ORIGINAL RESEARCH
Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users in Drop in Centers in Southern Iran Alireza Salehi, MD, MPH, PhD, Mojtaba Naghshvarian, MD, PhD, Maryam Marzban, MSc, PhD, and Kamran Bagheri Lankarani, MD
Objectives: Drop in Centers (DICs) are organizations in which health and social services are delivered to drug users on the basis of harmreduction strategies. The aim of this epidemiological study was to estimate the prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection at these centers over a 6-year period. Methods: All of the DICs (7 in total) visited were located in Shiraz, the capital city of Fars province, southern Iran. Every patient record in these centers was studied between April 2006 and April 2011. Complementary information on the frequency of HIV was collected from the Voluntary Counseling and Testing services. A logistic regression model was applied to data analysis. The study explored risk factors associated with HIV and HCV infections, which were primarily high-risk sexual behavior. Results: This study examined 1,327 people, 79.5% of whom were males. The mean age of first substance use and the first injection among intravenous drug users (IDUs) were 20.24 ± 6.11 and 26.5 ± 7.3 years, respectively. In total, 13.5% and 20.2% of the subjects who registered at the DICs were infected with HCV and HIV, respectively. Shared injection, history of imprisonment, maleness, unsafe sex, inadequate housing, and low education were risk factors for HIV infection. Shared injection, unsafe sex, history of imprisonment, and maleness were predisposing factors for HCV infection. A history of imprisonment and substance use upon registration at the DIC were significant risk factors for female sex workers. Conclusions: Our study emphasized the implementation of preventive measures like education and needle exchange program as harmreduction strategies. Drop in Centers are important for the management of health problems, including HIV infection and social problems such as crime. Periodic epidemiological studies on DICs are necessary to monitor and modulate the services delivered by these centers. From the Health Policy Research Center (AS, MM, KBL), Shiraz University of Medical Sciences, Shiraz, Iran; and Tehran University of Medical Sciences (MN), Tehran Iran. Received for publication September 1, 2013; accepted December 27, 2014. Funded by the Health Policy Research Center of the Shiraz University of Medical Sciences. The authors report no other conflicts of interest. Send correspondence and reprint requests to Alireza Salehi, MD, MPH, PhD, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Email: ([email protected] or salehiar @sums.ac.ir). C 2015 American Society of Addiction Medicine Copyright ISSN: 1932-0620/15/0903-0181 DOI: 10.1097/ADM.0000000000000112
Key Words: Drop in Center, drug user, HIV, HCV, Iran (J Addict Med 2015;9: 181–187)
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ubstance use, a phenomenon with a long history, is one of the most important economic and social challenges to human health. Annually, millions of dollars are spent worldwide to combat this problem (Hamid, 1998; Osmani et al., 1998; Ardebili and Rayejian, 1999; Najar, 2009). Estimates from the United Nations Office on Drug and Crime in 2011 show that approximately 153 million to 300 million people (3.5%-6.6% of the world’s population) are drug dependent. The report says that 22 million people in the United States are illicit drug users (Fedotov, 2012). The number of intravenous drug users (IDUs) in the Middle East and North Africa is estimated to be between 300,000 and 1,000,000, which is considerable in comparison with approximately 15.9 million users throughout the world (Mathers et al., 2008). Substance use in Iran has also a long history. In fact, traditional physicians such as Avicenna (980-1037 BC) documented its signs and symptoms and ways to cure it (Avecina, 1997; Hakim, 2009). Because of various reasons including the government’s disregard of the problem, the prevalence of drug abuse grew over the Safavid and Qajar dynasties (Shakeri, 2008). At present, the high prevalence of substance use involves a large number of youths in Iran and the geopolitical position of the country as a drug transition corridor for neighboring countries, such as Afghanistan and Pakistan, which are the 2 major manufacturers of these substances. According to Drug Control Headquarters (Tehran, Iran), 3400 military personnel have been killed in the fight against drugs since the Islamic Revolution in 1979 (Najar, 2011). According to the Ministry of Health and Medical Education report in October 2011, the number of regular drug abusers in the country was estimated to be 2 million to 2.2 million (Moayed, 2011). On the whole, previous studies have revealed that drug use trends in Iran increased between 1970 and 1990. The annual growth rate of substance use was approximately 8% between 1978 and 1988, which is 3 times that of the country’s population growth rate (Rahimimohavghar, 2002). According to the first national study on the burden of disease and risk factors, drug use is the fifth leading risk factor, after overweight and obesity, high blood pressure, physical inactivity, and hypercholesterolemie, attributable to the burden of disease. Moreover, substance use accounts for
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11.24% of the attributable burden of risk factors (Khosravi et al., 2010). Another report by the Iranian Ministry of Health and Medical Education showed that Fars Province ranked 10th in regard to the number of drug users, fourth in mortalities due to drug use in 2009 (Rafati et al., 2008). Drop in Centers (DICs) are organizations in which health and social services are delivered aim at harm-reduction programs. The purpose of the programs is to reduce negative social, economic, and health outcomes of substance use, even when the drug users fail to abstain (Slesnick et al., 2008). Preventive and proactive approaches to controlling substance use are a priority as these are more effective and more appropriate for the limited financial and human resources available to addicted people (Emmanuelli, 2004). To develop and maintain the DICs, health policy makers need to have a comprehensive understanding of the target groups. For example, an ideal DIC should be in a location easily accessible to all drug users and homeless people and delivered services around the clock (Zamani, 2008). Several studies conducted in Denmark, Norway, and Sudan have shown that counseling, harm-reduction programs, and voluntary tests were effective in preventing propensity to human immunodeficiency virus (HIV) (Amundsen et al., 2003). Harm-reduction programs started in Iran in 2002, the target groups including male and female IDUs and women whose sexual partners are IDUs. Most studies have shown that Iranian female drug users suffer more stigmas, and therefore they are often unwilling to seek treatment (Dolan et al., 2012). In many developing countries, one of the main methods of harm reduction is to implement needle and syringe programs (NSPs) (Vazirian et al., 2005), which is proved to be very effective in reducing the risk of HIV transmission. Harmreduction programs have been more successful than treatment program in reducing the risk of HIV transmission (Yuet, 2000; Wood, 2004). In northern Asia, most IDUs are unwilling to take part in drug cessation programs, so NSP is indicated in addition to other care strategies such as counseling (Kumpfer et al., 2003). In China, drug abusers who participated in needle exchange and counseling programs were found to have increased their knowledge of risky drug injecting behavior from 29% to 58% after ten months and reducing their risky behavior among IDUs in communities (Lin et al., 2004). There have been few epidemiologic studies on DICs in Iran. In a study in Kermanshah Province, western Iran in 2008, variables such as low education, indecent residence, unemployment, and shared injection in lower ages made IDUs not use harm-reduction programs (Mohamad et al., 2009). Another study investigated health policy makers’ views on harm-reduction programs and found that they, despite their initial objections, welcomed the programs (Khalitash et al., 2009). There are 7 DICs in Shiraz, the capital city of Fars Province, operating under the supervision of Shiraz University of Medical Sciences, of which 5 centers are devoted to men and 2 to women. The aim of this study was to estimate the prevalence of HIV and HCV infection in clients registered or referred to DICs for primary health and personal care, which is
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accompanied by factors influencing the risk of HIV and HCV infections and practicing as sex workers.
METHODS Setting and Participants The study setting included all DICs in Shiraz, which has a population of approximately 3 million. These DICs are governmental organizations, which were established according to geographical and population-based data, by experts in the field who had a good knowledge of the location. These centers provide primary health care, basic needs such as small quantities of food and toiletries for men and women, counseling, NSP, sexual health care, condom promotion, and access to Voluntary Counseling and Testing (VCT), which provides pretest and posttest counseling in addition to HIV and HCV test screening. All services are voluntary and provided free of charge. The DICs staff include a supervisor, a coordinator, a nurse, a part-time midwife, a social worker, a part-time psychologist, peer outreach groups, a chef, a barber, and several administrative staff, who are all involved with health promotion and infectious disease prevention measures. Methadone maintenance therapy clinics are located near the DICs and receptive to the referred clients. The researchers independent of the clinic approached the DICs to evaluate their activities for future planning. In this study, 7 DICs were visited, of which 2 are exclusively for women and 5 for men. The drug users’ records were examined in these centers between April 2006 and April 2011. To collect relevant information about their age, sex, level of education, imprisonment records, marital status, etc, complementary information on the frequency of HIV among this group of people was collected from the VCT centers of Shiraz University of Medical Sciences.
Data Processing and Analysis Out of 1931 records collected from the DICs and the VCT, 39 participants, including 22 from DIC and 17 from VCT, were eliminated because of duplication in each of the 2 data sources. Also, 12 participants were excluded because they resided outside Shiraz. We performed data linkage, using Microsoft Office Excel. The criteria for linkage were the sharing of 6 variables, including name, family name, father’s name, age, date of birth, and place of residence. Combination of the variables was used to define a unique ID for each participant in statistical analyses. In all, 553 participants registered in both centers were eliminated because of duplication after merging the 2 data sets. Finally, we were able to examine 1327 records of the study participants. In the first step, the association of different factors with HIV infection, history of being an IDU, and a female sex worker was analyzed using univariate logistic regression. Next, we entered significant variables (P > 0.20) into a multiple regression analysis by a backward conditional method for the people afflicted with HIV. Statistical analyses were performed using SPSS software (SPSS for Windows 16.0, SPSS, Chicago, Illinois). P value < 0.05 was considered as statistically significant. C
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RESULTS Demographic Characteristics The demographic characteristics of the participants are shown in Table 1. This study examined 1327 people, of whom 79.5% were males, 62.2% younger than 35 years, 33.3% married, and 16.7% divorced or separated. The prevalence of unemployment and inadequate housing (homelessness, shelters, and hangouts) was 56.6% and 30.3%, respectively. Twothirds of the subjects in the DICs had a history of imprisonment. Of the women attending these centers, 167 (62.3%) were sex workers. A history of unsafe sex in men and women was present in 15.0% and 14.5% subjects, respectively.
Types and Methods of Substance Use In total, 93.3% of the subjects had used drugs when they were registered in these DICs. The mean age of the first substance use was 20.24 ± 6.11 years with a minimum age of 7 years and a maximum age of 59 years. The mean age of the first injection among the IDUs was 26.5 ± 7.3 years, with a minimum of 11 years and a maximum of 66 years. The type of substance used included heroin 71.4%, methamphetamine (crystal) 7.5%, opium 7.1%, norgesic 5.6%, opium sap 1.2%, opium sap and opium 0.2%, and heroin combined with other types of substances 5.6%, and an unknown substance in 1.4% cases. Of the people registered in these centers, 810 were IDUs, of whom 534 were drug injectors and 276 used other methods in addition to injecting. There were 208 persons who smoked, 77 used other methods in addition to smoking, 44 used orally, 54 inhaled drugs, and 134 people did
Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users
not mention their method of drug use. Only 2.2% acquired their needles and syringes from pharmacies, 13% from DICs, whereas 54.4% obtained them from both DICs and pharmacies. A negligible percentage (0.02%) acquired needles and syringes from friends. The injection method used by the men was 14 times higher than that of women (odds ratio [OR] = 13.97; 95% CI: 10.06-19.39). Moreover, it was 2 times greater in those with a history of imprisonment (OR = 2.20; 95% CI: 1.70-2.85).
HIV and Hepatitis C Infection There were 179 subjects (13.5%) who had registered in the DICs as HCV positive, 167 were males (15.8% of all men), and 12 were females, which include 4.5% of all women. A total of 268 persons (20.2%) were infected with HIV, of whom 224 were males and 44 were females. In fact, about 1 in 5 of the men and 1 in 6 of the women covered by the services of the DICs were infected with HIV. The proportion of single subjects with HIV infection and HCV infection was 43% (n = 115) and 45%, (n = 80), respectively. All patients infected with HIV and/or HCV used heroin, which was utilized by 82% and 90% of those who used syringes and infected with HIV and HCV, respectively. Among people with unsafe sex practices, 117 (58.21%) and 85 cases (42.29%) were HIV and HCV positive, respectively. A quarter of the subjects with a history of imprisonment were infected with HIV. The evaluation of risk factors related to HIV and HCV and the history of high-risk sexual behavior in women are described in Tables 2 and 3.
TABLE 1. Demographic Characteristics of Subjects Registered at the Shiraz Drop in Centers Variables Sex Male Female Unknown Education Illiterate Primary school Secondary school High school University Unknown Place of residence Private house Rental house Homeless Fathers’ house Shelter Hangout Unknown History of imprisonment Yes No Unknown HCV infection Yes No Unknown C
Number (%) 1055 (79.5) 268 (20.2) 4 (0.3) 61 (4.6) 274 (20.6) 435 (32.8) 201 (15.1) 21 (1.6) 335 (25.3) 146 (11) 291 (21.9) 353 (26.6) 341 (25.7) 42 (3.2) 6 (0.5) 148 (11.1) 886 (66.8) 365 (27.5) 76 (5.7) 179 (13.5) 1142 (86.1) 6 (0.4)
Variables Marital Status Married Single Divorced Widow/widower Separated Unknown Occupation Jobless Worker Self-employed Employee Unknown Age group, y 0-25 26-35 36-45 46-55 >56 Unknown Being sex worker in women Yes No Unknown HIV infection Yes No Unknown
Number (%) 431 (32.5) 582 (43.9) 205 (15.4) 90 (6.8) 6 (0.4) 13 (1.0) 751 (56.6) 314 (23.6) 233 (17.5) 9 (0.8) 20 (1.5) 234 (17.7) 590 (44.5) 311 (23.4) 124 (9.3) 28 (2.1) 40 (3.0) 167 (62.3) 97 (36.2) 4 (1.5) 268 (20.2) 1051 (79.2) 8 (0.6)
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TABLE 2. Univariate Analysis of the Factors Associated With the Risk of HIV and HCV Infections in Subjects Registered at Shiraz Drop in Centers HIV Variables
Frequency
Sex Male Female Place of residenceb Indecent Decent Education Secondary school and lower High school and upper Shared injection Yes No Unsafe sex Yes No History of imprisonment Yes No Occupation Employed Unemployed
(%)a
HCV
OR (95% CI)
P
Frequency (%)
OR (95% CI)
P
224 (83.3) 41 (15.2)
1.49 (1.03-2.41)
0.031
167 (92.8) 11(6.1)
4.39 (2.35-8.21)
0.0001
161 (59) 32 (11)
3.01 (2.02-4.92)
0.0001
115 (63) 22 (12)
1.25 (0.92-1.72)
0.152
201 (74) 39 (14)
1.52 (1.31-1.77)
0.0001
144 (80) 22 (15)
1.16 (0.98-1.37)
0.073
222 (82.5) 38 (14.1)
34.11 (23.01-50.54)
0.0001
162 (90) 13 (7.2)
50.72 (28.18-91.28)
0.0001
117 (43.5) 152 (56.5)
8.92 (6.42-12.39)
0.0001
85 (47.2) 95 (52.8)
7.95 (5.60-11.28)
0.0001
214 (79.6) 53 (19.7)
1.87 (1.34-2.61)
0.0001
158 (87.8) 22 (12.2)
3.38 (2.12-5.38)
0.0001
127 (47) 142 (52.8)
1.21 (0.92-1.58)
0.159
87 (48) 93 (51.7)
1.29 (0.91-1.72)
0.152
a
Because of missing information, the sum of percentages did not add up to 100%. Private house, fathers’ house, and rental house as “decent” and homeless, shelter, and hangout as “indecent.” CI, confidence interval; OR, odds ratio. b
Shared injection, history of imprisonment, maleness, unsafe sex, inadequate housing, and low education of people infected with HIV in a univariate logistic regression is shown in Table 2. Also, the result of multiple regression analysis is depicted in Table 4. Education level (OR = 1.43; 95% CI: 1.06-1.93), shared needles (OR = 47.79; 95% CI: 24.32-93.89), unsafe sex (OR = 30.03; 95% CI: 10.50-85.83), history of imprisonment (OR = 2.49; 95% CI: 1.23-5.05), and sex (OR = 7.11, 95% CI: 3.27-15.45) were significant in a multiple regression model. Of the 4 significant variables in the multiple regression, only shared needles (OR = 36.78; 95% CI: 20.20-66.99) and unsafe sex (OR = 3.12; 95% CI: 2.01-4.85) remained significant predisposing factors to HCV infection.
As shown by univariate analysis, a history of imprisonment and substance use at the time of registration in the DIC were factors associated with being sex workers in women but were not significant variables in multiple regression model (Table 3).
DISCUSSION This study showed the female-to-male ratio being smaller than the mean world ratio. The first time injection was later in life compared to other countries. At that time, heroin users comprised the majority of clients, whose most common method was injection. Low education and lack of knowledge about safe injection, unsafe sex, and history of imprisonment in the majority of users are the risk factors for HIV and HCV
TABLE 3. Univariate Analysis of Factors Affecting Female Sex Workers Registered at Shiraz Drop in Center Variables Marital status Single Married Occupation Unemployed Employed Education Secondary school and lower High school and upper Drug abuse (at the time of registration) Yes No History of imprisonment Yes No
Frequency (%)a
OR (95% CI)
P
96 (57) 68 (40)
1.47 (0.52-4.14)
0.461
15 (9) 152 (91)
1.63 (0.75-3.35)
0.216
72 (43) 17 (10)
1.18 (0.56-2.46)
0.650
126 (75.4) 17 (10.2)
2.42 (1.17-5.02)
0.016
81 (48.5) 50 (29.9)
1.49 (1.04-2.13)
0.028
a
Because of missing information, the sum of percentages did not add up to 100%. CI, confidence interval; OR, odds ratio.
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Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users
TABLE 4. Multiple Regression Analysis of Factors Affecting the Risk of HIV and HCV Infections in Subjects Registered at Shiraz Drop in Centers HIV Variables Sex Male Female Place of residence Indecent Decent Education Secondary school and lower High school and upper Shared injection Yes No Unprotected sex Yes No History of imprisonment Yes No Occupation Employed Unemployed
HCV
OR (95% CI)
P
OR (95% CI)
P
7.11 (3.27-15.45)
0.0001
1.40 (0.50-3.89)
0.510
1.06 (0.82-1.36)
0.631
1.10 (0.84-1.43)
0.471
1.43 (1.06-1.93)
0.019
1.19 (0.86-1.63)
0.283
47.79 (23.01-50.54)
0.0001
36.78 (20.20-66.99)
0.0001
30.03 (10.50-85.83)
0.0001
3.12 (2.01-4.85)
0.0001
2.49 (1.23-5.05)
0.011
1.43 (0.63-4.24)
0.385
1.10 (0.80-1.52)
0.530
1.21 (0.85-1.70)
0.278
CI, confidence interval; OR, odds ratio.
infections. All of these points deserve more attention and implementing additional harm-reduction strategies. The highest HIV prevalence was observed among IDUs. According to the World Drug report, drug abuse is much more common in men than in women (Fedotov, 2012). In the present study, 80% of those registered in the DICs were men; however, during the 6-year study period the female-to-male ratio increased, these centers increased. In the United States, the difference between the 2 genders is small. In contrast, in developing countries such as India and Indonesia, the femaleto-male ratio is less than one tenth. Women are less likely to report their drug abuse especially in developing countries (Fedotov, 2012). On the contrary, in our country, stigma and discrimination against women have been decreased over time by increased knowledge and changed attitudes toward substance users. Also, the female-to-male ratio has changed in recent years. In this study, the largest age group was 25 to 35 years (44.5%), which is consistent with the findings of the Rapid Drug Survey. The mean age of drug users based on the Rapid Drug Survey study was 32.60 years, about half of whom were younger than 29 years (Narenjiha et al., 2010). In the present study, the mean age of the males was 33.75 years and that of the females was 32.20 years, whereas 62.2% of all drug users were younger than 35 years. The findings of our study and other studies in Iran indicated that the majority of drug users are middle aged; therefore, the training programs for reduced demand and drug seeking as a part of harm-reduction strategies should be focused on them. In this study, the mean age at the first drug use was 20 years and the age at the onset of injection was 26 in men and 27 in women (Battjes et al., 1992; Stoicescu, 2012;). In 2 studies conducted in Iran, the age at the first drug use was C
reported to be 23 years and the first injection occurred 26 to 32 years (Mohamad et al., 2009; Narenjiha et al., 2010). But in developed countries such as the United States, the mean age at the first injection is about 19 years. Likewise, in some Latin American countries such as Puerto Rico, IDU is also found in younger children and adolescents (Battjes et al, 1992; Stoicescu, 2012). The current pattern and type of substance use have been changed in Iran. This means that they changed from single substance to multiple substance users and from opium to methamphetamine use. Therefore, it seems that in our country the first time of intravenous drug use shifted to young ages. So more attention was paid to monitor substances users. The 6 to 7 years’ interval that is referred to as the difference between the first drug use and the first drug injection is an opportune period for preventive interventions. In this study, 58% of the people using harmful substance use had less than high school education. Several studies in Iran have shown an inverse relationship between education and drug usage (Mohamad et al., 2009; Narenjiha et al., 2010). Therefore, future emphasis on education and its promotion, in addition to efforts to reduce school dropout, by screening the high-risk students and starting intervention such as social skills training and so on, can play effective roles in the prevention of substance use. Although the level of education is a critical risk factor and an area for intervention, we should consider some potential confounding factors related to educational level like socioeconomic status. In this study, more than two-thirds of the participants had a history of imprisonment in which the risks of HIV and HCV infections were 1.87 and 3.38 times higher than those for other users. Studies have revealed that between 30% and 60% of substance users engage in antisocial behaviors (Sadock and Sadock, 2008). Therefore, in Iran presentational and
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educational programs have recently been considered for the prisoners. According to the study, the most common substance used was heroin (71.4%), followed by crystal (7.5%) and opium (7.1%). This agrees with the results of a study conducted in Kermanshah, where 86% of the addicts consumed heroin and 5.5% opium (Mohamad et al., 2009). Given these figures, and the type of services offered by the DICs, heroin users comprised the majority of clients. According to the study done in Persepolis clinic, which is a DIC in Tehran exclusively for women, the most frequently used substance (87.2%) was heroin (Dolan et al., 2012). Injection is one of the most harmful ways of using drugs. Worldwide, there is an estimated 13 million IDUs, of whom 75% live in developing countries (Fedotov, 2012). Most previous studies have shown that the highest rate of HIV is among IDUs in North Africa and Middle East countries, including Syria, Egypt, Libya, Oman, Iran, and Bahrain (Stoicescu, 2012). Some provinces of Iran, including Tehran, Khuzestan, Fars, and Sistan-Baluchestan, have similar levels to Egypt, which has the highest HIV prevalence among injecting drug users. The prevalence of substance use in these provinces has increased from 0.6% in 2006 to 6.7% in 2010 (Stoicescu, 2012). In this study, half of the IDUs had reported a history of shared needles and the rate of HIV infection in this group was 30 times higher than that in those who did not share needles. The prevalence of hepatitis C in IDUs has been reported to be between 50% and 90%, whereas the annual incidence is 10% to 30% worldwide (Hagan and Jarlais, 2000). According to a regional estimation model based on diseases in developing countries, it is estimated that each year about 2.3 million to 4.7 million HCI infection cases and 80 thousand to 160 thousand cases of HIV infection result from unsafe injections (Gough et al., 2010). Studies conducted in Europe and the United States have revealed that the prevalence of HIV infection in IDUs depend on the method and frequency of drug use (Gough et al., 2010; Bruandet et al., 2006). In Iran, the main method of HIV transmission is injecting drug use (Falahi, 2004). In our study, the respective prevalence of HIV and HCV infections was 20.3% and 13.6% among all participants, 25.4% and 18.8% in IDUs, and 82.5% and 90% in IDUs who shared needles. The results of univariate and multiple logistic regressions analyses demonstrate that shared needles and unsafe sex practices were the most important risk factors for HIV and HCV transmission. In this study, two-thirds of the women who registered in DICs were sex workers. HIV infection in this group was 3.2 times greater than that in other women. In a study conducted by Dolan et al. (2012), 58% of women who registered in DICs were sex workers. In another study conducted in Bangladesh, 63.1% of female sex workers had a history of drug injection. These results make synchronous services between DICs and VCT centers of great importance (Azim et al., 2006). Because of sociocultural aspects, there is no reliable information about sexual relationships among men. We could find only 8 of our participants involved in such practice, and therefore, we did not enter them into our prediction model.
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This study is one of the first epidemiologic studies about DICs in Iran, which evaluated all people referred to these centers in Shiraz. All populations located in Shiraz, which is the capital of Fars Province in southern Iran, were evaluated. One of the issues that challenged the process of model development is missing data, which is a common problem in most medical records. We used complete case analysis. Although in the study on the same data at the VCT centers of Shiraz, the authors recommended the application of the imputation method for handling the missing data (Baneshi et al., 2012), but because of its complexity, it could not be performed. In this study, the variables and the data collected from the DICs were not sufficiently comprehensive. Therefore, we tried to complete the data by referring to the VCT. In future study, we will contact these participants and invite them to the DIC centers for giving complete information obtain their status.
CONCLUSIONS This study shows that implementation of preventive measures such as education and needle exchange program is of paramount importance for minimizing high-risk behavior in drug users, who should also undergo comprehensive training. Drop in Centers are important and necessary especially for management of serious infections such as HIV and other social misconducts such as crime. Harm-reduction programs should be focused on middle-age groups, especially men. Women and their high-risk sexual behavior need more interventions. Therefore, it is important to pay attention to development of DICs especially for women. In addition to the development of DICs, periodic epidemiologic studies on these centers are necessary to monitor and evaluate their interventions and services. Moreover, prisoners are part of community and need careful consideration because they are at high risk for HIV and HCV infections.
ACKNOWLEDGMENTS The authors thank the DICs and VCT members for their valuable cooperation. They also thank those who helped us with this study, especially the clients, and interviewers. REFERENCES Amundsen EJ, Eskild A, Stigum H, et al. Legal access to needles and syringes/needle exchange programmes versus HIV counseling and testing to prevent transmission of HIV among intravenous drug users: a comparative study of Denmark, Norway and Sweden. Eur J Public Health 2003;13:252– 258. Ardebili MA, Rayejian M. Norooz Project a joint document in control of drugs, between the Islamic Republic of Iran and the Office of the United Nations Drug Control (English translated). Available at: http://dchq.ir/html/index. php. Published 1999. Accessed August 2013. Avecina, Ghanoon (English translated). Sharafkandi Translate. Tehran, Iran: Soroush Publication; 1997. Azim T, Chowdhury EI, Reza M, et al. Vulnerability to HIV infection among sex worker and non-sex worker female injecting drug users in Dhaka, Bangladesh: evidence from the baseline survey of a cohort study. Harm Reduct J 2006;3:33. Baneshi MR, Faramarzi H, Marzban M. Prevention of disease complications through diagnostic models: how to tackle the problem of missing data? Iran J Public Health 2012;41(1):66–72. Battjes RJ, Leukefeld CG, Pickens RW. Age at first injection and HIV risk among intravenous drug users. Am J Drug Alcohol Abuse 1992;18:263– 273. C
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Bruandet A, Lucidarme D, Decoster A, et al. Incidence and risk factors of HCV infection in a cohort of intravenous drug users in the North and East of France (English translated). Rev Epidemiol Sante Publique 2006;54:1. Dolan K, Salimi S, Nassirimanesh B, et al. Six-month follow-up of Iranian women in methadone treatment: drug use, social functioning, crime, and HIV and HCV seroincidence. Subst Abuse 2012;3:37–43. Emmanuelli J. Harm reduction policy related to drug use: the needles exchange programs. Med Sci 2004;5:20. Falahi H. UNAIDS/UNICEF/WHO. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections–Islamic Republic of Iran. Ministry of Health Publication; 2004. Falahi H. National AIDS Committee Secretariat, Ministry of Health and Medical Education. Islamic Republic of Iran country report on Monitoring of the United Nations General Assembly Special Session on HIV and AIDS (English translated). Tehran, Iran: Ministry of Health Publication; 2010. Available at: http://www. unaids. rg/en/dataanalysis. Fedotov Y. World Drug Report 2012. UNODC United Nations Publication Sales No; 2012:E.12.XI. Gough E, Kempf MC, Graham L, et al. HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis. BMC Public Health 2010;10:777–787. Hakim ED. Resaleh Afyoniyeh (English translated). Tehran, Iran: Almae Publication; 2009. Hagan H, Jarlais DCD. HIV and HCV infection among injecting drug users. Mt Sinai J Med 2000;67:423–428. Hamid Gh. Cooperation with the International Narcotics Control Board (INCB) cooperation and interaction in implementing provisions of the three UN conventions (English translated). Available at: http://www.incb.org. Published 1998. Khalitash A, Majdzadeh SR, Ehterami M. Surveys of public participation policy regarding the use of harm reduction programs for drug (English translated). Hakim J 2009;12:64–54. Khosravi ANF, Rahbar MR, Motlagh ME, et al. Health Indicators in Iran. Tehran, Iran: Publication of Ministry of Health and Education in Iran; 2010;1:5–150. (in Persian). Kumpfer KL, Alvarado R, Whiteside HO. Family-based interventions for substance use and misuse prevention. Subst Use Misuse 2003;38:1759– 1787. Lin P, Fan Z, Yang F, et al. Evaluation of a pilot study on needle and syringe exchange program among injecting drug users in a community in Guangdong, China. Chin J Prev Med 2004;38:305. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet (Lond, Engl) 2008;372:1733–1745.
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Moayed AS. Report of Ministry of Health and Education Science (English translated). Available at: http://www.behdasht.gov.ir. Published 2011. Mohamad K, Majlesi F, Namdari H, et al. Depending on the cause of harm reduction for injection drug users under DIC Kermanshah province (English translated). J Public Health Med Sci 2009;1:11–22. Najar M. General policies regarding the system of Narcotics, the Supreme (English translated). Leader statement Web site. Available at: www.dchq. qir. Published 2009. Najar M. Report of Center for Drugebattl (English translated). Available at: http://www.dchq.ir/images/AMALKARD/amalkarddchq.pdf . Published 2011. Narenjiha H, Nouri R, Akbarian M, et al. The experience of life time non-fatal overdose of drugs in Iranian substance abusers (English translated). Iran J Psychiatry Clin Psychol 2010;15:327–333. Osmani ZA, Najjar MM, Zahir AM. Border Project Between the Islamic Republic of Iran, Pakistan and UNDCP triangular Initiative (English translated). Available at: http://www.undoc.org. Published 1998. Rafati M, Ghotbi M, Ahmadnia H. Principles of Care for Non Communicable Disease. Tehran, Iran: Publication of Ministry of Health and Education in Iran; 2008;1:177–186. Rahimimohavghar RM. 30 years trend in drug abuse situation in Iran (English translated). Hakim Res J 2002;5:171–181. Sadock BJ, Sadock VA. Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. Shakeri AH. Britain’s Historic Role in the Promotion of Drug (English translated). Tehran, Iran: Gotenberg; 2008. Slesnick N, Glassman M, Garren R, et al. How to open and sustain a drop-in center for homeless youth. Child Youth Serv Rev 2008;7:727–734. Stoicescu C. The Global State of Harm Reduction 2012 Towards an Integrated Response. London, United Kingdom: Harm Reduction International; 2012. Vazirian M, Nassirimanesh B, Zamani S, et al. Needle and syringe sharing practices of injecting drug users participating in an outreach HIV prevention program in Tehran, Iran: a cross-sectional study. Harm Reduct J 2005;2:19. Wood E, Spittal P, Li K, et al. Inability to access addiction treatment and risk of HIV infection among injection drug users. J Acquir Immune Defici Syndr 2004;36:750–754. Yuet W. Substance abuse and developments in harm reduction. Can Med Assoc J 2000;162:697–700. Zamani S. Integrated Bio-Behavioral Surveillance for HIV Infection Among Injecting Drug Users in Iran (English translated). Tehran, Iran: Ministry of Health and Medical Education Publication; 2008.
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Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users in Drop in Centers in Southern Iran Alireza Salehi, MD, MPH, PhD, Mojtaba Naghshvarian, MD, PhD, Maryam Marzban, MSc, PhD, and Kamran Bagheri Lankarani, MD
Objectives: Drop in Centers (DICs) are organizations in which health and social services are delivered to drug users on the basis of harmreduction strategies. The aim of this epidemiological study was to estimate the prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection at these centers over a 6-year period. Methods: All of the DICs (7 in total) visited were located in Shiraz, the capital city of Fars province, southern Iran. Every patient record in these centers was studied between April 2006 and April 2011. Complementary information on the frequency of HIV was collected from the Voluntary Counseling and Testing services. A logistic regression model was applied to data analysis. The study explored risk factors associated with HIV and HCV infections, which were primarily high-risk sexual behavior. Results: This study examined 1,327 people, 79.5% of whom were males. The mean age of first substance use and the first injection among intravenous drug users (IDUs) were 20.24 ± 6.11 and 26.5 ± 7.3 years, respectively. In total, 13.5% and 20.2% of the subjects who registered at the DICs were infected with HCV and HIV, respectively. Shared injection, history of imprisonment, maleness, unsafe sex, inadequate housing, and low education were risk factors for HIV infection. Shared injection, unsafe sex, history of imprisonment, and maleness were predisposing factors for HCV infection. A history of imprisonment and substance use upon registration at the DIC were significant risk factors for female sex workers. Conclusions: Our study emphasized the implementation of preventive measures like education and needle exchange program as harmreduction strategies. Drop in Centers are important for the management of health problems, including HIV infection and social problems such as crime. Periodic epidemiological studies on DICs are necessary to monitor and modulate the services delivered by these centers. From the Health Policy Research Center (AS, MM, KBL), Shiraz University of Medical Sciences, Shiraz, Iran; and Tehran University of Medical Sciences (MN), Tehran Iran. Received for publication September 1, 2013; accepted December 27, 2014. Funded by the Health Policy Research Center of the Shiraz University of Medical Sciences. The authors report no other conflicts of interest. Send correspondence and reprint requests to Alireza Salehi, MD, MPH, PhD, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Email: ([email protected] or salehiar @sums.ac.ir). C 2015 American Society of Addiction Medicine Copyright ISSN: 1932-0620/15/0903-0181 DOI: 10.1097/ADM.0000000000000112
Key Words: Drop in Center, drug user, HIV, HCV, Iran (J Addict Med 2015;9: 181–187)
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ubstance use, a phenomenon with a long history, is one of the most important economic and social challenges to human health. Annually, millions of dollars are spent worldwide to combat this problem (Hamid, 1998; Osmani et al., 1998; Ardebili and Rayejian, 1999; Najar, 2009). Estimates from the United Nations Office on Drug and Crime in 2011 show that approximately 153 million to 300 million people (3.5%-6.6% of the world’s population) are drug dependent. The report says that 22 million people in the United States are illicit drug users (Fedotov, 2012). The number of intravenous drug users (IDUs) in the Middle East and North Africa is estimated to be between 300,000 and 1,000,000, which is considerable in comparison with approximately 15.9 million users throughout the world (Mathers et al., 2008). Substance use in Iran has also a long history. In fact, traditional physicians such as Avicenna (980-1037 BC) documented its signs and symptoms and ways to cure it (Avecina, 1997; Hakim, 2009). Because of various reasons including the government’s disregard of the problem, the prevalence of drug abuse grew over the Safavid and Qajar dynasties (Shakeri, 2008). At present, the high prevalence of substance use involves a large number of youths in Iran and the geopolitical position of the country as a drug transition corridor for neighboring countries, such as Afghanistan and Pakistan, which are the 2 major manufacturers of these substances. According to Drug Control Headquarters (Tehran, Iran), 3400 military personnel have been killed in the fight against drugs since the Islamic Revolution in 1979 (Najar, 2011). According to the Ministry of Health and Medical Education report in October 2011, the number of regular drug abusers in the country was estimated to be 2 million to 2.2 million (Moayed, 2011). On the whole, previous studies have revealed that drug use trends in Iran increased between 1970 and 1990. The annual growth rate of substance use was approximately 8% between 1978 and 1988, which is 3 times that of the country’s population growth rate (Rahimimohavghar, 2002). According to the first national study on the burden of disease and risk factors, drug use is the fifth leading risk factor, after overweight and obesity, high blood pressure, physical inactivity, and hypercholesterolemie, attributable to the burden of disease. Moreover, substance use accounts for
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11.24% of the attributable burden of risk factors (Khosravi et al., 2010). Another report by the Iranian Ministry of Health and Medical Education showed that Fars Province ranked 10th in regard to the number of drug users, fourth in mortalities due to drug use in 2009 (Rafati et al., 2008). Drop in Centers (DICs) are organizations in which health and social services are delivered aim at harm-reduction programs. The purpose of the programs is to reduce negative social, economic, and health outcomes of substance use, even when the drug users fail to abstain (Slesnick et al., 2008). Preventive and proactive approaches to controlling substance use are a priority as these are more effective and more appropriate for the limited financial and human resources available to addicted people (Emmanuelli, 2004). To develop and maintain the DICs, health policy makers need to have a comprehensive understanding of the target groups. For example, an ideal DIC should be in a location easily accessible to all drug users and homeless people and delivered services around the clock (Zamani, 2008). Several studies conducted in Denmark, Norway, and Sudan have shown that counseling, harm-reduction programs, and voluntary tests were effective in preventing propensity to human immunodeficiency virus (HIV) (Amundsen et al., 2003). Harm-reduction programs started in Iran in 2002, the target groups including male and female IDUs and women whose sexual partners are IDUs. Most studies have shown that Iranian female drug users suffer more stigmas, and therefore they are often unwilling to seek treatment (Dolan et al., 2012). In many developing countries, one of the main methods of harm reduction is to implement needle and syringe programs (NSPs) (Vazirian et al., 2005), which is proved to be very effective in reducing the risk of HIV transmission. Harmreduction programs have been more successful than treatment program in reducing the risk of HIV transmission (Yuet, 2000; Wood, 2004). In northern Asia, most IDUs are unwilling to take part in drug cessation programs, so NSP is indicated in addition to other care strategies such as counseling (Kumpfer et al., 2003). In China, drug abusers who participated in needle exchange and counseling programs were found to have increased their knowledge of risky drug injecting behavior from 29% to 58% after ten months and reducing their risky behavior among IDUs in communities (Lin et al., 2004). There have been few epidemiologic studies on DICs in Iran. In a study in Kermanshah Province, western Iran in 2008, variables such as low education, indecent residence, unemployment, and shared injection in lower ages made IDUs not use harm-reduction programs (Mohamad et al., 2009). Another study investigated health policy makers’ views on harm-reduction programs and found that they, despite their initial objections, welcomed the programs (Khalitash et al., 2009). There are 7 DICs in Shiraz, the capital city of Fars Province, operating under the supervision of Shiraz University of Medical Sciences, of which 5 centers are devoted to men and 2 to women. The aim of this study was to estimate the prevalence of HIV and HCV infection in clients registered or referred to DICs for primary health and personal care, which is
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accompanied by factors influencing the risk of HIV and HCV infections and practicing as sex workers.
METHODS Setting and Participants The study setting included all DICs in Shiraz, which has a population of approximately 3 million. These DICs are governmental organizations, which were established according to geographical and population-based data, by experts in the field who had a good knowledge of the location. These centers provide primary health care, basic needs such as small quantities of food and toiletries for men and women, counseling, NSP, sexual health care, condom promotion, and access to Voluntary Counseling and Testing (VCT), which provides pretest and posttest counseling in addition to HIV and HCV test screening. All services are voluntary and provided free of charge. The DICs staff include a supervisor, a coordinator, a nurse, a part-time midwife, a social worker, a part-time psychologist, peer outreach groups, a chef, a barber, and several administrative staff, who are all involved with health promotion and infectious disease prevention measures. Methadone maintenance therapy clinics are located near the DICs and receptive to the referred clients. The researchers independent of the clinic approached the DICs to evaluate their activities for future planning. In this study, 7 DICs were visited, of which 2 are exclusively for women and 5 for men. The drug users’ records were examined in these centers between April 2006 and April 2011. To collect relevant information about their age, sex, level of education, imprisonment records, marital status, etc, complementary information on the frequency of HIV among this group of people was collected from the VCT centers of Shiraz University of Medical Sciences.
Data Processing and Analysis Out of 1931 records collected from the DICs and the VCT, 39 participants, including 22 from DIC and 17 from VCT, were eliminated because of duplication in each of the 2 data sources. Also, 12 participants were excluded because they resided outside Shiraz. We performed data linkage, using Microsoft Office Excel. The criteria for linkage were the sharing of 6 variables, including name, family name, father’s name, age, date of birth, and place of residence. Combination of the variables was used to define a unique ID for each participant in statistical analyses. In all, 553 participants registered in both centers were eliminated because of duplication after merging the 2 data sets. Finally, we were able to examine 1327 records of the study participants. In the first step, the association of different factors with HIV infection, history of being an IDU, and a female sex worker was analyzed using univariate logistic regression. Next, we entered significant variables (P > 0.20) into a multiple regression analysis by a backward conditional method for the people afflicted with HIV. Statistical analyses were performed using SPSS software (SPSS for Windows 16.0, SPSS, Chicago, Illinois). P value < 0.05 was considered as statistically significant. C
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RESULTS Demographic Characteristics The demographic characteristics of the participants are shown in Table 1. This study examined 1327 people, of whom 79.5% were males, 62.2% younger than 35 years, 33.3% married, and 16.7% divorced or separated. The prevalence of unemployment and inadequate housing (homelessness, shelters, and hangouts) was 56.6% and 30.3%, respectively. Twothirds of the subjects in the DICs had a history of imprisonment. Of the women attending these centers, 167 (62.3%) were sex workers. A history of unsafe sex in men and women was present in 15.0% and 14.5% subjects, respectively.
Types and Methods of Substance Use In total, 93.3% of the subjects had used drugs when they were registered in these DICs. The mean age of the first substance use was 20.24 ± 6.11 years with a minimum age of 7 years and a maximum age of 59 years. The mean age of the first injection among the IDUs was 26.5 ± 7.3 years, with a minimum of 11 years and a maximum of 66 years. The type of substance used included heroin 71.4%, methamphetamine (crystal) 7.5%, opium 7.1%, norgesic 5.6%, opium sap 1.2%, opium sap and opium 0.2%, and heroin combined with other types of substances 5.6%, and an unknown substance in 1.4% cases. Of the people registered in these centers, 810 were IDUs, of whom 534 were drug injectors and 276 used other methods in addition to injecting. There were 208 persons who smoked, 77 used other methods in addition to smoking, 44 used orally, 54 inhaled drugs, and 134 people did
Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users
not mention their method of drug use. Only 2.2% acquired their needles and syringes from pharmacies, 13% from DICs, whereas 54.4% obtained them from both DICs and pharmacies. A negligible percentage (0.02%) acquired needles and syringes from friends. The injection method used by the men was 14 times higher than that of women (odds ratio [OR] = 13.97; 95% CI: 10.06-19.39). Moreover, it was 2 times greater in those with a history of imprisonment (OR = 2.20; 95% CI: 1.70-2.85).
HIV and Hepatitis C Infection There were 179 subjects (13.5%) who had registered in the DICs as HCV positive, 167 were males (15.8% of all men), and 12 were females, which include 4.5% of all women. A total of 268 persons (20.2%) were infected with HIV, of whom 224 were males and 44 were females. In fact, about 1 in 5 of the men and 1 in 6 of the women covered by the services of the DICs were infected with HIV. The proportion of single subjects with HIV infection and HCV infection was 43% (n = 115) and 45%, (n = 80), respectively. All patients infected with HIV and/or HCV used heroin, which was utilized by 82% and 90% of those who used syringes and infected with HIV and HCV, respectively. Among people with unsafe sex practices, 117 (58.21%) and 85 cases (42.29%) were HIV and HCV positive, respectively. A quarter of the subjects with a history of imprisonment were infected with HIV. The evaluation of risk factors related to HIV and HCV and the history of high-risk sexual behavior in women are described in Tables 2 and 3.
TABLE 1. Demographic Characteristics of Subjects Registered at the Shiraz Drop in Centers Variables Sex Male Female Unknown Education Illiterate Primary school Secondary school High school University Unknown Place of residence Private house Rental house Homeless Fathers’ house Shelter Hangout Unknown History of imprisonment Yes No Unknown HCV infection Yes No Unknown C
Number (%) 1055 (79.5) 268 (20.2) 4 (0.3) 61 (4.6) 274 (20.6) 435 (32.8) 201 (15.1) 21 (1.6) 335 (25.3) 146 (11) 291 (21.9) 353 (26.6) 341 (25.7) 42 (3.2) 6 (0.5) 148 (11.1) 886 (66.8) 365 (27.5) 76 (5.7) 179 (13.5) 1142 (86.1) 6 (0.4)
Variables Marital Status Married Single Divorced Widow/widower Separated Unknown Occupation Jobless Worker Self-employed Employee Unknown Age group, y 0-25 26-35 36-45 46-55 >56 Unknown Being sex worker in women Yes No Unknown HIV infection Yes No Unknown
Number (%) 431 (32.5) 582 (43.9) 205 (15.4) 90 (6.8) 6 (0.4) 13 (1.0) 751 (56.6) 314 (23.6) 233 (17.5) 9 (0.8) 20 (1.5) 234 (17.7) 590 (44.5) 311 (23.4) 124 (9.3) 28 (2.1) 40 (3.0) 167 (62.3) 97 (36.2) 4 (1.5) 268 (20.2) 1051 (79.2) 8 (0.6)
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TABLE 2. Univariate Analysis of the Factors Associated With the Risk of HIV and HCV Infections in Subjects Registered at Shiraz Drop in Centers HIV Variables
Frequency
Sex Male Female Place of residenceb Indecent Decent Education Secondary school and lower High school and upper Shared injection Yes No Unsafe sex Yes No History of imprisonment Yes No Occupation Employed Unemployed
(%)a
HCV
OR (95% CI)
P
Frequency (%)
OR (95% CI)
P
224 (83.3) 41 (15.2)
1.49 (1.03-2.41)
0.031
167 (92.8) 11(6.1)
4.39 (2.35-8.21)
0.0001
161 (59) 32 (11)
3.01 (2.02-4.92)
0.0001
115 (63) 22 (12)
1.25 (0.92-1.72)
0.152
201 (74) 39 (14)
1.52 (1.31-1.77)
0.0001
144 (80) 22 (15)
1.16 (0.98-1.37)
0.073
222 (82.5) 38 (14.1)
34.11 (23.01-50.54)
0.0001
162 (90) 13 (7.2)
50.72 (28.18-91.28)
0.0001
117 (43.5) 152 (56.5)
8.92 (6.42-12.39)
0.0001
85 (47.2) 95 (52.8)
7.95 (5.60-11.28)
0.0001
214 (79.6) 53 (19.7)
1.87 (1.34-2.61)
0.0001
158 (87.8) 22 (12.2)
3.38 (2.12-5.38)
0.0001
127 (47) 142 (52.8)
1.21 (0.92-1.58)
0.159
87 (48) 93 (51.7)
1.29 (0.91-1.72)
0.152
a
Because of missing information, the sum of percentages did not add up to 100%. Private house, fathers’ house, and rental house as “decent” and homeless, shelter, and hangout as “indecent.” CI, confidence interval; OR, odds ratio. b
Shared injection, history of imprisonment, maleness, unsafe sex, inadequate housing, and low education of people infected with HIV in a univariate logistic regression is shown in Table 2. Also, the result of multiple regression analysis is depicted in Table 4. Education level (OR = 1.43; 95% CI: 1.06-1.93), shared needles (OR = 47.79; 95% CI: 24.32-93.89), unsafe sex (OR = 30.03; 95% CI: 10.50-85.83), history of imprisonment (OR = 2.49; 95% CI: 1.23-5.05), and sex (OR = 7.11, 95% CI: 3.27-15.45) were significant in a multiple regression model. Of the 4 significant variables in the multiple regression, only shared needles (OR = 36.78; 95% CI: 20.20-66.99) and unsafe sex (OR = 3.12; 95% CI: 2.01-4.85) remained significant predisposing factors to HCV infection.
As shown by univariate analysis, a history of imprisonment and substance use at the time of registration in the DIC were factors associated with being sex workers in women but were not significant variables in multiple regression model (Table 3).
DISCUSSION This study showed the female-to-male ratio being smaller than the mean world ratio. The first time injection was later in life compared to other countries. At that time, heroin users comprised the majority of clients, whose most common method was injection. Low education and lack of knowledge about safe injection, unsafe sex, and history of imprisonment in the majority of users are the risk factors for HIV and HCV
TABLE 3. Univariate Analysis of Factors Affecting Female Sex Workers Registered at Shiraz Drop in Center Variables Marital status Single Married Occupation Unemployed Employed Education Secondary school and lower High school and upper Drug abuse (at the time of registration) Yes No History of imprisonment Yes No
Frequency (%)a
OR (95% CI)
P
96 (57) 68 (40)
1.47 (0.52-4.14)
0.461
15 (9) 152 (91)
1.63 (0.75-3.35)
0.216
72 (43) 17 (10)
1.18 (0.56-2.46)
0.650
126 (75.4) 17 (10.2)
2.42 (1.17-5.02)
0.016
81 (48.5) 50 (29.9)
1.49 (1.04-2.13)
0.028
a
Because of missing information, the sum of percentages did not add up to 100%. CI, confidence interval; OR, odds ratio.
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Prevalence of HIV, HCV, and High-Risk Behaviors for Substance Users
TABLE 4. Multiple Regression Analysis of Factors Affecting the Risk of HIV and HCV Infections in Subjects Registered at Shiraz Drop in Centers HIV Variables Sex Male Female Place of residence Indecent Decent Education Secondary school and lower High school and upper Shared injection Yes No Unprotected sex Yes No History of imprisonment Yes No Occupation Employed Unemployed
HCV
OR (95% CI)
P
OR (95% CI)
P
7.11 (3.27-15.45)
0.0001
1.40 (0.50-3.89)
0.510
1.06 (0.82-1.36)
0.631
1.10 (0.84-1.43)
0.471
1.43 (1.06-1.93)
0.019
1.19 (0.86-1.63)
0.283
47.79 (23.01-50.54)
0.0001
36.78 (20.20-66.99)
0.0001
30.03 (10.50-85.83)
0.0001
3.12 (2.01-4.85)
0.0001
2.49 (1.23-5.05)
0.011
1.43 (0.63-4.24)
0.385
1.10 (0.80-1.52)
0.530
1.21 (0.85-1.70)
0.278
CI, confidence interval; OR, odds ratio.
infections. All of these points deserve more attention and implementing additional harm-reduction strategies. The highest HIV prevalence was observed among IDUs. According to the World Drug report, drug abuse is much more common in men than in women (Fedotov, 2012). In the present study, 80% of those registered in the DICs were men; however, during the 6-year study period the female-to-male ratio increased, these centers increased. In the United States, the difference between the 2 genders is small. In contrast, in developing countries such as India and Indonesia, the femaleto-male ratio is less than one tenth. Women are less likely to report their drug abuse especially in developing countries (Fedotov, 2012). On the contrary, in our country, stigma and discrimination against women have been decreased over time by increased knowledge and changed attitudes toward substance users. Also, the female-to-male ratio has changed in recent years. In this study, the largest age group was 25 to 35 years (44.5%), which is consistent with the findings of the Rapid Drug Survey. The mean age of drug users based on the Rapid Drug Survey study was 32.60 years, about half of whom were younger than 29 years (Narenjiha et al., 2010). In the present study, the mean age of the males was 33.75 years and that of the females was 32.20 years, whereas 62.2% of all drug users were younger than 35 years. The findings of our study and other studies in Iran indicated that the majority of drug users are middle aged; therefore, the training programs for reduced demand and drug seeking as a part of harm-reduction strategies should be focused on them. In this study, the mean age at the first drug use was 20 years and the age at the onset of injection was 26 in men and 27 in women (Battjes et al., 1992; Stoicescu, 2012;). In 2 studies conducted in Iran, the age at the first drug use was C
reported to be 23 years and the first injection occurred 26 to 32 years (Mohamad et al., 2009; Narenjiha et al., 2010). But in developed countries such as the United States, the mean age at the first injection is about 19 years. Likewise, in some Latin American countries such as Puerto Rico, IDU is also found in younger children and adolescents (Battjes et al, 1992; Stoicescu, 2012). The current pattern and type of substance use have been changed in Iran. This means that they changed from single substance to multiple substance users and from opium to methamphetamine use. Therefore, it seems that in our country the first time of intravenous drug use shifted to young ages. So more attention was paid to monitor substances users. The 6 to 7 years’ interval that is referred to as the difference between the first drug use and the first drug injection is an opportune period for preventive interventions. In this study, 58% of the people using harmful substance use had less than high school education. Several studies in Iran have shown an inverse relationship between education and drug usage (Mohamad et al., 2009; Narenjiha et al., 2010). Therefore, future emphasis on education and its promotion, in addition to efforts to reduce school dropout, by screening the high-risk students and starting intervention such as social skills training and so on, can play effective roles in the prevention of substance use. Although the level of education is a critical risk factor and an area for intervention, we should consider some potential confounding factors related to educational level like socioeconomic status. In this study, more than two-thirds of the participants had a history of imprisonment in which the risks of HIV and HCV infections were 1.87 and 3.38 times higher than those for other users. Studies have revealed that between 30% and 60% of substance users engage in antisocial behaviors (Sadock and Sadock, 2008). Therefore, in Iran presentational and
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educational programs have recently been considered for the prisoners. According to the study, the most common substance used was heroin (71.4%), followed by crystal (7.5%) and opium (7.1%). This agrees with the results of a study conducted in Kermanshah, where 86% of the addicts consumed heroin and 5.5% opium (Mohamad et al., 2009). Given these figures, and the type of services offered by the DICs, heroin users comprised the majority of clients. According to the study done in Persepolis clinic, which is a DIC in Tehran exclusively for women, the most frequently used substance (87.2%) was heroin (Dolan et al., 2012). Injection is one of the most harmful ways of using drugs. Worldwide, there is an estimated 13 million IDUs, of whom 75% live in developing countries (Fedotov, 2012). Most previous studies have shown that the highest rate of HIV is among IDUs in North Africa and Middle East countries, including Syria, Egypt, Libya, Oman, Iran, and Bahrain (Stoicescu, 2012). Some provinces of Iran, including Tehran, Khuzestan, Fars, and Sistan-Baluchestan, have similar levels to Egypt, which has the highest HIV prevalence among injecting drug users. The prevalence of substance use in these provinces has increased from 0.6% in 2006 to 6.7% in 2010 (Stoicescu, 2012). In this study, half of the IDUs had reported a history of shared needles and the rate of HIV infection in this group was 30 times higher than that in those who did not share needles. The prevalence of hepatitis C in IDUs has been reported to be between 50% and 90%, whereas the annual incidence is 10% to 30% worldwide (Hagan and Jarlais, 2000). According to a regional estimation model based on diseases in developing countries, it is estimated that each year about 2.3 million to 4.7 million HCI infection cases and 80 thousand to 160 thousand cases of HIV infection result from unsafe injections (Gough et al., 2010). Studies conducted in Europe and the United States have revealed that the prevalence of HIV infection in IDUs depend on the method and frequency of drug use (Gough et al., 2010; Bruandet et al., 2006). In Iran, the main method of HIV transmission is injecting drug use (Falahi, 2004). In our study, the respective prevalence of HIV and HCV infections was 20.3% and 13.6% among all participants, 25.4% and 18.8% in IDUs, and 82.5% and 90% in IDUs who shared needles. The results of univariate and multiple logistic regressions analyses demonstrate that shared needles and unsafe sex practices were the most important risk factors for HIV and HCV transmission. In this study, two-thirds of the women who registered in DICs were sex workers. HIV infection in this group was 3.2 times greater than that in other women. In a study conducted by Dolan et al. (2012), 58% of women who registered in DICs were sex workers. In another study conducted in Bangladesh, 63.1% of female sex workers had a history of drug injection. These results make synchronous services between DICs and VCT centers of great importance (Azim et al., 2006). Because of sociocultural aspects, there is no reliable information about sexual relationships among men. We could find only 8 of our participants involved in such practice, and therefore, we did not enter them into our prediction model.
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This study is one of the first epidemiologic studies about DICs in Iran, which evaluated all people referred to these centers in Shiraz. All populations located in Shiraz, which is the capital of Fars Province in southern Iran, were evaluated. One of the issues that challenged the process of model development is missing data, which is a common problem in most medical records. We used complete case analysis. Although in the study on the same data at the VCT centers of Shiraz, the authors recommended the application of the imputation method for handling the missing data (Baneshi et al., 2012), but because of its complexity, it could not be performed. In this study, the variables and the data collected from the DICs were not sufficiently comprehensive. Therefore, we tried to complete the data by referring to the VCT. In future study, we will contact these participants and invite them to the DIC centers for giving complete information obtain their status.
CONCLUSIONS This study shows that implementation of preventive measures such as education and needle exchange program is of paramount importance for minimizing high-risk behavior in drug users, who should also undergo comprehensive training. Drop in Centers are important and necessary especially for management of serious infections such as HIV and other social misconducts such as crime. Harm-reduction programs should be focused on middle-age groups, especially men. Women and their high-risk sexual behavior need more interventions. Therefore, it is important to pay attention to development of DICs especially for women. In addition to the development of DICs, periodic epidemiologic studies on these centers are necessary to monitor and evaluate their interventions and services. Moreover, prisoners are part of community and need careful consideration because they are at high risk for HIV and HCV infections.
ACKNOWLEDGMENTS The authors thank the DICs and VCT members for their valuable cooperation. They also thank those who helped us with this study, especially the clients, and interviewers. REFERENCES Amundsen EJ, Eskild A, Stigum H, et al. Legal access to needles and syringes/needle exchange programmes versus HIV counseling and testing to prevent transmission of HIV among intravenous drug users: a comparative study of Denmark, Norway and Sweden. Eur J Public Health 2003;13:252– 258. Ardebili MA, Rayejian M. Norooz Project a joint document in control of drugs, between the Islamic Republic of Iran and the Office of the United Nations Drug Control (English translated). Available at: http://dchq.ir/html/index. php. Published 1999. Accessed August 2013. Avecina, Ghanoon (English translated). Sharafkandi Translate. Tehran, Iran: Soroush Publication; 1997. Azim T, Chowdhury EI, Reza M, et al. Vulnerability to HIV infection among sex worker and non-sex worker female injecting drug users in Dhaka, Bangladesh: evidence from the baseline survey of a cohort study. Harm Reduct J 2006;3:33. Baneshi MR, Faramarzi H, Marzban M. Prevention of disease complications through diagnostic models: how to tackle the problem of missing data? Iran J Public Health 2012;41(1):66–72. Battjes RJ, Leukefeld CG, Pickens RW. Age at first injection and HIV risk among intravenous drug users. Am J Drug Alcohol Abuse 1992;18:263– 273. C
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