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Dual HIV risk and vulnerabilities among people who inject drugs in Iran: Findings from a nationwide study in 2020

Harm Reduction Journal volume 21, Article number: 187 (2024) Cite this article

Abstract

Introduction

People who inject drugs (PWID) are a key population at risk of HIV in Iran. We measured the prevalence and covariates of HIV-related risk behaviours among PWID in Iran.

Methods

We conducted a respondent-driven bio-behavioural surveillance survey among PWID from July 2019 to March 2020 in 11 major cities. We assessed PWID’s recent (i.e., last three months) HIV-related risk behaviours using a four-level categorical variable: Only unsafe injection (i.e., sharing needles/syringes or injecting equipment), only unsafe sex (i.e., unprotected sex), dual HIV risk (i.e., both unsafe injection and unprotected sex), and safe injection and sex. Data were summarized using RDS-weighted analysis. Multinomial logistic regression models were built to characterize HIV-related risk behaviours and relative risk ratio (RRR) with 95% confidence interval (CI) were reported.

Results

Overall, 2562 men who inject drugs (MWID) were included in the regression analysis. The RDS-weighted prevalence of dual HIV risk was 1.3% (95% CI: 0.8, 1.9), only unsafe injection was 4.5%, and only unsafe sex was 11.8%. Compared to the safe injection and sex group, dual HIV risk was significantly and positively associated with multiple partnership (RRR = 15.06; 3.30, 68.73). Only unsafe injection was significantly associated with homelessness in the last 12 months (RRR: 3.02; 95% CI: 1.34, 6.80). Only unsafe sex was significantly associated with multiple partnership (RRR = 6.66; 4.27, 10.38), receiving free condoms (RRR = 1.71; 1.01, 2.89), receiving free needles (RRR = 2.18; 1.22, 3.90), and self-received risk for HIV (RRR = 2.51; 1.36, 4.66). Moreover, history of HIV-testing in the last three months was significantly associated with only unsafe injection (RRR = 2.71; 1.84, 3.80). Among the 90 women who injected drugs, none reported dual HIV risk behaviours.

Discussion and conclusions

While the low prevalence of dual HIV risk among PWID is encouraging, unprotected sexual practices among PWID is concerning. Expanding sexual health education and care services as well as tailored interventions aimed at reducing high-risk sexual activities among PWID are warranted. Additionally, tackling potential misperceptions about risk of HIV transmission among PWID in Iran is warranted.

Introduction

In 2022, an estimated 14.8 million people aged 15–64 injected drugs globally, with a pooled HIV prevalence of 15.2% [1]. HIV risk is 3.5 and 2.1 times higher for people who inject cocaine and opiates, respectively, compared to those who do not inject drugs [2]. The Eastern Mediterranean Region (EMR) faces a constant increase in new HIV infections, compounded by limited quality and quantity of HIV data [3, 4]. Estimates indicate that the prevalence of advanced HIV disease diagnoses in the EMR rose from 27.3% in 2017 to 37.0% in 2019 [5]. Iran mirrors this trend, with a projected HIV incidence increasing by 174% by 2030 [6]. In 2020, HIV prevalence among people who inject drugs (PWID) in Iran was 3.5% [7], with an estimated 242,651 active PWID [8].

HIV epidemics primarily expand among PWID networks through unsafe injection practices [9], behaviours frequently reported in Iran. For example, in 2010, the prevalence of recent non-sterile needle use and shared injection among Iranian PWID was 36.9% and 12.6%, respectively, with significantly higher frequencies among those engaging in polysubstance use [10,11,12]. PWID also face HIV risk through unsafe sexual practices, accounting for over 10% of HIV acquisition in this population [13]. A considerable proportion of PWID engage in dual HIV risk behaviours (i.e., both unsafe injection and unprotected sex), elevating their risk of HIV acquisition and transmission [14]. In 2013, 24.6% of Iranian PWID reported recent engagement in dual HIV risk behaviours [14].

Despite Iran’s expansion of harm reduction programs and services, and the decreasing HIV prevalence among PWID in the past decade [7], safe injection and sexual practices remain suboptimal. Nation-wide estimates from 2010 to 2013 indicate that only 32.3% and 27% of PWID practiced safe sex and injection in the previous year, respectively [14]. Given the importance of monitoring HIV-related behaviours among PWID for informing Iran’s HIV prevention policies and interventions, an up-to-date assessment of these practices is essential. This study aims to estimate the prevalence of HIV-related behaviours and their covariates among a nation-wide sample of PWID in Iran. Additionally, we will examine the association between recent HIV testing and different risk profiles of PWID as a secondary objective.

Methods

Study design

Data were obtained from a nation-wide bio-behavioural surveillance survey (BBSS) from July 2019 to March 2020, the details of which are previously described [15]. In brief, we recruited a respondent-driven sample (RDS) of 2,684 PWID in 11 major cities representing different geographical regions of Iran. Participants were eligible if they were at least 18 years old, self-reported injection drug use at least once during the past 12 months, were residents of the city of the study site, provided verbal consent, and had a valid RDS referral coupon. Given the limited number of women recruited in the study (n = 90), only men who inject drugs (MWID) were included in the analytical dataset (n = 2562). Characteristics of women who inject drugs included in the survey are presented in Supplement A.

Recruitment process

The recruitment process was initiated by seed selection who were respected PWID within their community with large social networks. Each seed received three RDS referral coupons, valid for three weeks and were trained by the study team to refer peers to the study. The referred PWID received three referral RDS coupons and the process was repeated until the required sample size was recruited (Fig. 1). In each city, the recruitment process was initiated by selecting 3–5 seeds at the first step. Additional seeds were recruited in cases where referral chains were interrupted, or if the coupons had expired. Every participant received 2 USD as an incentive for completing the survey and HIV and Hepatitis C (HCV) tests. They also received about 1 USD for each successful referred individual.

Fig. 1
figure 1

Overview of the study recruitment process

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Data collection instrument

A standard questionnaire was used to collect PWID’s characteristics and behaviours. The questionnaire collected information on socio-demographic characteristics, drug use and injection history, sexual behaviours history, HIV testing, HIV knowledge, and harm reduction service utilization. After the interview, participants completed a rapid HCV and a rapid HIV test (SD-Bioline, South Korea) followed by a confirmatory test (Unigold HIV test), if the initial HIV test result was reactive. PWID who tested positive in both tests were referred to voluntary counseling and testing centres to be linked to care and treatment.

Outcome variables

We assessed participants’ recent (i.e., during the last three months) HIV-related risk behaviours using a four-level categorical outcome variable: only unsafe injection (i.e., sharing needles/syringes or injecting equipment); only unsafe sex (i.e., unprotected sex with any paying or casual partner); dual HIV risk (i.e., both unsafe injection and sex); and safe injection and sex (i.e., neither unsafe injection nor unsafe sex). Since reusing self-used needles/syringes or injecting equipment does not contribute to increased HIV acquisition risks, this behaviour was not considered a high-risk behaviour for HIV in the analysis. History of recent HIV testing (i.e., in the last three months) was defined as the secondary outcome of interest.

Covariates

The selection of covariates was informed by Rhodes’ risk environment framework [16, 17]. The covariates were categorized into four different clusters, including individual, behavioural, environmental, and HIV-related factors. The individual factors included age (< 30 or ≥ 30), education (less than high school, high school or above), and marital status (married [i.e., married, temporarily married, living with a partner] or unmarried [i.e., divorced, separated, widowed, single]). The behavioural factors included daily injection (i.e., injecting any drugs, at least once per day) in the last three months (yes or no), multiple partnership (i.e., having more than one sexual partner) in the last 12 months (yes or no), public injection in the last three months (yes or no), and primary drug injected in the last three months (opioids or stimulants). The environmental factors included incarceration in the last 12 months (yes or no), homelessness in the last 12 months (yes or no), receipt of free condoms in the last three months (yes or no), and receipt of free needles/syringes in the last three months (yes or no). The HIV-related factors included self-reported HIV status (positive or negative) and self-perceived risk for HIV (no/low risk or moderate/high risk).

Statistical analysis

RDS-weighted descriptive statistics across various covariates stratified by different outcome levels were reported using RDS analyst version 1.8-6. Covariates with P-value < 0.15 in the bivariable analysis were imported to the multinomial logistic regression model [18]. As using weighted regression model could result in inflated type-I error, poor parameter coverage, and biased estimates, the unweighted analysis was used to conduct the primary regression analysis [19]. Multinomial logistic regression models were developed in four steps. First, we built multinomial models for the individual covariates. Second, we included the behavioural covariates and the significant covariates from the first model. Third, we included the environmental covariates and the significant covariates from the second model. Lastly, HIV-related covariates and the significant covariates from the previous model were included in the final model which also included a random-effects variable to account for city-level heterogeneities in the dataset. Relative risk ratio (RRR) with 95% CI were measured and reported, and P-values < 0.05 were considered as statistically significant. In order to assess the association between recent HIV testing and HIV-related high-risk behaviours, a logistic regression model was used and adjusted odds ratios (AOR) for age, sex, daily injection, and multiple sexual partnerships with 95% CI were reported. Stata (version 14.2) was used for all statistical analyses.

Ethical considerations

Verbal informed consent was obtained from all participants before the interview. Data collection was anonymous, and the interviews were conducted in a private room within the facilities. Refusing to participate in the study did not impact PWID’s access to healthcare services. The ethical committee of Kerman University of Medical Sciences reviewed and approved the study (Ethics Code: IR.KMU.1397.573).

Results

Descriptive statistics

Overall, 2,562 MWID who answered the injecting and sexual behaviour questions were included in the analytical sample. MWID had a mean (SD) age of 41.1 (9.3) years old and most (67.3%) did not have any high school or above educational levels (Table 1). Among MWID, the prevalence of only unsafe injection was 4.5% (95% CI: 3.1, 5.9), only unsafe sex was 11.8% (95% CI: 9.7, 13.9), dual HIV risk was 1.3% (95% CI: 0.8, 1.9), and safe injection and sex was 82.4% (95% CI: 79.8, 84.9). Among the 90 women who injected drugs, none reported dual HIV risk behaviours (See Supplement A). Moreover, the RDS-weighted prevalence of dual HIV risk in east (8.3%) and north (7.9%) was higher than other regions of the country (See Supplement B). Among the MWID living with HIV, no one reported dual HIV risk; 21.5% (95% CI: 13.6, 31.2) had only unsafe injection and 1.1% (95% CI: 0.0, 5.8) had only unsafe sex (Fig. 2). Among HIV-negative MWID, the prevalence of dual HIV risk was 1.3% (95% CI: 0.8, 1.9), only unsafe injection was 7.5% (95% CI: 6.4, 8.5), and only unsafe sex was 13.0% (95% CI: 11.7, 14.4).

Fig. 2
figure 2

Prevalence of HIV-related high-risk behaviours among men who inject drugs based on the confirmed results of serologic HIV test

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Table 1 Characteristics of the men who inject drugs based on their HIV-related high-risk behaviours: dual HIV risk, only unsafe injection, only unsafe sex, and safe injection and sex (N = 2562)
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Factors associated with HIV-related high-risk behaviours

As shown in Table 2, compared to those with safe injection and sex in the previous three months, dual HIV risk was significantly and positively associated with multiple partnership in the last 12 months (RRR: 15.06; 95% CI: 3.30, 68.73). While, none of the individual and behavioural factors were significantly associated with only unsafe injection, homelessness in the last 12 months (RRR: 3.02; 95% CI: 1.34, 6.80) was significantly and positively associated with the risk of only unsafe injection. Additionally, multiple partnership (RRR: 6.66; 95% CI: 4.27, 10.38), moderate/high self-perceived HIV risk (RRR: 2.51; 95% CI: 1.36, 4.66), receiving free condoms (RRR: 1.71; 95%CI: 1.01, 2.89), and receiving free needles in the last three months (RRR: 2.18; 95% CI: 1.22, 3.90) were significantly and positively associated with only unsafe sex.

Table 2 Factors associated with HIV-related high-risk behaviours among men who inject drugs which included in the study, 2020 (N = 2562)
Full size table

The association between HIV-related high-risk behaviours and recent HIV testing

Compared to the PWID with safe injection and safe sex, those who reported only unsafe injection within the last three months were more likely to have tested for HIV (AOR: 2.71; 95% CI: 1.84, 3.80). However, no significant association was found among PWID who had dual HIV risk (AOR: 1.20; 95% CI: 0.51, 2.82) and those who had only unsafe sex (AOR: 1.01; 95% CI: 0.69, 1.48).

Discussion

Our nationwide study on an RDS study of MWID in Iran characterized their injection and sexual behaviours. We found that about two-thirds had practiced safe injection and sex in the previous three months. However, multiple partnership and structural adversities (e.g., homelessness) were associated with increased risk of recent HIV-related behaviours. Among a small sample of women who were included in our study, none had dual HIV risk and 80% reported safe injection and sex practices. Safe injection and sex practices were high among MWID regardless of their HIV sero-status. Moreover, the PWID who had only unsafe injection were more likely to get tested for HIV. However, there was no significant association between recent HIV testing and dual HIV risk and only unsafe sex.

While estimates of dual HIV risks among PWID are scarce, the prevalence of dual HIV risk among PWID in our study was significantly lower than previous figures in Iran (26.5% in 2010 and 26.4% in 2013) [14] and in other countries (e.g., 26.2% in the USA in 2009 [20] and 16.8% in Georgia in 2009 [21]). Moreover, less than one in ten MWID had only unsafe injection during the last three months, compared to 23.3% in 2010 and 24.6% in 2013 in previous surveys in Iran [14]. Unsafe injection practices were also significantly lower than other low- and middle-income countries, such as 47.7% in the past six months in India [22], 39.2% in the last injection in Pakistan [23], and 55.6% in the last month in Turkey [24]. While causal analyses on the factors attributed to such declines are lacking in Iran, the drop in high risk sexual and injection practices among MWID could be partly associated with Iran’s expansion of harm reduction services and opioid agonist therapy in the past decade [25, 26].

Our estimates revealed that practicing only unsafe sex was the most common HIV-related high-risk behaviour among MWID. However, it is encouraging that the prevalence of only unsafe sex among MWID has relatively decreased compared to the previous estimations in Iran (18.0% in 2010 and 22.0% in 2013) [14] and is lower than other low- and middle-income countries, such as Ghana (88% in the last month) [27], Vietnam (58% with casual partners during the last six months) [28], Mozambique (52.4% in the last year) [29], and Nigeria (31.6% in the last month) [30]. While the observed differences could point to the increasing availability of condom use and elevated sexual health-related knowledge among PWID in the past few years, it could also be partly explained by how unsafe sex is defined across different studies. Indeed, we defined unsafe sex as unprotected sex with any paying or casual partner, as using condoms in marital relationships could be complicated by a range of factors, such as pregnancy intentions and gender expectations [31, 32]. However, previous surveys in Iran [14] and elsewhere [27, 29, 30] have defined unsafe sex as any unprotected sex with non-paying or paying partners which would increase their prevalence estimates.

Multiple sexual partnerships significantly increased the risk of dual HIV risk and only unsafe sex among MWID. This is of particular importance given that previous estimates suggest that HIV prevalence among injecting and non-injecting female partners of MWID in Iran could be as high as 7.7% [33]. In addition, MWID with multiple sexual partners are significantly likely to engage in sexual relationships with female sex workers [34, 35]. For example, in Vietnam more than one in three of the 340 MWID in a survey conducted in 2011 had sexual contact with female sex workers during the last year [36]. Such sexual relationships that increase the potential for bridging HIV to the general population and HIV-negative marginalized populations [35, 37] are concerning and need to be highlighted and re-emphasized in harm reduction services and HIV educational campaigns in Iran. Moreover, it is important to ensure that condom promotion interventions continue to be supported and Iran’s recent shift in population control policies [38] and restrictions imposed on accessing readily available contraception services [39] do not create barriers to accessing condoms among marginalized populations, including PWID. Notably, the fact that around half of the sexually active MWID reported receipt of free condoms, underscores their unmet needs and the need for expanding the coverage of the condom distribution programs through novel interventions at the individual, organizational, and environmental levels, such as establishing mail-based platforms, condom distribution machines, as well as complementing condom distribution programs with other community-level risk reduction services and efforts [40,41,42].

Our findings suggest that PWID who engaged in only unsafe injections were more likely to get tested for HIV; however, there were no association between recent testing and high-risk sexual behaviours, including dual HIV risk and only unsafe sex. While this requires further investigations, it could be partly attributed to the fact that the importance of sexual transmission of HIV is substantially overshadowed by a focus on shared injection practices among PWID [43]. Despite the well-established importance of sexual transmission of HIV, harm reduction programs primarily emphasize injection-related behaviours among PWID [44]. This could result in a misperception about HIV risk among PWID, implying that they are at risk of HIV solely due to injection practices, while high-risk sexual behaviours are neglected. These findings highlight the need for balanced harm reduction strategies addressing both injection and sexual risks among PWID in Iran. Clear, accurate harm reduction messaging that emphasizes the dual nature of HIV transmission risks is crucial to improving HIV testing uptake among them.

Women constituted a minority of our study sample, a finding that should be interpreted cautiously. This underrepresentation likely reflects both the lower prevalence of injection drug use among women in Iran and the hidden nature of this population due to socio-structural stigma. In Iran, an estimated 3% of PWID are women [45, 46], which is significantly lower than global estimates of 19% (i.e., 2.8 million out of 14.8 million) [1]. This disparity could be attributed to less common substance use among Iranian women (i.e., about one-fifth that of men) and extreme socio-economic marginalization of women who inject drugs. The conservative socio-cultural context of Iran perpetuates stigmatizing attitudes towards women who use drugs, resulting in their decreased connection to substance use services compared to men [47,48,49,50,51]. These women face severe consequences, including potential loss of child custody, due to gender-specific expectations and cultural norms [50, 52, 53]. Despite their smaller numbers, women who inject drugs represent a highly marginalized population with significant health-related needs [54]. While establishing women-specific centres has shown promise in enhancing service access [55], further research is crucial to investigate the unique health needs of this marginalized group.

Limitations

We acknowledge our study’s limitations. First, due to the cross-sectional nature of this study, we are unable to make causal associations between the HIV-related high-risk behaviours and assessed covariates. Second, data of the bahavioural variables in this study were collected through face-to-face interviews which could result in social desirability and recall biases. In order to minimize these problems, we measured recent behaviours among the participants. Third, in spite of efforts to recruit different subgroups of the PWID population in Iran, this RDS sample does not represent all of them. However, the study team minimized the number of seeds in each city to reach longer referral chains and reduce this limitation as much as possible. Lastly, the prevalence of dual risk was low and the results regarding this behaviour should be interpreted with caution given the limited statistical power.

Conclusions

This study illustrated that majority of the PWID in Iran engaged in safe injection and sex. However, more than one in ten engaged in sexual risk behaviours with their non-paying partners. While our findings are encouraging and highlight an overall decline in HIV-related risk behaviours among PWID in Iran compared to the past few years, there remains a gap in PWID’s access to free condoms. The unmet sexual need of certain subgroups of PWID calls for scaling up targeted and novel individual- and community-level sexual health promotion interventions, as well as condom promotion educational campaigns tailored towards PWID.

Data availability

The data supporting the findings of this study can be obtained by contacting the corresponding author, and upon the approval of Iran’s Ministry of Health. These data are not publicly accessible as they include information that may jeopardize the privacy of the research participants.

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Acknowledgements

We acknowledge the supervisors and staff of the collaborative universities who assisted us in data collection and implementation of the study.

Funding

The project was supported by the Centre for Communicable Disease Control and Prevention of Iran’s Ministry of Health and Medical Education, and the National Institute for Medical Research Development (NIMAD Grant no. 973382).

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Authors and Affiliations

  1. HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

    Soheil Mehmandoost, Mehrdad Khezri, Niloofar Aghaali, Mostafa Shokoohi, Ali Akbar Haghdoost, Fatemeh Tavakoli, Hamid Sharifi & Mohammad Karamouzian

  2. Department of Health Sciences, Faculty of Applied Health Sciences, Brock University, St. Catharines, ON, Canada

    Mostafa Shokoohi

  3. Centre on Drug Policy Evaluation, Saint Michael’s Hospital, Toronto, ON, Canada

    Mohammad Karamouzian

  4. Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA

    Hamid Sharifi

  5. Department of Epidemiology, New York University School of Global Public Health, New York, NY, USA

    Mehrdad Khezri

  6. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

    Mohammad Karamouzian

Authors
  1. Soheil Mehmandoost
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  2. Mehrdad Khezri
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  3. Niloofar Aghaali
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  4. Mostafa Shokoohi
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  5. Ali Akbar Haghdoost
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  6. Fatemeh Tavakoli
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  8. Mohammad Karamouzian
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Contributions

SM: Data analysis & interoperation, methodology, manuscript drafting; MKH: Data collection, manuscript editing; MS: Study design, manuscript editing; AAH: Study design, manuscript editing; FT: Data collection, manuscript editing; NA: Data analysis, manuscript editing; HS: Study design, manuscript editing; MK: Study design, data analysis & interoperation, manuscript editing, supervision; All authors reviewed and revised the initial draft and approved the final manuscript.

Corresponding author

Correspondence to Mohammad Karamouzian.

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Mehmandoost, S., Khezri, M., Aghaali, N. et al. Dual HIV risk and vulnerabilities among people who inject drugs in Iran: Findings from a nationwide study in 2020. Harm Reduct J 21, 187 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12954-024-01107-6

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Keywords

Harm Reduction Journal

ISSN: 1477-7517