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Background Access to sufficient, safe, culturally appropriate, and nutritious food is essential for maintaining both physical and mental health. Despite a growing body of evidence suggesting that sexual minority (SM) people experience significant disparities in socioeconomic and material resource security, there remains a paucity of empirical studies examining the prevalence of food insecurity among SM people relative to their heterosexual peers. Objectives To determine the prevalence of adult and household food insecurity across sexual orientation groups in the United States after adjusting for multiple covariates. Methods We combined 7 cycles of US NHANES, 2003-2016 (N = 21,300) to examine sexual orientation-based disparities in adult food security among lesbian/gay (n = 373), bisexual (n = 606), same-sex experienced (SSE, n = 693), other sexual minorities (OSMs, n = 88), and heterosexual (n = 19,540) people. Food (in)security was measured using the US Food Security Survey Module and categorized as secure, marginally insecure, moderately insecure, and severely insecure. Results Severe adult food insecurity was higher among bisexuals (17.16%; 95% CI: 14.36, 20.38), SSE (13.71%; 95% CI: 11.34, 16.48), OSMs (12.50%; 95% CI: 7.04, 21.24), and lesbians/gays (13.14%; 95% CI: 10.07, 16.97) compared with heterosexuals (8.23%; 95% CI: 7.85, 8.62). Multivariable multinomial logistic regression analysis adjusting for gender, race/ethnicity, age, citizenship, education, household size, income, cycle year, emergency food use, and Supplemental Nutrition Assistance Program participation showed that bisexuals, OSMs, SSE, and lesbians/gays were more likely to experience moderate to severe food insecurity compared with heterosexuals. Conclusions SM people are significantly more likely to experience increased likelihood of food insecurity relative to their heterosexual peers.

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.

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.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.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.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.

Epidemiologic studies point to multiple health inequities among sexual minority people, but few studies have examined mortality. Some causes of death are more preventable than others, and access to prevention is theorized to follow patterns of access to social and material resources. The objective of this study is to compare estimates of preventable mortality between sexual minority (SM)-i.e., bisexual, lesbian, gay-and heterosexual adults in Canada.A population-based retrospective cohort with 442,260 (unweighted N) Canadian adults, ages 18-59 years, was drawn from the Canadian Community Health Survey/Canadian Mortality Database linked database (2003-2017). The Rutstein preventability rating index was used to classify cause-specific mortality (low/high). Longitudinal analyses were conducted using Cox proportional hazards models.SM respondents had higher hazard of all-cause mortality (unadjusted hazard ratio [uHR] 1.28, 95% CI 1.06, 1.55). The uHR increased when the outcome was limited to highly-preventable causes of mortality (uHR 1.43, 95% CI 1.14, 1.80). The uHR further increased in sensitivity analyses using higher thresholds of the Rutstein index. SM respondents had higher hazard of cause-specific mortality for heart disease (uHR 1.53, 95% CI 1.03, 2.29), accidents (uHR 1.97, 95% CI 1.01, 3.86), HIV (uHR 75.69, 95% CI 18.77, 305.20), and suicide (uHR 2.22, 95% CI 0.93, 5.30) but not for cancer (uHR 0.86, 95% CI 0.60, 1.25). The adjusted HR (aHR) for highly-preventable mortality was not attenuated by adjustment for confounders (aHR 1.57, 95% CI 1.20, 2.05) but was reduced by adjustment for hypothesized mediators relating to access to social and material resources (marital status, children, income, education; aHR 1.11, 95% CI 0.78, 1.58).Preventable mortality was elevated for SM Canadians compared to heterosexuals. Early and broad access to sexual minority-affirming primary and preventive healthcare should be expanded.

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.

Methanol poisoning has been a significant public health challenge for several decades in Iran. Even though alcohol use is highly criminalized, people consume illicit alcohol, which tends to be predominantly homemade and often contains methanol. Consequently, thousands of individual poisonings and hundreds of deaths annually are attributable to methanol poisoning. From February 19, 2020 through April 27, 2020, the 2019 coronavirus disease (COVID-19) epidemic rapidly expanded in Iran, and has been associated with 90,481 confirmed cases and 5710 confirmed deaths. Secondary to misinformation about the potential for alcohol to neutralize SARS-CoV-2, there has also been a significant escalation in methanol-related morbidity and mortality, with over 5000 people poisoned and over 500 confirmed deaths for the same period from February through April 2020. In some provinces, the case-fatality rate of methanol poisoning was higher than that from COVID-19. The high morbidity and mortality associated with methanol poisoning preceding and exacerbated by COVID-19 highlight the potential population level health impacts of the implementation of evidence-based education and harm reduction strategies focused on alcohol use across Iran.

HIV infection and substance use synergistically impact health outcomes of people with HIV. In this study, we assessed the prevalence of substance use among women living with HIV (WLWH) and compared them with expected values from general data.Cigarette smoking, frequency of alcohol consumption, last-month non-prescribed cannabis use (vs. last-year use), and last 3 months regular (≥once/week) and occasional (once/week) use of crack/cocaine, speed (amphetamine), and heroin (vs. last-year use) were examined in WLWH from the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS; N = 1422) and compared with general population women from the 2013-2014 Canadian Community Health Survey (CCHS; N = 46,831). Age/ethnoracial-standardized prevalence differences (SPD) and 95% confidence intervals (CI) were reported.Compared to expected estimates from general population women, a higher proportion of WLWH reported daily cigarette smoking (SPD: 26.8% [95% CI: 23.9, 29.7]), smoking ≥20 cigarettes/day (SPD: 11.6% [9.8, 13.6]), regular non-prescribed cannabis use (SPD: 8.0% [4.1, 8.6]), regular crack/cocaine use (SPD: 16.7% [13.1, 20.9]), regular/occasional speed use (SPD: 2.4% [1.2, 4.7]), and heroin use (SPD: 11.2% [8.3, 15.0]). However, WLWH reported lower frequencies of alcohol consumption and binge drinking than their counterparts in the general population.Cigarette smoking and illicit drug use, but not alcohol use or binge drinking, were more prevalent in WLWH than would be expected for Canadian women with a similar age and ethnoracial group profile. These findings may indicate the need for women-centered harm reduction programs to improve health outcomes of WLWH in Canada.

Background Evidence on the association between socioeconomic status (SES) and multiple sclerosis (MS) is inconsistent. We examined the association of several indicators of SES with MS in an Iranian population. Methods We conducted a population-based incident case-control study with 547 incident cases and 1057 general population controls in Iran, 2015. Data was collected using telephone interviews and indicators of SES i.e. parental education, and household SES during adolescence using asset variables. Adjusted odds ratios (AORs) were estimated using multiple logistic regression model. Results Parental education levels were not significantly associated with MS development. Household SES during adolescence was insignificantly associated with an increased risk of MS diagnosis (P = 0.575). Conclusion We did not identify an association between household SES during adolescence, parental education levels, and a subsequent risk of developing MS in an Iranian population.

Worldwide, crystal methamphetamine (CM) use and associated high-risk sexual behaviors are a concern, but they are less studied among female sex workers (FSW) in developing countries. This study aimed to characterize the prevalence and individual, interpersonal, and structural correlates of self-reported past-month CM use among FSW in Iran.FSW aged ≥ 18 years who reported penetrative sex with more than one client in the last year were recruited (analytic sample: 1295). Data were collected in one-on-one interviews using a standardized behavioral questionnaire. Poisson regression model was used to assess the correlated of past-month self-reported CM use by crude and adjusted prevalence ratio (APR) and 95% confidence intervals (CI).Non-injecting and injecting CM use was reported by 15.0% (95% CI: 8.7, 24.7) and 0.9% (95% CI: 0.4, 2.1) of participants. CM use was positively associated with concurrent use of opioids (APR from 2.08 to 3.84, P-value 0.01), higher number of sexual partners (APR: 2.05, P-value: 0.018), housing instability (APR: 3.54, P-value: 0.001), and history of forced sex (APR: 1.47, P-value: 0.050).A considerable number of FSWs use CM along with opioids, have a higher number of sexual partners, forced sex, and housing instability. Both prevention strategies as well as strategies to reduce harm associated with CM need to be added to current programs that predominantly focus on opioid dependency and male drug injectors.

Introduction We identified the prevalence and correlates of past-year illicit drug use among transgender people in Ontario, Canada, and disparities with the age-standardized non-transgender population. Methods Data on transgender persons aged 16 + (n = 406) were obtained from Trans PULSE, a respondent-driven sampling (RDS) survey (2009–2010). Overall and sex-specific estimates of past-year drug use (cocaine and amphetamines, based on data availability) in the reference population were obtained from Ontario residents aged 16 + (n = 39, 980) in the Canadian Community Health Survey (2009–2010), and standardized to the overall and gender-specific transgender age distributions. For regression analyses with Trans PULSE data, past-year drug use included drug types associated with high risk of physical, psychological, and social harm to the user, and RDS-II weights were applied to frequencies and prevalence ratios (PR) derived from blockwise logistic regression models. Results An estimated 12.3% (95% CI: 7.7, 17.0) of transgender Ontarians had used at least one of the specified drugs in the past year, with no significant difference by gender identity. Transgender Ontarians were more likely to use both cocaine (standardized prevalence difference; SPD = 6.8%; 95% CI = 1.6, 10.9) and amphetamines (SPD = SPD = 1.3%, 95% CI = 0.2, 3.1) as compared to the age-standardized non-transgender population. History of transphobic assault, homelessness or underhousing, and sex work were associated with greater drug use among transgender persons. Conclusions The prevalence of cocaine and amphetamine use among transgender people in Ontario, Canada was higher than in the age-standardized reference population. Social exclusion predicted within-group variation in drug use among transgender persons.

Background Female sex workers (FSWs) experience adversities regarding social determinants of health (SDH) and behavioural factors including illicit drug use. This study aimed to assess the clustered impact of SDH on illicit drug use among FSWs in Iran. Methods We surveyed 1,347 FSWs in 13 major cities in 2015. Latent class analysis was conducted to identify distinct classes of five measured SDH including low education, unemployment, unstable housing, last-year incarceration and sexual violence. We examined the association of these classes with five illicit drug use patterns using multivariable generalized linear model with Poisson family and log link, and reported adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI). Results We identified five SDH classes: Class 1: no SDH adversities; Class 2: mainly unemployment; Class 3: low education and unemployment; Class 4: sexual violence and unemployment; and Class 5: multiple SDH adversities. The prevalence of last-month drug use ranged from 7.0% in Class 1 to 53.3% in Class 5. Compared to FSWs in Class 1, those in Class 2 (aPR: 2.47, 95% CI: 1.15, 5.27), Class 3 (aPR: 3.69, 95% CI: 1.62, 8.36), Class 4 (aPR: 4.49, 95% CI: 1.71, 11.78) and Class 5 (aPR: 6.35, 95% CI: 2.42, 16.69) were more likely to report last-month drug use. The same patterns were observed for specific drugs of opium use, crystal methamphetamine use, and heroin-crack use, as well as poly-drug use. Conclusion Socio-structural determinants are clustered together and elevate the likelihood of illicit drug use among FSWs. Our findings highlighted the significance of assessing and addressing such key determinants of health in drug use harm reduction programs targeting FSWs.

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.

Background For a better understanding of the current situation of drug use in Iran, we utilized the network scale-up approach to estimate the prevalence of illicit drug use in the entire country. Methods We implemented a self-administered, street-based questionnaire to 7535 passersby from the general public over 18 years of age by street based random walk quota sampling (based on gender, age and socio-economic status) from 31 provinces in Iran. The sample size in each province was approximately 400, ranging from 200 to 1000. In each province 75% of sample was recruited from the capital and the remaining 25% was recruited from one of the large cities of that province through stratified sampling. The questionnaire comprised questions on demographic information as well as questions to measure the total network size of participants as well as the network size in each of seven drug use groups including Opium, Shire (combination of Opium residue and pure opium), Crystal Methamphetamine, heroin/crack (which in Iranian context is a cocaine-free drug that mostly contains heroin, codeine, morphine and caffeine with or without other drugs), Hashish, Methamphetamine/LSD/ecstasy, and injecting drugs. The estimated size for each group was adjusted for transmission and barrier ratios. Results The most common type of illicit drug used was opium with the prevalence of 1500 per 100,000 population followed by shire (660), crystal methamphetamine (590), hashish (470), heroin/crack (350), methamphetamine, LSD and ecstasy (300) and injecting drugs (280). All types of substances were more common among men than women. The use of opium, shire and injecting drugs was more common in individuals over 30 whereas the use of stimulants and hashish was largest among individuals between 18 and 30 years of age. Conclusion It seems that younger individuals and women are more desired to use new synthetic drugs such as crystal methamphetamine. Extending the preventive programs especially in youth as like as scaling up harm reduction services would be the main priorities in prevention and control of substance use in Iran. Because of poor service coverage and high stigma in women, more targeted programs in this affected population are needed.