'You just prefer to die early!': how socioecological context impedes treatment for people living with HIV in Iran.

INTRODUCTION: Despite the low prevalence of HIV and broad provision of antiretroviral therapy, the Middle East and North Africa (MENA) remains the only region where new HIV infections and AIDS-related deaths are not declining. There is a dearth of evidence from MENA on antiretroviral therapy engagement. In this qualitative study, we sought to identify the ways in which successful treatment is hindered in Iran, which is home to 24% of HIV infections in MENA. METHODS: From August 2018 to January 2019, we used purposive sampling and conducted 12 individual interviews and 8 focus group discussions with 27 female and 31 male patients, in addition to 5 individual interviews with HIV care providers and 1 focus group discussion with 8 care providers. Social constructivism augmented with realist-informed thematic analysis was used to understand how the socioecological context triggers cognitive and affective mechanisms that disrupt antiretroviral therapy. RESULTS: The use of Thematic Network Analysis resulted in the identification of three key cognitive and affective mechanisms that appear to shape treatment experience and are triggered via HIV's socioecological context and changing economic conditions in Iran: denial in response to societal negative perceptions of HIV; fear in response to societal lack of awareness regarding HIV and misinformation; and despair in response to HIV-related stigma and enacted discrimination, economic insecurity and social support. CONCLUSIONS: To our knowledge, this is the first study within MENA to identify pathways through which successful treatment is hindered. It appears that lack of societal awareness regarding HIV is specific to low prevalence settings, such as MENA countries, where negative perceptions, stigma, discrimination and misinformation regarding HIV and its treatment produce denial, fear and despair, acting as mechanisms that disrupt antiretroviral therapy. The experience of despair, in response to changing economic conditions and social support, further impacts treatment experience.

Tailored mHealth intervention for improving treatment adherence for people living with HIV in Iran (HamRaah): protocol for a feasibility study and randomised pilot trial with a nested realist evaluation.

INTRODUCTION: Middle East and North Africa (MENA) has a rising rate of new HIV infections and AIDS-related mortality. Consistent adherence to antiretroviral therapy (ART) leads to viral suppression, preventing HIV transmission and treatment failure. mHealth interventions can improve ART adherence by providing tailored support and directing patients to existing healthcare services. HamRaah (Persian for 'together-in-path') is the first mHealth-based intervention in a MENA country and is designed to improve adherence through two-way mobile messaging for people recently diagnosed with HIV in Tehran, Iran. The objectives of this pilot randomised controlled trial (RCT) are to examine the feasibility, acceptability and preliminary effectiveness of HamRaah, and to develop an explanatory theory for any observed effects through a nested realist evaluation. METHODS: A feasibility study and two-arm RCT of HamRaah, with an embedded realist evaluation will be conducted. Participants will be randomised 1:1 to HamRaah or routine care for a 6-month intervention. The initial effectiveness of HamRaah will be assessed through the primary outcome of self-reported ART adherence and several secondary outcomes: retention in care, CD4 count and viral suppression. A theory-driven realist evaluation framework will be used to develop an explanatory theory regarding what works, for whom, how and in what context. ETHICS AND DISSEMINATION: The study received ethical clearance from Tehran University of Medical Sciences Ethics Committee and Oxford Tropical Research Ethics Committee People living with HIV in Tehran and key country stakeholders in HIV policy and programming have been involved in the development of HamRaah and this pilot trial. Participants will provide informed consent prior to study enrolment. The results will be disseminated to all stakeholders and presented in peer-reviewed journal publications and conferences. TRIAL REGISTRATION NUMBER: IRCT20100601004076N23; Pre-results.

HIV in Iran: onset, responses, and future directions.

Iran, a country in the Middle East and North Africa (MENA) region, has been actively involved in the fight against HIV/AIDS over the past three decades. The unique features of the HIV epidemic in Iran are reflected by the modes of transmission and its recent changes to improve management and prevention programs. In this review, we recount the initial onset and subsequent spread of HIV infection in Iran, beginning with the first case diagnosed to the ongoing responses and most recent achievements in controlling this epidemic. Although in the MENA region, Iran is one of the pioneers in implementing pertinent policies including harm reduction services to decrease HIV incidence, drug injection still continues to be the major risk of infection. In line with other nations, the programs in Iran aim at the UNAIDS 90-90-90 targets (UNAIDS 90-90-90 global targets to end the AIDS epidemic by 2020: by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression) and to eliminate mother-to-child HIV transmission. In this article, we discuss the strengths and shortcomings of the current HIV programs and offer suggestions to provide a better perspective to track and respond to the HIV epidemic. More generally, our account of the national religious and cultural circumstances as well as obstacles to the approaches chosen can provide insights for decision-makers in other countries and institutions with comparable settings and infrastructures.

Expression of mir-221, mir-29a, mir-155 and mir-146a in Peripheral Blood Mononuclear Cell (PBMC) in HIV-1 Infected Patients.

AIMS AND OBJECTIVES: In patients infected by HIV-1, some cellular biomarkers such as microRNAs have an important function in the suppression or progression of the disease. The aim of the current study is to evaluate the expression of mir-221, mir-29a, mir-155, and mir-146a in HIV-1 infected patients. METHODS: The miRNAs of 60 HIV-1 infected patients (sample group) and 20 healthy controls (normal group) were extracted from their peripheral mononuclear cells. We used TaqMan-based Real-- time PCR for evaluation of expression mir-155, mir-221, mir-29a and mir-146a by the comparative method. To evaluate differences among the data, one-way ANOVA was used. The expression of mir-155 and mir-146a in HIV-1 patients (sample group) was down-regulated in comparison with healthy controls (normal group) with a confidence value (p <0.001). In addition, in the sample group, the expression of mir-221 was downregulated compared to the normal group (p <0.001). RESULTS: There was no significant difference in expression mi-29a in the sample and control group. In the sample group, mir-221 had a low expression, and mir-29a had a high expression, respectively. According to the results of the current study and comparative studies, it seems that the microRNA has an important role in the progression or suppression of HIV-1 infection. CONCLUSION: However, the data showed that besides other cellular and viral factor, these miRNAs could be used as a biomarker. However, the miRNAs field experts are in general agreement that more investigation is needed to use miRNAs as a biomarker in HIV.

Epidemiology of HIV in Iran.

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

Woman's Sexual Health Knowledge and Needs Assessment in Behavioral Clinics and Shelters in Tehran.

Objective: The aim of this study was to assess the sexual health knowledge among females seeking consultation in behavioral clinics or shelters with emphasis on sexual routs of HIV transmission. Materials and methods: In this study 250 women who have attended behavioral clinics or shelters in Tehran were recruited and a standardized questionnaire which asked about demographics, sexual partner and knowledge about HIV/STDs was used. Results: The median age of our cases was 40.82% and among them 16% were married but lived alone. Among the total 250 cases, 56% (140) were sexually active in the last 30 days, 19.2% (48) had a history of a one-night stand and 2.4% had more than 1 sexual partner. 212 cases answered questions about condom use, 60% (127) of them did not use condoms at all. For knowledge about signs and symptoms related to STDs, 63% believed that abdominal pain has no relation to STDs. Also 44%, 43%, 37%,and 40% believed that dyspareunia, dysuria, malodorous vaginal discharge and change in color of vaginal discharge, respectively had no relation to STDs and 13% of whom presented with these symptoms in the past 30 days had not seek medical evaluation. Conclusion: It is a necessity to emphasize the use of condoms among the male population however in this study it was a challenge to do so because it goes against the government's campaign of pro-natalism. Improving the knowledge of protected sex should start from the teenage years and at school to have maximum STD prevention planning. Most women in our study did not know about healthy sexual lifestyle and this shows the need of sexual health education before marriage or even at school.

Effect of a Short-term Lifestyle Modification Program on Quality of Life, Anthropometric Characteristics and CD4+T Cell Count of HIV Infected Patients in Tehran/Iran: A Randomized Controlled Trial.

CONTEXT: Increasing physical activity and promoting healthy behaviors may play a key role in reducing the adverse effects of antiretroviral therapy and HIV. OBJECTIVE: This study investigated the effects of an 8-week lifestyle modification program (LMP) on quality of life, anthropometric characteristics and CD4+T cell count of people living with HIV (PLWH). METHODS: Thirty PLWH taking ART were randomly assigned to a lifestyle modification program (LMP) (n = 15) or standard care control (CON) group (n = 15). All volunteers underwent body composition, CD4+T cell count measurement and quality of life assessments at the beginning and end of a two-month experimental period. RESULTS: At follow-up, we observed a significant increase in CD4+T cell count (117.52 cells/mm3; 95% CI, 36.59-198.45) and all subscales and total quality of life score (Short-Form 36 (SF-36) in the LMP group. While we did not observe a significant change in body composition for the LMP group, we did observe a significant increase in body fat (1.75%; 95% CI, 0.15, 2.33) and a reduction in lean body mass (-1.26; 95% CI, -1.26, -2.39) for the CON group. CONCLUSION: A LMP can be safely used as an effective intervention for improving quality of life and immune competence of PLWH who lack time to participate in a structured exercise regimen. TRIAL REGISTRATION: IRCT 201604034076N18. Registered: 2016-05-05 .web address of TRIAL: en.search.irct.ir/trial/4262.

Effect of 8 Weeks of Hospital-Based Resistance Training Program on TCD4+ Cell Count and Anthropometric Characteristic of Patients With HIV in Tehran, Iran: A Randomized Controlled Trial.

Ghayomzadeh, M, SeyedAlinaghi, S, Shamsi, MM, Rezaei, S, Earnest, CP, Akbarnejad, S, Taj, L, Mohraz, M, Navalta, JW, Ghasemi, P, and Voltarelli, FA. Effect of 8 weeks of hospital-based resistance raining program on TCD4+ cell count and anthropometric characteristic of patients with HIV in Tehran, Iran: A randomized controlled trial. J Strength Cond Res 33(4): 1146-1155, 2019-We examined the effects of an 8-W circuit resistance training (RES) program using elastic bands and body weight on TCD4+ cell counts and anthropometry in patients with HIV. Patients (N = 21) receiving antiretroviral therapy were randomly assigned to resistance training (RES; n = 14) or control (CON; n = 7) groups. RES (3/W) consisted of training with elastic bands and bodyweight training focusing on major muscle groups. CON received standard care. Statistical analyses were performed using general linear models adjusted for age, sex, length of infection, and respective baseline measures. The primary outcome was TCD4+, and secondary outcomes were anthropometry indices. Tertiary assessments explored Pearson correlations surrounding the relationship between changes in anthropometry and TCD4+. We observed significant increases in TCD4+ count accompanying RES training (105.50 cells·mm, 95% confidence interval [CI], 47.42-163.59), whereas CON significantly decreased (-41.01 cells·mm, 95% CI, -126.78 to 44.76). Significant between-group differences were noted (p < 0.02; n = 0.42). We also observed significant reductions in fat mass for RES (1.18 kg, 95% CI = 1.80 to -0.56) vs. increased fat mass for CON (1.21 kg, 95% CI, 0.31 to 2.11). Significant between-group differences were noted (p = 0.001, n = 0.64). Similar effects were noted for lean body mass. No significant changes were observed for body mass. Significant correlations were observed for fat mass (r = -0.699, p = 0.001) and lean mass (r = 0.553, p = 0.017), but not body mass (r = -0.390, p = 0.109) vs. changes in TCD4+. Our results suggest that the RES program used in this study is effective for improving TCD4+ status and body composition in patients with HIV.

HIV Prevalence and Correlations in Prisons in Different Regions of the World: A Review Article.

The prevalence of HIV is substantially higher among prisoners than the general population, while the incidence varies considerably in different regions around the world. If we consider Sub-Saharan Africa as one region with the highest prevalence of HIV, data on African prisoners would be limited. Despite the low prevalence of HIV in the Middle East and North Africa, its incidence is rising in these regions with a few exceptions; there are insufficient data on HIV prevalence in prisons. A similar situation is present in both Pacific and Central Asia as well as in Eastern Europe. A high rate of infection is mainly observed among prisoners in Western and Central parts of Europe, since the data from these are more available than other parts. Nowadays, the sexual transmission mode and tattooing are important ways in HIV risks among prisoners after injecting drug use as the most common route of HIV transmission in all regions. However, it is difficult to compare and analyze the prevalence of HIV among prisoners in different regions regarding the limited data and different methods which they used in collecting data. Eventually, it can certainly be said that prisons are one of the high-risk places for HIV transmission; on the other hand, can be a suitable place for implementing HIV case-finding, linkage to treatment and harm reduction programs.

HIV-1 Drug Resistance Profiles for the HIV Protease and Reverse Transcriptase Gene in Patients Receiving Combination Therapy in Tehran, Iran.

BACKGROUND: Determination of the drug-resistant mutations has a crucial role in the management of HIV-1 infected patients. OBJECTIVE: The aim of the current study was to evaluate drug resistance profile of Reverse transcriptase and Proteasegenes, and to find the correlation between drug resistance mutations and ART regimen to intensifyphysicians'options for the most effective therapy which could also influence the establishment of health-related policies at the national level in Iran. METHOD: HIV-1 RNA of 34 samples was extracted from plasma and RT Nested- PCR was performed and the final products were sequenced. Stanford HIV drug resistance sequence database was used for interpretation of the data. RESULTS: In 14 patients out of 15, the following mutations were observed; Nucleoside RT Inhibitor (NRTI)-Resistance Mutations with the prevalence of 11 patients having this mutation at codon 184 (73%) and Non-Nucleoside RT Inhibitor (NNRTI)-Resistance Mutations with the prevalence of 8 patients having NNRTI mutations at codon 103(53%).In 17 patients, major Protease Inhibitor (PI) Resistance Mutations were found out in 2 (12%) of them while the minor PI was found in7 (41%) patients. CONCLUSION: An antiretroviral treatment consisting of nucleoside reverse transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor and protease inhibitor, impairs the emergence of a resistant strain and descends its prevalence among the community. Having a high rate mutation in participants of this study raises concerns about treatment failure in HIV infected people in Iran. Observing high mutations rates in participants of this study raises concerns about treatment failure in HIV infected people in Iran.

Successful Outcome of Autologous Stem Cell Transplantation for Relapsed or Refractory Germ Cell Tumors.

Background: Treatment of choice for patients with refractory germ cell tumors (GCT) or recurrence after platinum containing chemotherapy regimens is not yet well recognized. This study is aimed to evaluate the role of high-dose chemotherapy (HDCT) followed by an autologous hematopoietic stem cell transplantation (ASCT) as the second-or third-line of salvage therapy in GCT patients. Materials and Methods: Since 1997 to 2013, 13 GCT patients failing at least one salvage chemotherapy protocol were included in the study. The patients underwent chemotherapy, and then after a primary response the ASCT was performed. Survival analysis was done using Kaplan-Meier method. Results: Eleven patients were male and 2 were female. All patients had gonadal tumors except one that had mediastinal GCT. Median follow-up time was 5.45±3.19 years. The estimated 5-year overall and disease-free survival rates were 84.00% and 69.23%, respectively. Five relapses after ASCT and 2 deaths occurred, and the cause of death was due to the relapse of primary disease in both cases. Transplant-related mortality (TRM) did not happen among the study participants. Conclusion: our results showed acceptable outcomes for ASCT in refractory or relapsed GCT in terms of survival and treatment-related mortality. Larger prospective studies will be required to elucidate different aspects of such an interpretation.

Pseudomonas Aeruginosa Osteomyelitis of the Pubic Bone: A Case Report.

Pubic osteomyelitis is a rare disease usually results from various gynecologic and urologic surgeries. We present a-78 year old-woman admitted to the Infectious Department of Imam Khomeini Hospital in June 2014 with pubic osteomyelitis caused by pseudomonas aeruginosa followed by hysterectomy.