correlates of substance use among homeless youth in Kerman, a city in southeast Iran. In a cross-sectional survey by convenience sampling, we recruited 202 homeless youth from September to December 2017. Data were collected in face-to-face interviews using a standardized questionnaire. Youth were eligible if they were 15–29 years old and homeless or unstably housed for at least one month during last year. Factors associated with substance use were characterized by multivariable logistic regression analysis. In our survey, 50.0% (95% CI 43.0–56.9) of homeless youth reported substance use in the last month. The most common substances used were heroin (34.0%), alcohol (31.2% – illegal in Iran), and methamphetamine (24.0%). Substance use was associated with male sex (adjusted odds ratio [AOR] 6.57, 95% CI 2.72, 15.85), age 25–29 vs. 15–24 years (AOR 4.02, 95% CI 1.57, 10.29), current tobacco use (AOR 6.49, 95% CI 2.63, 16.00), and absolute homelessness vs. relative homelessness (AOR 7.75, 95% CI 2.90, 20.68). Findings highlight the need for prevention programs to reduce substance use-related harm among homeless youth, particularly among tobacco users and those completely homeless. Innovative strategies are needed reach the absolutely homeless and simultaneously address the substance use and competing social welfare needs of this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Prisons often serve as high-risk environments for drug use, and incarcerated people are at a high risk for substance use-related mental and physical harms. This study aimed to determine the prevalence of non-injection drug use inside the prison and its related factors among incarcerated people in Iran. Methods: We utilized data from three national bio-behavioral surveillance surveys conducted among incarcerated people in Iran in 2009, 2013, and 2017. Eligibility criteria were being ≥ 18 years old, providing informed consent, and being incarcerated for over a week. Overall, 17,228 participants across all surveys were recruited through a multi-stage random sampling approach. Each participant underwent a face-to-face interview and HIV test. The primary objective of the study was to assess self-reported non-injection drug use within the prison environment within the last month. A multivariable logistic regression model was built to determine associated covariates with drug use inside prison and an adjusted odds ratio (aOR) with 95% confidence intervals (CI) were reported. Result: The prevalence of non-injection drug use inside the prison was 24.1% (95% CI 23.5, 24.7) with a significant decreasing trend (39.7% in 2009, 17.8% in 2013, 14.0% in 2017; p-value < 0.001). Overall, 44.0% of those who used drugs were also receiving opioid agonist therapy (OAT) and we noted that in 2017, 75.1% of those on OAT used stimulants. In the multivariable logistic regression model, the year of interview (2013: aOR = 1.43 and 2009: aOR = 5.60), younger age (19–29: aOR = 1.14 and 30–40: aOR = 1.37), male sex (aOR = 3.35), < high school education (aOR = 1.31), having a history of previous incarceration (aOR = 1.26), and having a history of lifetime HIV testing (aOR = 1.76) were significantly and positively associated with recent non-injection drug use inside the prison. Conclusions: Approximately one in four incarcerated people in Iran reported drug use within the last month inside prisons. While a declining trend in non-injection drug use was noted, substantial gaps persist in harm reduction programs within Iranian prisons. In particular, there is a pressing need for improvements in drug treatment programs, focusing on the integration of initiatives specifically designed for people who use stimulants. [ABSTRACT FROM AUTHOR]

Injection drug use is the primary driver of the 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 2684 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 were 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. [ABSTRACT FROM AUTHOR]

This correction notice is related to an article titled "Non-injection drug use among incarcerated people in Iran: Findings from three consecutive national bio-behavioral surveys" published in the Harm Reduction Journal. The correction addresses an error in Figure 2 of the original article, where some numbers were missing. The corrected version of Figure 2, which shows non-injection drug and opioid agonist therapy (OAT) use inside prisons in the last month, can be found in the correction notice. The correction notice also includes the names of the authors of the original article. [Extracted from the article]

Street children are vulnerable against HIV because of poverty, lack of family support, adult supervision, social exclusion, lack of access to health services and their special living environment. Required educational program could decrease the danger of transmission of HIV in this group. This study would investigate the effects of HIV prevention educational on street children's attitude and knowledge in the southeast of Iran. Totally, 60 street children were randomized into the intervention and control groups. Knowledge and attitude of the participants about HIV/AIDS were evaluated. Using two-day meeting, the intervention group received some information on the prevention, diagnosis, care and treatment and wrong and right believes of HIV/AIDS. The control group received nothing about the topic. Children settled in a childcare center by the end of the survey and after 30 days the knowledge and attitude of both groups were evaluated again. The result of the study presented significant increase in street children's attitude and knowledge of intervention group compared to control group and before intervention. Follow-up data collected 1 month later revealed that the children who received the HIV/AIDS intervention subsequently had greater HIV/AIDS knowledge and favorable attitude toward HIV/AIDS. We showed by a two-day educational meeting, the knowledge and attitude of the street children could be improved. This improved knowledge and attitude could protect them against high-risk behaviors. • Street children are vulnerable to HIV/AIDS. • It is essential to conduct educational interventions on street children's knowledge and attitude. • HIV/AIDS prevention education could significantly improve street children's knowledge and attitude. [ABSTRACT FROM AUTHOR]

Background: There is no systematic review on the prevalence of HIV drug resistance (HIVDR) in Iran. We aimed to estimate the prevalence of HIVDR among people living with HIV (PLHIV) in Iran. We assessed HIVDR prevalence in antiretroviral therapy (ART) naïve PLHIV (i.e., those without a history of ART) and PLHIV receiving ART. Method: We systematically searched Scopus, PubMed, Web of Science, Embase, Iranian databases (Iranian Medical Research Information System, Magiran, and Scientific Information Database), the references of studies, and Google Scholar until March 2023. A random-effects model was used to calculate a point estimate and 95% confidence interval (95% CI) for the prevalence of HIVDR in PLHIV. Results: Among 461 potential publications, 22 studies were included in the meta-analysis. The pooled prevalence of acquired HIVDR in PLHIV receiving ART was 34% (95% CI: 19, 50) for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), 27% (95% CI: 15, 41) for non-nucleoside reverse transcriptase inhibitors (NNRTIs), and 9% (95% CI: 3, 18) for protease inhibitors (PIs). The pooled prevalence of acquired HIVDR in treatment failure PLHIV was 50% (95% CI: 31, 69) for NRTIs, 49% (95% CI: 29, 69) for NNRTIs, 11% (95% CI: 2, 24) for PIs, and 1% (95% CI: 0, 4) for integrase inhibitors (INIs). The pooled prevalence of transmitted HIVDR in ART-naïve people was 3% (95% CI; 1, 6) for NRTIs, 5% (95% CI: 2, 9) for NNRTIs, and 0 for PIs and INIs. Conclusion: The prevalence of HIVDR was relatively high in both ART-naïve PLHIV and those receiving ART. Without universal pretreatment HIVDR testing and more frequent routine HIV viral load testing among PLHIV who are on ART, the HIVDR prevalence might increase in PLHIV in Iran. [ABSTRACT FROM AUTHOR]

Background: Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran. Methods: This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome. Results: The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation. Conclusion: Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation. [ABSTRACT FROM AUTHOR]

Background: Many people with high-risk sexual or injection behaviors use harm reduction services with different identities and are therefore counted more than once in client databases. This practice results in inaccurate statistics on the number of clients served and the effective reach of these services. This study aimed to determine the levels of double counting of clients of harm reduction services, including needle and syringe programs, condom distribution, HIV testing and counseling, and methadone maintenance in five cities in Iran. Methods: Between September and March 2020, our study included 1630 clients, 115 staff of harm reduction centers, and 30 experts in the field of harm reduction in five cities in Iran. Clients of harm reduction services were asked about using harm reduction services multiple times at the same center or at different centers in the last year using different identities. Estimates of double counting derived from client responses were validated by panels of center staff and experts in harm reduction. Results: Synthesizing data from clients, staff, and experts, the final estimates of double counting of clients using harm reduction services were: HIV testing 10% (95% confidence interval [CI] 0–15), needle and syringe programs 17% (95% CI 8.5–20), condom distribution programs 13% (95% CI 3–19), HIV/STI counseling 10% (95% CI 0–16), and methadone maintenance 7% (95% CI 2–10). Conclusion: Double counting of clients in harm reduction services in Iran is substantial. Data on clients reach by harm reduction services need to be corrected for double counting to improve program planning, client population size estimation, and efficient resource allocation. [ABSTRACT FROM AUTHOR]

Background: Providing services to people living with HIV (PLWH) faced many challenges during the COVID-19 pandemic. This study aimed to examine the impact of the COVID-19 pandemic on providing HIV/AIDS-related services in Iran. Methods: In this qualitative study, the participants were included by purposive sampling between November 2021 and February 2022. Virtually focused group discussion (FGD) meetings were conducted with the first group including policymakers, service providers, and researchers (n = 17), and the interviews were conducted telephonic and face-to-face using a semi-structured guide with the second group including people who received services (n = 38). Data were analyzed by content analysis using the inductive method in MAXQDA 10 software. Results: Six categories were obtained, including mostly affected services, ways of the effect of COVID-19, healthcare systems reaction, effects on social inequality, opportunities created by the pandemic, and suggestions for the future. In addition, people who received services believed the COVID-19 pandemic has affected their life in several ways, including getting COVID-19, mental and emotional problems during the pandemic, financial problems, changes in the care plan, and changes in high-risk behaviors. Conclusion: Considering the level of community involvement with the issue of COVID-19 and the shock caused by the pandemic, as mentioned by the world health organization, it is necessary to improve health systems' resilience for better preparedness for similar conditions. [ABSTRACT FROM AUTHOR]

Background: Female sex workers (FSWs) are at higher risk of HIV due to high-risk sexual and drug use related behaviors. This study characterized sexualized substance use among FSWs in Iran. Methods: In 2015, 1,337 FSWs were recruited from centers for vulnerable women and through outreach efforts in 13 major cities in Iran. Data were collected via face-to-face interviews from consenting FSWs on a range of socio-demographic and behavioral characteristics. The primary outcome of interest was sexualized substance use, defined as reporting alcohol or drug use before or during sex in the past month. Bivariable and multivariable modified Poisson regression models were used to assess the correlates of sexualized substance use. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were reported. Results: The prevalence of sexualized substance use was 31.3% (95% CI: 28.7, 34.0). Inconsistent condom use during sex with clients in the past month (aPR = 1.31; 95% CI: 1.01, 1.71), regular (i.e., at least weekly in the past month) alcohol use (aPR = 2.87; 95% CI: 2.17, 3.80), regular opioid use (aPR = 2.09; 95% CI: 1.45, 3.02), regular stimulant use (aPR = 2.68; 95% CI: 2.12, 3.39), and self-reported HIV negative status (aPR= 1.88; 95% CI: 1.14, 3.10) were significantly and positively associated with sexualized substance use. Conclusions: Sexualized substance use was associated with riskier sexual behavior and self-reported HIV sero-negativity. Harm reduction messaging to FSWs needs to go beyond focusing on sexual health promotion and further highlight the risks associated with sexualized substance use. [ABSTRACT FROM AUTHOR]

Background: Incarcerated people are at a disproportionate risk of contracting HIV. We estimated the prevalence and correlates of HIV testing among incarcerated people with a history of HIV-related high-risk behaviours in Iran.Methods: Data for this analysis were obtained from three consecutive nationwide bio-behavioural surveillance surveys of a random sample of incarcerated people in 2009 (n = 5953), 2013 (n = 5490), and 2017 (n = 5785). History of testing for HIV in the last 12 months was the primary outcome variable. HIV testing was examined among those with a history of HIV-related high-risk behaviours (i.e., having multiple sex partnerships, injection drug use practices, or a history of having a tattoo). The outcome variable was divided into three categories: Never tested for HIV, ever tested for HIV inside the prison in the last 12 months, and ever tested for HIV outside the prison in the last 12 months. We used multivariable multinomial logistic regression models to examine factors associated with HIV testing.Results: Overall, 8,553 participants with a history of HIV-related high-risk behaviors with valid responses to the HIV testing question were included in the analysis. Although HIV testing inside prison has increased (23% [2009], 21.5% [2013], and 50.3% [2017]: P-value < 0.001), the prevalence of HIV testing outside prison has decreased (7.7% [2009], 7.5% [2013], 4.1% [2017]: P-value < 0.001) over time. Our multivariable multinomial regression model showed older age (Relative-risk ratio [RRR]: 1.24, 95% Confidence Intervals [CI]: 1.05, 1.47), history of the previous incarceration (RRR: 1.46, 95% CI: 1.24, 1.71), currently receiving methadone maintenance therapy inside prison (RRR: 2.09, 95% CI: 1.81, 2.43), having access to condoms inside prison (RRR: 1.42, 95% CI: 1.20, 1.68) and sufficient HIV knowledge (RRR: 1.74, 95% CI: 1.47, 2.05) were significantly associated with an increased probability of having an HIV test in the last 12 months inside prison.Conclusion: HIV testing among high-risk Iranian prisoners has increased from 2009 to 2017. However, HIV testing remains considerably low, and half of the incarcerated people with a history of HIV-related high-risk behaviours had never tested for HIV inside prison. Evidence-based programs are needed to optimize HIV testing inside and outside prisons and identify those at greater risk of HIV. [ABSTRACT FROM AUTHOR]

We characterized overdose prevalence and its correlates among people who inject drugs (PWID) in Iran. Our analysis included 2618 PWID with a recent history of drug injection, recruited from 11 cities across Iran using a respondent-driven sampling approach. The primary outcome was a lifetime history of drug-related non-fatal overdose. The nation-wide lifetime prevalence of overdose among PWID was 21.7%, with considerable variations across different cities. In the multivariable analysis, older age, being men, history of homelessness, younger age at injection initiation, recent stimulant injection, recent non-prescribed benzodiazepine use, lifetime suicide attempt, and HIV sero-positivity were positively associated with a history of non-fatal overdose. Our findings underscore the need for comprehensive and tailored approaches to overdose prevention and treatment in Iran, including increased access to take-home naloxone for PWID. The diverse risk profiles of PWID should also be considered in the development of substance use harm reduction policies in Iran, reflecting their varied needs in terms of mental, physical, and social well-being. [ABSTRACT FROM AUTHOR]

This study aimed to determine the prevalence and the correlation between early sexual intercourse and its consequences among men who inject drugs (MWID) in Iran. In this cross-sectional survey, 2399 subjects who inject drugs were recruited using facility-based sampling from ten cities in 2014. A structured questionnaire was used to collect data regarding the participants' sexual and drug-related practices. Early sexual intercourse was defined as having sex before the age of 18 years old. Among the study samples, 2333 subjects were men and 2027 of them reported a lifetime history of their sexual intercourse. Totally, 1978 (97.6%) MWID reported their age at the time of their first sexual intercourse. The prevalence of early sexual intercourse was estimated as 32.9%. Using the multivariable logistic regression, it was shown that early sexual contact is significantly associated with age < 30 years old (adjusted Odds Ratio [aOR]: 1.52; p-value < 0.001), and drug abuse debut < 16 years old (aOR: 3.49; p-value < 0.001). As well, those with a history of early sexual intercourse had more condomless sex during the last 12 months (aOR: 1.46; p-value < 0.001). Moreover, they had more access to a free condom within 12 months (aOR: 1.31; p-value = 0.04). One in three MWID experienced early sexual intercourse. MWID who had early sexual intercourse were younger. They had higher risk profiles such as drug abuse at a younger age, as well as more outcomes like condomless sex in the last 12 months. So, age at the time of the first sexual intercourse should be considered in sexual health and HIV prevention programs among MWID. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.Methods: This study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.Results: A total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.Conclusion: Our integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population. [ABSTRACT FROM AUTHOR]