HIV prevalence and continuum of care among incarcerated people in Iran from 2010 to 2017.

BACKGROUND: Incarcerated people are at an increased risk of contracting HIV and transmitting it to the community post-release. In Iran, HIV epidemics inside prisons were first detected in the early 1990s. We assessed the HIV prevalence and its correlates, as well as the continuum of care among incarcerated people in Iran from 2010 to 2017. METHODS: We used data collected in three national bio-behavioral surveillance surveys among incarcerated individuals in 2010 (n = 4,536), 2013 (n = 5,490), and 2017 (n = 5,785) through a multistage cluster sampling approach. HIV was tested by the ELISA method in 2010 and 2013 surveys and rapid tests in 2017. Data on demographic characteristics, risky behaviors, HIV testing, and treatment were collected via face-to-face interviews. HIV prevalence estimates along with 95% confidence intervals (CI) were reported. Using data from the 2017 round, multivariable logistic regression models were built to assess the correlates of HIV sero-positivity and conduct HIV cascade of care analysis. RESULTS: The HIV prevalence was 2.1% (95% CI: 1.2%, 3.6%) in 2010, 1.7% (95% CI: 1.3%, 2.1%) in 2013, and 0.8% (95% CI: 0.6%, 1.1%) in 2017 (trend P value < 0.001). Among people with a history of injection drug use, HIV prevalence was 8.1% (95% CI: 4.6%, 13.8%) in 2010, 6.3% (95% CI: 4.8%, 8.3%) in 2013, and 3.9% (95% CI: 2.7%, 5.7%) in 2017. In 2017, 64% (32 out of 50) of incarcerated people living with HIV were aware of their HIV status, of whom 45% (9 out of 20) were on antiretroviral therapy, and of whom 44% (4 out of 9) were virally suppressed (< 1000 copies/ml). CONCLUSIONS: While HIV prevalence has decreased among incarcerated people in Iran, their engagement in the HIV continuum of care is suboptimal. Further investments in programs to link incarcerated people to HIV care and retain them in treatment are warranted.

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.

Remaining Gap in HIV Testing Uptake Among Female Sex Workers in Iran.

We estimated the prevalence of recent HIV testing (i.e., having an HIV test during the last 12 months and knew the results) among 1295 HIV-negative Iranian female sex workers (FSW) in 2015. Overall, 70.4% (95% confidence intervals: 59.6, 79.3) of the participants reported a recent HIV testing. Concerns about their HIV status (83.2%) was reported as the most common reason for HIV testing. Incarceration history, having >5 paying partners, having >1 non-paying partner, receiving harm reduction services, utilizing healthcare services, and knowing an HIV testing site were significantly associated with recent HIV testing. In contrast, outreach participants, having one non-paying sexual partner, and self-reported inconsistent condom use reduced the likelihood of recent HIV testing. HIV testing uptake showed a ~2.5 times increase among FSW since 2010. While these findings are promising and show improvement over a short period, HIV testing programs should be expanded particularly through mobile and outreach efforts.

Knowledge, Attitude, and Practice of Clerical Students with Respect to HIV/AIDS in Iran, 2011.

In this study, knowledge and attitude of Iranian clerical students toward HIV and AIDS was assessed. Through a cross-sectional study, 367 clerical students were surveyed, in convenience sampling method, in the Qom seminary in 2011, utilizing a self-administered structured questionnaire. The questionnaire was piloted on 20 clerical student volunteers, internal consistency measured with Cronbach's alpha was 0.89. Participants' scores of knowledge and attitude were calculated out of 100. The level of knowledge in 37.33 % of participants was good (scores >80), whereas 46.05 and 16.62 % had moderate (40 < scores ≤ 80) and poor (scores ≤40) levels of knowledge, respectively. The mean score of knowledge and attitude was 58.29 (95 % CI 56.11-60) and 77.26 (95 % CI 75.92-78.59) out of 100, respectively. A significant correlation was observed between level of knowledge and attitude (r = 0.33, P < 0.001). Knowledge score appeared to be significantly higher in women compared to men (p = 0.04). With an increase in age, the level of knowledge significantly decreased (r = -0.10, P = 0.02). We could also detect a statistically significant relationship between attending educational courses on HIV/AIDS and inclusion of HIV/AIDS topics in the individual's sermons (P < 0.001). Although clerical students had shown some sort of positive attitudes toward HIV, their knowledge still needs to be improved to enable them to deliver more accurate information to the community during the course of their speeches. Having HIV-related courses as part of their curriculum or aside may contribute a lot to this.

HIV prevalence and risk behaviours among people who inject drugs in Iran: the 2010 National Surveillance Survey.

OBJECTIVES: To assess the prevalence of HIV and related risk behaviours among people who inject drugs (PWID) in Iran. METHODS: We conducted a national cross-sectional bio-behavioural surveillance survey between March and July 2010, interviewing male PWID from a geographically dispersed sample through a facility-based sampling method. RESULTS: We recruited 2480, and tested 2290 PWID. The overall prevalence of HIV was 15.2% (95% CI 9.7% to 23.1%). Among those who had injected drugs over the last month, 36.9% had used a non-sterile needle, and 12.6% had practiced shared injection. Over the past 12 months preceding the interview, 30.4% had sold sex for money, drugs, goods or a favour. In the multivariate analysis, the prevalence of HIV had a positive association with age, while having above high school education, and permanent job were protective. CONCLUSIONS: Unsafe injection, and sexual risk behaviours are still frequent and the prevalence of HIV among PWID remains high. Intensified efforts are needed to prevent the further spread of HIV among Iranian PWID and their sexual partners.

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.

Estimated mortality due to seasonal influenza in southeast of Iran, 2006/2007 to 2011/2012 influenza seasons.

BACKGROUND: Global estimates showed an estimate of up to 650,000 seasonal influenza-associated respiratory deaths annually. However, the mortality rate of seasonal influenza is unknown for most countries in the WHO Eastern Mediterranean Region, including Iran. We aimed to estimate the excess mortality attributable to seasonal influenza in Kerman province, southeast Iran for the influenza seasons 2006/2007-2011/2012. METHODS: We applied a Serfling model to the weekly total pneumonia and influenza (PI) mortality rate during winter to define the epidemic periods and to the weekly age-specific PI, respiratory, circulatory, and all-cause deaths during non-epidemic periods to estimate baseline mortality. The excess mortality was calculated as the difference between observed and predicted mortality. Country estimates were obtained by multiplying the estimated annual excess death rates by the populations of Iran. RESULTS: We estimated an annual average excess of 40 PI, 100 respiratory, 94 circulatory, and 306 all-cause deaths attributable to seasonal influenza in Kerman; corresponding to annual rates of 1.4 (95% confidence interval [CI] 1.1-1.8) PI, 3.6 (95% CI 2.6-4.8) respiratory, 3.4 (95% CI 2.1-5.2) circulatory, and 11.0 (95% CI 7.3-15.6) all-cause deaths per 100,000 population. Adults ≥75 years accounted for 56% and 53% of all excess respiratory and circulatory deaths, respectively. At country level, we would expect an annual of 1119 PI to 8792 all-cause deaths attributable to seasonal influenza. CONCLUSIONS: Our findings help to define the mortality burden of seasonal influenza, most of which affects adults aged ≥75 years. This study supports influenza prevention and vaccination programs in older adults.

Prevalence and Correlates of Sexual Violence Experienced by Female Sex Workers in Iran: Results from a National HIV Bio-Behavioral Surveillance Survey.

Sexual violence increases the risk of adverse health outcomes among female sex workers (FSWs). Using data from the 2015 national bio-behavioral survey, we explored the experience of sexual violence and its associated factors among Iranian FSWs. Lifetime and recent sexual violence were reported by 40.1% and 16.9%, respectively. History of substance use, ever engaging in anal sex, engaging in group sex within the last year, a high number of clients, recent unstable housing, and incarceration increased the likelihood of experiencing recent sexual violence. These findings underscore the need for community-empowerment and policy-level interventions to address violence among FSWs in Iran.

Estimation of HIV incidence and its trend in three key populations in Iran.

In Iran, People Who Inject Drugs (PWID), Female Sex Workers (FSW), and prisoners are the main key populations at risk of HIV infection. This study aimed to evaluate the trend of HIV incidence among PWID, FSW and prisoners as an impact measure of HIV harm reduction and prevention efforts in Iran. Data were obtained from the two rounds of national bio-behavioral surveillance surveys among FSW (2010 (n = 872), 2015 (n = 1339)), PWID (2010 (n = 2417), 2014 (n = 2307)), and prisoners (2009 (n = 4536), 2013 (n = 5390)) through facility-based (FSW and PWID surveys) and cluster sampling (prisoner surveys). Time-at-risk was calculated assuming the age at first sex or drug injection as the beginning of the at-risk period and the age at the time of the interview or date when they received a positive HIV test result as the end of this period, adjusted for interval censoring. HIV incidence among PWID in 2014 was 5.39 (95% CI 4.71, 6.16) per 1,000 person-years (PY), significantly lower than in 2009 (17.07, 95% CI 15.34, 19.34). Similarly, HIV incidence was 1.12 (95% CI 0.77, 1.64) per 1,000 PY among FSW in 2015, a significant drop from 2010 (2.38, 95% CI 1.66, 3.40). Also, HIV incidence decreased among prisoners from 1.34 (95% CI: 1.08, 1.67) in 2009 to 0.49 (95% CI: 0.39, 0.61) per 1,000 PY in 2013. Our findings suggest that after an increase in the 2000s, the HIV incidence may have been decreased and stabilized among key populations in Iran.

Awareness of and Knowledge About STIs Among Nonmedical Students in Iran.

CONTEXT: Evidence on STI knowledge among Iranian nonmedical university students is limited. Information is needed to inform research and policies to improve the sexual health of university students in Iran. METHODS: A convenience sample of 742 male and female undergraduate and graduate students was recruited from five nonmedical public and private universities in Iran in 2014. Respondents' awareness of and knowledge about STIs were assessed using a validated questionnaire. Chi-square tests, student t tests and one-way analysis of variance were used to compare the percentage of respondents giving correct responses across subgroups of students. RESULTS: Half of the respondents had ever heard of STIs, but most could not correctly identify STIs in a list of diseases. A total of 49%, 42% and 9% of the respondents had low, moderate and high STI knowledge scores, respectively. Respondents reported online sources (62%) and friends (32%) as their main sources of information about STIs, and those who were older, ever-married or more educated were more knowledgeable than other respondents. CONCLUSIONS: Given that the Internet was students' main source of information, increasing the accessibility and visibility of credible Internet sites about sexual health is warranted. Also, key individuals in students' networks (e.g., parents, teachers, peers) should be equipped with required training and knowledge on STI-related topics and be actively involved in sexual health education efforts.

Lifetime Abortion of Female Sex Workers in Iran: Findings of a National Bio-Behavioural Survey In 2010.

INTRODUCTION: Unintended pregnancies and abortion may be considered as occupational hazards for female sex workers (FSWs). As our understanding of contraceptive and abortion practices of Iranian FSWs is very limited, this study tries to assess the dynamics of contraception and abortion among this sub-population. METHODS: This survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 14 cities in Iran. Data were collected through face-to-face interviews using a pilot-tested standardized risk assessment questionnaire. We applied the logistic regression model to investigate the correlates of induced abortion among FSWs. RESULTS: Of the 863 participants with valid responses to the abortion variable, 35.3% (95% CI: 32.1-38.6) acknowledged ever induced abortion and the annual rate of abortion was estimated at 20.7 per 1000 women. Around 31.2% of FSWs reported no usual contraceptive use, 32.6% barrier method, 23.6% non-barrier modern contraception methods, and 12.5% dual protection. In our multivariable model, older age (Adjusted Odds Ratio (AOR) = 1.74, 95% Confidence Interval (CI): 1.02, 2.96), group sex (AOR = 1.92, 95% CI: 1.10, 3.35), history of travel for sex work (AOR = 1.55, 95% CI: 1.09, 2.20), sexual violence (AOR = 1.77, 95% CI: 1.25, 2.50), STIs in last year (AOR = 1.53, 95% CI: 1.09, 2.14), and accessing family planning services (AOR = 1.76, 95% CI: 1.24, 2.49) were significant predictors of lifetime abortion. CONCLUSIONS: The reproductive health needs of Iranian FSWs are unmet and around one-third of FSWs reported induced abortion. Scaling-up comprehensive family planning services and empowering FSWs to have safer sex practices may help them to prevent unintended pregnancies and further risk of HIV transmission.

Increasing Trend in Colorectal Cancer Incidence in the Southeast of Iran 2003-2013: A Population Based Cancer Registry Study.

Rates based on age-adjusted incidence of colorectal cancers over a 10-year period in Kerman, the biggest province of Iran, were estimated from 2003 to 2013. Data were obtained from the population-based cancer registry unit of Kerman University of Medical Sciences (CR-KMU). Information included age, sex, city, ICD-O and year of registry. Our trend analyses cover 3.91% of the Iranian population. The data set comprised cases diagnosed from 2003 to 2013.The population of over 20 years was interpolated using 2003 and 2010 censuses. Then, truncated age-adjusted incidence rates were calculated. Increase was noted from 2003-2009 to 2010-2013 for 731 cancer cases considered in the analysis. The increases was most prominent in 2009. Totally, the frequency of the cancer was greater in males. Moreover, calculating truncated age-adjusted incidence rate indicated that the most prevalent age of colorectal incidence was in the 50-59 year age group except in 2007-2008 and 2012- 2013, when greatest incidences occurred in people aged 60-69 years. Our data revealed that the incidence rates of colorectal cancer have increased over the past decade in our region of Iran.

Trend in the prevalence of obesity and overweight among Iranian children and adolescents: a systematic review and meta-analysis.

OBJECTIVE: Childhood obesity is an important predisposing factor for most non-communicable diseases. The aim of this review was to provide evidence on the prevalence and trends of childhood obesity and overweight in Iran. METHODS: Multiple international and Iranian scientific databases were searched for relevant literatures. Two independent reviewers identified relevant papers in several steps. Separate meta-analyses (using fixed- or random-effect models) were performed to estimate the overall, age, sex, and age-sex specific prevalence of obesity and overweight. Stratified analysis based on Centers for Disease Control and Prevention, International Obesity Task Force, and World Health Organization definition criteria and study year also were performed. RESULTS: We included 107 studies in the meta-analysis (49 English and 58 Persian). Based on Centers for Disease Control and Prevention definition criteria, the overall prevalence of obesity and overweight remained relatively constant in the 2000s and are estimated to be about 5.1% (95% confidence interval [CI], 4.4-5.8) and 10.8% (95% CI, 10.2-11.4), respectively. The meta-regression analysis showed that the prevalence of obesity and overweight did not vary significantly with respect to sex and age of study participants. Girls had a lower prevalence of obesity and higher prevalence of overweight than boys. CONCLUSION: This review, which is the first of its kind in the Middle East and North Africa, suggests that although the trend in the prevalence of childhood obesity in Iranian children is not considerably high, but the escalating trend of excess weight among young children is alarming and should be considered by providers of interventional preventive programs at national and regional levels.

Risk and vulnerability of key populations to HIV infection in Iran; knowledge, attitude and practises of female sex workers, prison inmates and people who inject drugs.

UNLABELLED: Background In this study data of three national surveys conducted among female sex workers (FSW), prison inmates and people who inject drugs (PWID) were presented and compared in relation to knowledge, attitude, and practises. METHODS: The surveys were conducted in 2009 and 2010 and included 2546 PWID, 872 FSW and 5530 prison inmates. Knowledge, attitude and practises towards HIV were measured through similar questions for each category. RESULTS: Over 90% of all participants had ever heard of HIV/AIDS, although only approximately half of them perceived themselves at risk of contracting HIV. More than 80% were able to correctly identify the ways of preventing the sexual transmission of HIV; while more than two-thirds did not use condom in their last sexual contact. Approximately 20% of prisoners and FSW had a history of injecting drugs. Among all participants who have injected drugs, prisoners had the highest unsafe injecting behaviour at the last injection (61%), followed by FSW (11%) and PWID (3%). CONCLUSIONS: Despite major efforts to control the HIV epidemic in Iran, the level of risk and vulnerability among prisoners, FSW and PWID is still high. The level of comprehensive knowledge about HIV/AIDS is relatively good; however, their risk perception of contracting HIV is low and high-risk behaviours are prevalent. Therefore, HIV prevention programs should be redesigned in a more comprehensive way to identify the best venues to reach the largest number of people at a higher risk of contracting HIV and decrease their risk overlaps and vulnerability factors.

Comparison of three interview methods on response pattern to sensitive and non-sensitive questions.

BACKGROUND: To get more precise responses when gathering information about sensitive topics such as drug use, it is important to use the most optimal method. OBJECTIVES: This study was carried out to address the impact of three interview methods (street-based, household, and telephone interviews) on response pattern to sensitive and non-sensitive questions in terms of participation, disclosure and discontinuing rates. PATIENTS AND METHODS: We selected three culturally diverse major cities of Iran. Then, we randomly selected 300 subjects, 100 for each type of interview, from each major city (899 in total). For street-based interviews only pedestrians who were walking alone were recruited, for household interviews only one individual from each house participated (3-4 houses in each alley were selected), and for telephone interviews we selected phone numbers using a random number list. We asked five non-sensitive and five sensitive (related to drug use and sexual contact among their personal network) questions. RESULTS: For telephone and household interviews, relative to street-based interviews, participants were less likely to disclose alcohol and drug-related behaviors (Adjusted OR = 0.76; 95% CI: 0.60- 0.97) and sexual behaviors among their network (Adjusted OR telephone/street-based = 0.64; 95% CI: 0.39- 1.07 and Adjusted OR household/ street-based = 0.56; 95% CI: 0.33- 0.95). We found that participants who were interviewed via the telephone were more likely (Adjusted OR = 1.24) and those who were interviewed at home were less likely (Adjusted OR = 0.86) to report non-sensitive information compared to participants who were interviewed on the street; however, these findings were not statistically significant. The largest participation rate and the least discontinuation rate were observed for household interviews. CONCLUSIONS: It seems that the methods of interview effect response to both sensitive and non-sensitive questions. We believe that for street-based interviews, respondents may disclose more sensitive information than telephone and household interviews.

The projection of burden of disease in Islamic Republic of Iran to 2025.

OBJECTIVE: Iran as a developing country is in the transition phase, which might have a big impact on the Burden of Disease and Injury (BOD). This study aims to estimate Burden of Disease and Injury (BOD) in Iran up to 2025 due to four broad cause groups using Disability-Adjusted Life Year (DALY). METHODS: The impacts of demographic and epidemiological changes on BOD (DemBOD and EpiBOD) were assessed separately. We estimated DemBOD in nine scenarios, using different projections for life expectancy and total fertility rate. EpiBOD was modeled in two scenarios as a proportion of DemBOD, based on the extracted parameters from an international study. FINDINGS: The BOD is projected to increase from 14.3 million in 2003 to 19.4 million in 2025 (95% uncertainty interval: 16.8, 21.9), which shows an overall increase of 35.3%. Non-communicable diseases (12.7 million DALY, 66.0%), injuries (4.6 million DALY, 24.0%), and communicable diseases, except HIV/AIDS (1.8 million DALY, 9%) will be the leading causes of losing healthy life. Under the most likely scenario, the maximum increase in disease burden due to DemBOD is projected to be observed in HIV/AIDS and Non-communicable diseases (63.9 and 62.4%, respectively) and due to EpiBOD in HIV/AIDS (319.5%). CONCLUSION: It seems that in the following decades, BOD will have a sharp increase in Iran, mainly due to DemBOD. It seems that communicable diseases (except HIV/AIDS) will have less contribution, and especially non-communicable diseases will play a more significant role.