Publications by authors named "Ali Mirzazadeh"

104 Publications

Modelling the COVID-19 pandemic in context: an international participatory approach.

BMJ Glob Health 2020 12;5(12)

Centre for Mathematics, Computation and Cognition, Federal University of ABC Center of Mathematics Computing and Cognition, Santo Andre, São Paulo, Brazil.

The SARS-CoV-2 pandemic has had an unprecedented impact on multiple levels of society. Not only has the pandemic completely overwhelmed some health systems but it has also changed how scientific evidence is shared and increased the pace at which such evidence is published and consumed, by scientists, policymakers and the wider public. More significantly, the pandemic has created tremendous challenges for decision-makers, who have had to implement highly disruptive containment measures with very little empirical scientific evidence to support their decision-making process. Given this lack of data, predictive mathematical models have played an increasingly prominent role. In high-income countries, there is a long-standing history of established research groups advising policymakers, whereas a general lack of translational capacity has meant that mathematical models frequently remain inaccessible to policymakers in low-income and middle-income countries. Here, we describe a participatory approach to modelling that aims to circumvent this gap. Our approach involved the creation of an international group of infectious disease modellers and other public health experts, which culminated in the establishment of the COVID-19 Modelling (CoMo) Consortium. Here, we describe how the consortium was formed, the way it functions, the mathematical model used and, crucially, the high degree of engagement fostered between CoMo Consortium members and their respective local policymakers and ministries of health.
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http://dx.doi.org/10.1136/bmjgh-2020-003126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759758PMC
December 2020

Unsafe Injection Is Associated with Higher HIV Testing after Bayesian Adjustment for Unmeasured Confounding.

Arch Iran Med 2020 12 1;23(12):848-855. Epub 2020 Dec 1.

Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center.

Background: To apply a novel method to adjust for HIV knowledge as an unmeasured confounder for the effect of unsafe injection on future HIV testing.

Methods: The data were collected from 601 HIV-negative persons who inject drugs (PWID) from a cohort in San Francisco. The panel-data generalized estimating equations (GEE) technique was used to estimate the adjusted risk ratio (RR) for the effect of unsafe injection on not being tested (NBT) for HIV. Expert opinion quantified the bias parameters to adjust for insufficient knowledge about HIV transmission as an unmeasured confounder using Bayesian bias analysis.

Results: Expert opinion estimated that 2.5%-40.0% of PWID with unsafe injection had insufficient HIV knowledge; whereas 1.0%-20.0% who practiced safe injection had insufficient knowledge. Experts also estimated the RR for the association between insufficient knowledge and NBT for HIV as 1.1-5.0. The RR estimate for the association between unsafe injection and NBT for HIV, adjusted for measured confounders, was 0.96 (95% confidence interval: 0.89,1.03). However, the RR estimate decreased to 0.82 (95% credible interval: 0.64, 0.99) after adjusting for insufficient knowledge as an unmeasured confounder.

Conclusion: Our Bayesian approach that uses expert opinion to adjust for unmeasured confounders revealed that PWID who practice unsafe injection are more likely to be tested for HIV - an association that was not seen by conventional analysis.
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http://dx.doi.org/10.34172/aim.2020.113DOI Listing
December 2020

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

AIDS 2021 Mar;35(4):529-542

Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco, USA.

Iran, a country in the Middle East and North Africa (MENA) region, has been actively involved in the fight against HIV/AIDS over the past three decades. The unique features of the HIV epidemic in Iran are reflected by the modes of transmission and its recent changes to improve management and prevention programs. In this review, we recount the initial onset and subsequent spread of HIV infection in Iran, beginning with the first case diagnosed to the ongoing responses and most recent achievements in controlling this epidemic. Although in the MENA region, Iran is one of the pioneers in implementing pertinent policies including harm reduction services to decrease HIV incidence, drug injection still continues to be the major risk of infection. In line with other nations, the programs in Iran aim at the UNAIDS 90-90-90 targets (UNAIDS 90-90-90 global targets to end the AIDS epidemic by 2020: by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression) and to eliminate mother-to-child HIV transmission. In this article, we discuss the strengths and shortcomings of the current HIV programs and offer suggestions to provide a better perspective to track and respond to the HIV epidemic. More generally, our account of the national religious and cultural circumstances as well as obstacles to the approaches chosen can provide insights for decision-makers in other countries and institutions with comparable settings and infrastructures.
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http://dx.doi.org/10.1097/QAD.0000000000002757DOI Listing
March 2021

COVID-19 and Social Distancing: A Pandemic of Advanced Diseases Is at Birth.

Arch Iran Med 2020 09 1;23(9):651-652. Epub 2020 Sep 1.

Stein Eye Institute, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.

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http://dx.doi.org/10.34172/aim.2020.81DOI Listing
September 2020

Induced abortion and associated factors among female sex workers in Iran.

Eur J Contracept Reprod Health Care 2020 Dec 17;25(6):434-438. Epub 2020 Sep 17.

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

Objectives: Induced abortion is an occupational hazard for female sex workers (FSWs). This study aimed to examine the prevalence and factors associated with induced abortion among FSWs in Iran.

Methods: 1337 FSWs aged ≥18 years who reported selling sex to more than one male client in the past 12 months were recruited in 13 major cities in Iran between January and August 2015. Bivariable and multivariable modified Poisson regression models were constructed to examine the correlates of induced abortion. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported.

Results: Lifetime induced abortion was reported by 621 of 1335 participants (46.5%; 95% CI 43.8, 49.2). Older age (APR for ≥ 35 vs. < 25 years, 1.46; 95% CI: 1.03, 2.07), having ever been married (APR 1.58; 95% CI 1.05, 2.39), having ever worked in a brothel (APR 1.19; 95% CI 1.02, 1.38) and a lifetime history of being raped (APR 1.19; 95% CI 1.03, 1.38) were significantly associated with lifetime induced abortion (all  < 0.05).

Conclusion: The high prevalence of induced abortion among FSWs in Iran is concerning. Evidence-informed programmes targeting FSWs in Iran would improve their knowledge and encourage contraceptive use as well as promote pregnancy prevention and post-abortion care.
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http://dx.doi.org/10.1080/13625187.2020.1815007DOI Listing
December 2020

Prevalence and incidence of pre-hypertension and hypertension (awareness/control) in Iran: findings from Kerman coronary artery diseases risk factors study 2 (KERCADRS).

J Hum Hypertens 2020 Sep 14. Epub 2020 Sep 14.

Institute for Health Policy Studies, University of California, San Francisco, CA, USA.

Hypertension (HTN) is an important cause of cardiovascular-related morbidity and mortality. The present study was conducted to investigate the prevalence and incidence rate of pre-HTN, diagnosed and undiagnosed HTN, as well as its control and associated factors in adult population in southeast Iran. In a randomized household survey, 9987 participants aged 15-80 years were recruited into the study. HTN was confirmed through examination or using antihypertensive drug(s). Pre-HTN and HTN were defined as 120-139/80-89 and ≥140/90 mmHg for systolic and diastolic BP, respectively. The prevalence of pre-HTN was 28.5%. The prevalence of HTN was 19.2% (13.9% diagnosed and 5.3% undiagnosed). HTN increased with age (from 4% in 15-24 to 67.8% in 75-80 years). Men had higher pre-HTN (35.6% vs. 23.4%) and undiagnosed HTN (7.5% vs. 3.8%) than women. Of those diagnosed, 46.5% had uncontrolled BP, in which, women had better conditions than men (45.6% vs. 47.4%). Obesity, positive family history of HTN, anxiety, and low physical activity were the most significant predictors of HTN. The prevalence of pre-HTN decreased but there was no change in the prevalence of HTN during the last 5 years. The 5-year incidence rate/100 person-years of pre-HTN and HTN was 6.6 and 3.7, respectively. Although there are some promising signs of reducing pre-HTN and slowing HTN rise, currently, almost one-fifth of the adult population suffers from HTN. Given the poor BP control in patients with diagnosed HTN, especially in men, alarms that more effective interventions and strategies are needed to reduce deleterious consequences of HTN.
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http://dx.doi.org/10.1038/s41371-020-00392-5DOI Listing
September 2020

Understanding the Reasons for Sharing Syringes or Needles to Inject Drugs: Conventional Content Analysis.

Addict Health 2020 Apr;12(2):98-108

Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.

Background: This qualitative study was undertaken with the aim to identify the reasons for sharing syringes or needles among people who inject drugs (PWID) in Iran.

Methods: We used purposive sampling to recruit 4 groups of participants, male PWID (n = 14), female PWID (n = 6), service providers (n = 8), and human immunodeficiency virus (HIV)/addiction experts (n = 9). Data were collected through 2 focus group discussions (FGDs) among male PWID, and semi-structured interviews with female PWID, service providers, and HIV/addiction experts. Using conventional content analysis, themes were extracted for reasons for sharing needles to inject drugs.

Findings: We found 13 themes for barriers such as low perceived risk of HIV, high stigma around drug injection and use, low access to harm reduction education and prevention services due to their limited working hours as a well as uneven geographical distribution of services, some structural barriers like incarceration, poverty, and homelessness, and several competing survival needs beyond the injection-related safe behaviors.

Conclusion: Our study was able to provide the perspectives of both PWID and health care authorities and providers towards several barriers to accessing HIV prevention services that lead to needle sharing among PWID in Iran. These barriers need to be addressed to achieve the target of HIV epidemic control.
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http://dx.doi.org/10.22122/ahj.v12i2.255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395933PMC
April 2020

Estimating COVID-19-Related Infections, Deaths, and Hospitalizations in Iran Under Different Physical Distancing and Isolation Scenarios.

Int J Health Policy Manag 2020 Aug 1. Epub 2020 Aug 1.

Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.

Background: Iran is one of the first few countries that was hit hard with the coronavirus disease 2019 (COVID-19) pandemic. We aimed to estimate the total number of COVID-19 related infections, deaths, and hospitalizations in Iran under different physical distancing and isolation scenarios.

Methods: We developed a susceptible-exposed-infected/infectious-recovered/removed (SEIR) model, parameterized to the COVID-19 pandemic in Iran. We used the model to quantify the magnitude of the outbreak in Iran and assess the effectiveness of isolation and physical distancing under five different scenarios (A: 0% isolation, through E: 40% isolation of all infected cases). We used Monte-Carlo simulation to calculate the 95% uncertainty intervals (UIs).

Results: Under scenario A, we estimated 5 196 000 (UI 1 753 000-10 220 000) infections to happen till mid-June with 966 000 (UI 467 800-1 702 000) hospitalizations and 111 000 (UI 53 400-200 000) deaths. Successful implantation of scenario E would reduce the number of infections by 90% (ie, 550 000) and change the epidemic peak from 66 000 on June 9, to 9400 on March 1, 2020. Scenario E also reduces the hospitalizations by 92% (ie, 74 500), and deaths by 93% (ie, 7800).

Conclusion: With no approved vaccination or therapy available, we found physical distancing and isolation that include public awareness and case-finding and isolation of 40% of infected people could reduce the burden of COVID-19 in Iran by 90% by mid-June.
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http://dx.doi.org/10.34172/ijhpm.2020.134DOI Listing
August 2020

Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran.

Subst Abuse Treat Prev Policy 2020 08 5;15(1):56. Epub 2020 Aug 5.

Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.

Background: The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.

Methods: Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.

Results: In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.

Conclusions: Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.
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http://dx.doi.org/10.1186/s13011-020-00298-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405425PMC
August 2020

HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran.

Int J Drug Policy 2020 Oct 24;84:102868. Epub 2020 Jul 24.

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; Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA. Electronic address:

Background: The HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran.

Methods: Using data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID.

Results: The majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month.

Conclusion: The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.
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http://dx.doi.org/10.1016/j.drugpo.2020.102868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738401PMC
October 2020

Opioid agonist therapy uptake among people who inject drugs: the findings of two consecutive bio-behavioral surveillance surveys in Iran.

Harm Reduct J 2020 07 22;17(1):50. Epub 2020 Jul 22.

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, Haftbagh Highway, Kerman, 7616913555, Iran.

Background: Opioid agonist therapy (OAT) uptake has been associated with multiple positive health outcomes among people who inject drugs (PWID). This study evaluated the pattern of OAT uptake among PWID in two consecutive national bio-behavioral surveillance surveys (2010 and 2014) in Iran.

Methods: Data were obtained from two national bio-behavioral surveillance surveys (N = 1783 and N = 2166) implemented using convenience sampling at the harm reduction facilities and street venues in 10 geographically diverse urban centers across Iran. Multivariable logistic regression models were built to determine the correlates of OAT uptake for the 2014 survey, and adjusted odds ratios (AORs) along with 95% confidence intervals (CI) were reported.

Results: The prevalence of OAT uptake decreased from 49.2% in 2010 to 45.8% in 2014 (P value = 0.033). OAT uptake varied across the studied cities ranging from 0.0 to 69.3% in the 2010 survey and 3.2 to 75.5% in the 2014 survey. Ever being married (AOR = 1.40; 95% CI 1.12, 1.75), having a history of incarceration (AOR = 1.56; 95% CI 1.16, 2.09), and human immunodeficiency virus (HIV) sero-positivity (AOR = 1.63; 95% CI 1.08, 2.50) were associated with OAT uptake. Conversely, PWID who reported using only non-opioid drugs (AOR = 0.43; 95% CI 0.26, 0.71) and those who reported concurrent use of opioid and non-opioid drugs (AOR = 0.66; 95% CI 0.51, 0.86) were less likely to uptake OAT.

Conclusions: Although OAT uptake among PWID in Iran is above the 40% threshold defined by the World Health Organization, there remain significant disparities across urban settings in Iran. Importantly, the OAT services appear to be serving high-risk PWID including those living with HIV and those with a history of incarceration. Evaluating service integration including mental health, HIV and hepatitis C virus care, and other harm reduction services may support the optimization of health outcomes associated with OAT across Iran.
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http://dx.doi.org/10.1186/s12954-020-00392-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373839PMC
July 2020

Estimation of Coronavirus Disease 2019 Burden and Potential for International Dissemination of Infection From Iran.

Ann Intern Med 2020 07;173(1):73-74

Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran (A.A.H.).

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http://dx.doi.org/10.7326/L20-0592DOI Listing
July 2020

Prevalence and correlates of initiating injection drug use before the age of 18 years in Iran: results of a national survey.

J Addict Dis 2020 Jul-Sep;38(3):334-338. Epub 2020 Jun 29.

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.

In this study, we sought to determine factors relating to initiating injection drug use before the age of 18 years in Iran. In this cross-sectional survey, people who inject drugs were recruited using facility-based sampling in 10 cities in Iran in 2014. Adults (≥18 year) who reported injecting drugs at least one time during the last year were included. A structured questionnaire collected behaviors related to injection, sexual risk, and HIV testing. Based on the reported age of first injection, we grouped participants into that initiating injection drug use by before 18-year old versus 18- and after 18-year old. Of 2356 participants, 199 (8.5%, 95% CI 7.4-9.6) started injecting before the age of 18 years. Initiating injection drug use before the age of 18 years were more likely to be <30-year old (39.4% vs. 19.7%,  < .001), report syringe and needle sharing (15.0% vs. 5.4%,  < .001), have sex with other men (24.3% vs. 15.6%,  < .001), and have complete knowledge about HIV (92.5% vs. 86.4%,  < .001). People who started injection at younger ages had higher risk profiles and should be prioritized for substance use treatment, harm reduction, and HIV prevention programs.
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http://dx.doi.org/10.1080/10550887.2020.1765076DOI Listing
June 2020

Epidemiological characteristics of COVID-19: a systematic review and meta-analysis.

Epidemiol Infect 2020 06 29;148:e130. Epub 2020 Jun 29.

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.

Our understanding of the Coronavirus disease 2019 (COVID-19) continues to evolve and there are many unknowns about its epidemiology. This study aims to synthesise case fatality rate (CFR) among confirmed COVID-19 patients, incubation period and time from onset of COVID-19 symptoms to first medical visit, intensive care unit (ICU) admission, recovery, and death. We searched MEDLINE, Embase, Google Scholar, and bibliographies of relevant articles from 01 December 2019 to 11 March 2020 without any language restrictions. Quantitative studies that recruited people with confirmed COVID-19 diagnosis were included. Two independent reviewers extracted the data. Out of 1675 non-duplicate studies, 43 were included in the meta-analysis. The pooled mean incubation period was 5.68 (99% confidence interval [CI]: 4.78, 6.59) days. The pooled mean number of days from the onset of COVID-19 symptoms to first clinical visit was 4.92 (95% CI: 3.95, 5.90), ICU admission was 9.84 (95% CI: 8.78, 10.90), recovery was 18.55 (95% CI: 13.69, 23.41), and death was 15.93 (95% CI: 13.07, 18.79). Pooled CFR among confirmed COVID-19 patients was 0.02 (95% CI: 0.02, 0.03). We found that the incubation period and lag between the onset of symptoms and first clinical visit for COVID-19 are longer than other respiratory viral infections including Middle East respiratory syndrome and severe acute respiratory syndrome; however, the current policy of 14 days of mandatory quarantine for everyone potentially exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might be too conservative. Longer quarantine periods might be more justified for extreme cases.
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http://dx.doi.org/10.1017/S0950268820001430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343974PMC
June 2020

Early sex work initiation and its association with condomless sex and sexually transmitted infections among female sex workers in Iran.

Int J STD AIDS 2020 06;31(7):671-679

Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Early sex work initiation among female sex workers (FSWs) increases their vulnerabilities to high-risk sexual practices and sexually transmitted infections (STIs). We examined the association of early sex work with condomless sex indicators, HIV, and other STIs, including human papillomavirus, chlamydia, trichomoniasis, syphilis, and gonorrhea, among FSWs in Iran. We recruited 1347 FSWs from 13 cities in 2015, with 1296 participants (94.2%) reporting information about their age of sex work initiation. Early sex work was defined as the initiation of selling sex before 18 years of age. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported using multivariable logistic regression. Overall, 10.1% of FSWs reported early sex work initiation. FSWs who initiated sex work earlier were more likely to report last-month inconsistent condom use (aOR = 3.31, 95% CI: 1.82, 6.02) and condomless sex with last client (aOR = 1.72, 95% CI: 1.15, 2.56). There was no statistically significant association between early sex work and HIV (aOR = 1.40, 95% CI: 0.43, 4.53) and any other STIs (aOR = 1.01, 95% CI: 0.69, 1.48), except for chlamydia (aOR = 2.09, 95% CI: 1.08, 4.04). These findings suggest that FSWs with early sexual debut would benefit from differentiated interventions including screening for STIs and enhanced counseling for condom use.
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http://dx.doi.org/10.1177/0956462420913431DOI Listing
June 2020

Social and structural determinants of health associated with drug use patterns among female sex workers in Iran: A latent class analysis.

Int J Drug Policy 2020 Jun 3:102798. Epub 2020 Jun 3.

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; Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, California, United States. Electronic address:

Background: Female sex workers (FSWs) experience adversities regarding social determinants of health (SDH) and behavioural factors including illicit drug use. This study aimed to assess the clustered impact of SDH on illicit drug use among FSWs in Iran.

Methods: We surveyed 1,347 FSWs in 13 major cities in 2015. Latent class analysis was conducted to identify distinct classes of five measured SDH including low education, unemployment, unstable housing, last-year incarceration and sexual violence. We examined the association of these classes with five illicit drug use patterns using multivariable generalized linear model with Poisson family and log link, and reported adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI).

Results: We identified five SDH classes: Class 1: no SDH adversities; Class 2: mainly unemployment; Class 3: low education and unemployment; Class 4: sexual violence and unemployment; and Class 5: multiple SDH adversities. The prevalence of last-month drug use ranged from 7.0% in Class 1 to 53.3% in Class 5. Compared to FSWs in Class 1, those in Class 2 (aPR: 2.47, 95% CI: 1.15, 5.27), Class 3 (aPR: 3.69, 95% CI: 1.62, 8.36), Class 4 (aPR: 4.49, 95% CI: 1.71, 11.78) and Class 5 (aPR: 6.35, 95% CI: 2.42, 16.69) were more likely to report last-month drug use. The same patterns were observed for specific drugs of opium use, crystal methamphetamine use, and heroin-crack use, as well as poly-drug use.

Conclusion: Socio-structural determinants are clustered together and elevate the likelihood of illicit drug use among FSWs. Our findings highlighted the significance of assessing and addressing such key determinants of health in drug use harm reduction programs targeting FSWs.
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http://dx.doi.org/10.1016/j.drugpo.2020.102798DOI Listing
June 2020

Drug resistance patterns in HIV patients with virologic failure in Iran.

Arch Clin Infect Dis 2019 Dec 28;14(6). Epub 2019 Dec 28.

HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Kerman University of Medical Sciences, Kerman, Iran.

We reviewed the medical charts of 1,700 patients diagnosed with HIV who referred to a central HIV clinic in Tehran between 2004 and 2017. Participants who had a viral load of > 200 copies/mL after six months or more on antiretroviral therapy (ART) were grouped as virologic failure (VF). We assessed the demographic characteristics, diagnosis date, first ART regimen, and resistance to various ART drugs. Out of 1,700 patients, 72 (4.2%) had a treatment failure. Among those with treatment failure, 51.3% were on zidovudine + lamivudine + efavirenz, 13.9% were on tenofovir + lamivudine + lopinavir/ritonavir, and 12.5% were on tenofovir + emtricitabine + efavirenz. In patients with treatment failure, the highest resistance was to nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) combination (44.4%). In these patients, resistance to tenofovir (one of the NRTIs) was 29.1%. The highest treatment failure was observed among patients treated with nevirapine (NVP) and efavirenz (EFV)-based regimen. Our findings suggest that protease inhibitors should be considered as first-line drugs in ART regimens in VF patients in Iran.
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http://dx.doi.org/10.5812/archcid.96531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138207PMC
December 2019

The Prevalence and 5-Year Incidence Rate of Low Physical Activity in an Urban Population of 10,000 in Southeastern Iran: Relationship With Other Cardiovascular Risk Factors.

J Phys Act Health 2020 04 1;17(4):435-442. Epub 2020 Apr 1.

Background: Because of high prevalence of coronary artery diseases (CADs) in Iran and their relationship with low physical activity (LPA), this study aimed to measure the epidemic size of LPA, its incidence rate, and its relationship with other CAD risk factors in Kerman, Iran.

Methods: About 10,000 adults were randomly recruited through single-stage cluster sampling. Demographic characteristics, biochemical variables, smoking, opium use, mental status, and physical activities were assessed. The relationship between LPA and 7 other CAD risk factors was measured. Five-year incidence rate of LPA was calculated according to the data from the physically active participants in the first phase of the study (n = 3416) who attended the second phase after 5 years.

Results: The prevalence of low, moderate, and intense physical activity was 47.2%, 34.8%, and 18.0%, respectively. LPA rose from 45.1% to 62.2% after the age of 25 years. Women had higher LPA than men. Participants with LPA had significantly higher chance of cigarette smoking, diabetes, overweight/obesity, hypertension, and opium addiction. Five-year incidence rate of LPA was 5.1 persons/100 person-years among physically active population.

Conclusion: Almost half of the studied population suffering from LPA was at risk of CAD. Such risky lifestyle pattern while worsened in the last 5 years makes the emerging of CAD epidemic unavoidable, if appropriate timely interventions not being in place accordingly.
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http://dx.doi.org/10.1123/jpah.2019-0426DOI Listing
April 2020

Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study.

Sex Transm Infect 2020 02 13;96(1):68-75. Epub 2019 Dec 13.

Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.

Objective: The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran.

Methods: We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds.

Results: HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus.

Conclusions: HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.
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http://dx.doi.org/10.1136/sextrans-2018-053800DOI Listing
February 2020

HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis.

Arch Sex Behav 2020 08 7;49(6):1923-1937. Epub 2019 Nov 7.

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.

Given the high burden of HIV and other sexually transmitted infections (STIs) among female sex workers (FSW) and their potential role in bridging HIV/STIs into the general population, estimating the prevalence of HIV/STIs among FSW is essential for future research and policy developments. This systematic review and meta-analysis synthesize the available HIV/STIs data among FSW in Iran. We searched MEDLINE, PsycINFO, CINAHL, Embase, Web of Science, Google Scholar, and Iranian databases from inception through to January 2018. Inclusion criteria were original quantitative studies that measured HIV/STIs prevalence among FSW. Pooled prevalence estimates were calculated using random-effects meta-analyses. Out of a total of 299 screened studies, 12 were included with total study participants of 4328 FSW. Heterogeneity was present but meta-regression analyses revealed no significant association between HIV prevalence and year of publication, city, and age. Pooled HIV prevalence was 2.23% (95% confidence interval [CI] 0.82, 3.64). We estimated the prevalence of other STIs as 0.77% (95% CI 0.01, 1.53) for hepatitis B, 6.18% (95% CI 1.32, 11.04) for hepatitis C, 0.33% (95% CI 0.00, 0.66) for syphilis, 1.47% (95% CI 0.22, 2.71) for gonorrhea, 9.80% (95% CI 4.70, 14.91) for chlamydia, and 6.18% (95% CI 4.92, 7.43) for trichomonas vaginalis. Based on the existing evidence, HIV and STIs prevalence among FSW are relatively low in Iran. Strategies for timely diagnosis and treatment of HIV and other STIs among FSW and their sexual and injecting partners are needed to reduce the burden of HIV/STIs among these vulnerable populations in Iran.
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http://dx.doi.org/10.1007/s10508-019-01574-0DOI Listing
August 2020

The HIV treatment cascade in people living with HIV in Iran in 2014: Mixed-method study to measure losses and reasons.

Int J STD AIDS 2019 11 27;30(13):1257-1264. Epub 2019 Sep 27.

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.

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http://dx.doi.org/10.1177/0956462419867573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008700PMC
November 2019

Characterizing the relationship between incarceration and structural risks among female sex workers in Iran: findings of a nationwide biobehavioral surveillance survey.

Ann Epidemiol 2019 07 10;35:29-34. Epub 2019 May 10.

Department of Epidemiology and Biostatistics and Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA; School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Purpose: Given the adverse impacts of enforcement-based approaches toward sex work on female sex workers' (FSWs') health, safety, and well-being, we explored the prevalence and correlates of recent incarceration among FSWs in Iran.

Methods: From January to August 2015, we recruited FSWs from 21 harm reduction facilities and 152 FSWs from street venues in 13 major cities across Iran. Correlates of recent (i.e., last year) incarceration were assessed through an exploratory multivariable logistic regression model.

Results: A total of 90 of 1326 (6.8%) FSWs reported a recent incarceration; primary reasons for incarceration were drug-related (n = 48/90; 52.9%). Having a recent incarceration was significantly and positively associated with history of illicit drug use/injection (adjusted odds ratio [aOR] = 3.22, 95% confidence interval [CI]: 1.67, 6.19), rape in last year (aOR = 2.67, 95% CI: 1.65, 4.31), unstable housing (aOR = 2.28, 95% CI: 1.16, 4.91), and working in brothels (aOR = 2.22, 95% CI: 1.18, 4.16).

Conclusions: In sum, recent incarceration was significantly associated with history of drug use and sociostructural vulnerabilities. Taken together, these data suggest the potential health impacts of the integration of programs to mitigate substance use, sexual violence, and living conditions into comprehensive services for FSWs in Iran.
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http://dx.doi.org/10.1016/j.annepidem.2019.04.011DOI Listing
July 2019

Software Application Profile: The Anchored Multiplier calculator-a Bayesian tool to synthesize population size estimates.

Int J Epidemiol 2019 12;48(6):1744-1749

Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.

Estimating the number of people in hidden populations is needed for public health research, yet available methods produce highly variable and uncertain results. The Anchored Multiplier calculator uses a Bayesian framework to synthesize multiple population size estimates to generate a consensus estimate. Users submit point estimates and lower/upper bounds which are converted to beta probability distributions and combined to form a single posterior probability distribution. The Anchored Multiplier calculator is available as a web browser-based application. The software allows for unlimited empirical population size estimates to be submitted and combined according to Bayes Theorem to form a single estimate. The software returns output as a forest plot (to visually compare data inputs and the final Anchored Multiplier estimate) and a table that displays results as population percentages and counts. The web application 'Anchored Multiplier Calculator' is free software and is available at [http://globalhealthsciences.ucsf.edu/resources/tools] or directly at [http://anchoredmultiplier.ucsf.edu/].
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http://dx.doi.org/10.1093/ije/dyz101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6929553PMC
December 2019

Software Application Profile: The Anchored Multiplier calculator-a Bayesian tool to synthesize population size estimates.

Int J Epidemiol 2019 12;48(6):1744-1749

Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.

Estimating the number of people in hidden populations is needed for public health research, yet available methods produce highly variable and uncertain results. The Anchored Multiplier calculator uses a Bayesian framework to synthesize multiple population size estimates to generate a consensus estimate. Users submit point estimates and lower/upper bounds which are converted to beta probability distributions and combined to form a single posterior probability distribution. The Anchored Multiplier calculator is available as a web browser-based application. The software allows for unlimited empirical population size estimates to be submitted and combined according to Bayes Theorem to form a single estimate. The software returns output as a forest plot (to visually compare data inputs and the final Anchored Multiplier estimate) and a table that displays results as population percentages and counts. The web application 'Anchored Multiplier Calculator' is free software and is available at [http://globalhealthsciences.ucsf.edu/resources/tools] or directly at [http://anchoredmultiplier.ucsf.edu/].
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http://dx.doi.org/10.1093/ije/dyz101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6929553PMC
December 2019

Population Size Estimates of Street Children in Iran: Synthesis of Multiple Methods.

J Urban Health 2019 08;96(4):549-557

Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.

We used four methods (direct count, indirect count, wisdom of the crowd, and unique object multiplier) to map and estimate the population size of street children in six major cities in Iran in 2017. In aggregate for the six cities, the number of street children was estimated at 5296 (interquartile range [IQR] 4122-7071) using the median of the four methods. This corresponds to a rate of 16.3 (IQR 12.5-24.5) per 10,000 children age 5-18 years old, or 3.2 (IQR 2.4-5.3) per 10,000 total population. The total number for street children in the country is estimated at 26,000 (IQR 20,239-34,719) children. Results can help policy-makers advocate for resources, plan programs, and evaluate the reach of programs for street children. The maps created through the course of the population size estimation exercise can also guide outreach efforts to provide street children with health and social welfare services.
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http://dx.doi.org/10.1007/s11524-019-00354-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890866PMC
August 2019

Treatment cascade for hepatitis C virus in young adult people who inject drugs in San Francisco: Low number treated.

Drug Alcohol Depend 2019 05 27;198:133-135. Epub 2019 Feb 27.

Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.

Objective: To understand the number of young adult people who inject drugs (PWID) with hepatitis C virus (HCV) infection accessing direct-acting antiviral (DAA) treatment and their barriers and facilitators to treatment uptake.

Methods: Using prospective cohort data from young adult PWID in San Francisco with newly identified HCV infection, we calculated the number who: (i) accepted referral to DAA therapy, (ii) initiated DAA therapy, (iii) completed DAA therapy, and (iv) achieved sustained virologic response (SVR) or cure. Behavioral survey data identified possible barriers and facilitators to DAA therapy.

Results: Of 60 young adult PWID with new HCV infection identified between February 2015 and January 2018, thirty accepted a referral to HCV care; five initiated and completed HCV treatment and achieved cure. Barriers to DAA uptake included fear of medical establishments, competing basic needs, and delaying care because they were feeling well.

Conclusion: While few HCV-positive young adult PWID engaged in DAA therapy, all those who did achieved cure. Youth-tailored services that overcome the stigma and marginalization related to injection drug use are needed to improve treatment uptake.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482851PMC
May 2019

Estimating the Population Size of Female Sex Workers in Namibia Using a Respondent-Driven Sampling Adjustment to the Reverse Tracking Method: A Novel Approach.

JMIR Public Health Surveill 2019 Mar 14;5(1):e11737. Epub 2019 Mar 14.

Division of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention, Atlanta, GA, United States.

Background: Key populations, including female sex workers (FSWs), are at a disproportionately high risk for HIV infection. Estimates of the size of these populations serve as denominator data to inform HIV prevention and treatment programming and are necessary for the equitable allocation of limited public health resources.

Objective: This study aimed to present the respondent-driven sampling (RDS) adjusted reverse tracking method (RTM; RadR), a novel population size estimation approach that combines venue mapping data with RDS data to estimate the population size, adjusted for double counting and nonattendance biases.

Methods: We used data from a 2014 RDS survey of FSWs in Windhoek and Katima Mulilo, Namibia, to demonstrate the RadR method. Information from venue mapping and enumeration from the survey formative assessment phase were combined with survey-based venue-inquiry questions to estimate population size, adjusting for double counting, and FSWs who do not attend venues. RadR estimates were compared with the official population size estimates, published by the Namibian Ministry of Health and Social Services (MoHSS), and with the unadjusted RTM.

Results: Using the RadR method, we estimated 1552 (95% simulation interval, SI, 1101-2387) FSWs in Windhoek and 453 (95% SI: 336-656) FSWs in Katima Mulilo. These estimates were slightly more conservative than the MoHSS estimates-Windhoek: 3000 (1800-3400); Katima Mulilo: 800 (380-2000)-though not statistically different. We also found 75 additional venues in Windhoek and 59 additional venues in Katima Mulilo identified by RDS participants' responses that were not detected during the initial mapping exercise.

Conclusions: The RadR estimates were comparable with official estimates from the MoHSS. The RadR method is easily integrated into RDS studies, producing plausible population size estimates, and can also validate and update key population maps for outreach and venue-based sampling.
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http://dx.doi.org/10.2196/11737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437614PMC
March 2019

Condom Use and its Associated Factors Among Iranian Youth: Results From a Population-Based Study.

Int J Health Policy Manag 2018 11 1;7(11):1007-1014. Epub 2018 Nov 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.

Background: Given the young structure of Iran's population and the fact that extramarital sexual relationships are both prohibited by legislation and shunned by society and religion, examining condom use practices among Iranian youth is highly important. The aim of this study was to explore condom use and its correlates among Iranian young adults.

Methods: In a sample of 3,045 individuals aged 19-29 who were recruited from a nation-wide study, we analyzed data from 633 participants who reported a history of extramarital sex. Subjects were asked about their condom use practices during their last penetrative sex. Data were collected through a self-administered questionnaire where the respondents completed the survey on their own and passed it to trained gender-matched interviewers. Multivariable regression models were constructed to report adjusted odds ratios (AOR) along with 95% CI.

Results: Of the 633 participants, 222 (35.1%) reported condom use at last sex. Men reported significantly higher condom use than women (38.5% vs. 25.7%). Having a stable job (AOR = 1.86, 95% CI: 1.01, 3.43), higher knowledge of condom use (AOR = 1.57, 95% CI: 1.03, 2.37) and sexual transmission of HIV (AOR = 1.83, 95% CI: 1.18, 2.85) were positively associated with condom use at last sex. Conversely, experience of sex under the influence of substances (AOR = 0.66, 95% CI: 0.45, 0.94) was significantly associated with reduced odds of condom use at last sex.

Conclusion: This study shows that only one out of every three young adults reported using condoms at last sex. While educational programs are helpful, multi-sectoral approaches (eg, individual-, community-, and structural-level interventions) are required to change sexual behaviours towards safe sex practices and reinforce negotiating condom use among youth.
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http://dx.doi.org/10.15171/ijhpm.2018.65DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326636PMC
November 2018

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

PLoS One 2018 29;13(11):e0207681. Epub 2018 Nov 29.

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.

In Iran, People Who Inject Drugs (PWID), Female Sex Workers (FSW), and prisoners are the main key populations at risk of HIV infection. This study aimed to evaluate the trend of HIV incidence among PWID, FSW and prisoners as an impact measure of HIV harm reduction and prevention efforts in Iran. Data were obtained from the two rounds of national bio-behavioral surveillance surveys among FSW (2010 (n = 872), 2015 (n = 1339)), PWID (2010 (n = 2417), 2014 (n = 2307)), and prisoners (2009 (n = 4536), 2013 (n = 5390)) through facility-based (FSW and PWID surveys) and cluster sampling (prisoner surveys). Time-at-risk was calculated assuming the age at first sex or drug injection as the beginning of the at-risk period and the age at the time of the interview or date when they received a positive HIV test result as the end of this period, adjusted for interval censoring. HIV incidence among PWID in 2014 was 5.39 (95% CI 4.71, 6.16) per 1,000 person-years (PY), significantly lower than in 2009 (17.07, 95% CI 15.34, 19.34). Similarly, HIV incidence was 1.12 (95% CI 0.77, 1.64) per 1,000 PY among FSW in 2015, a significant drop from 2010 (2.38, 95% CI 1.66, 3.40). Also, HIV incidence decreased among prisoners from 1.34 (95% CI: 1.08, 1.67) in 2009 to 0.49 (95% CI: 0.39, 0.61) per 1,000 PY in 2013. Our findings suggest that after an increase in the 2000s, the HIV incidence may have been decreased and stabilized among key populations in Iran.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207681PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6264468PMC
April 2019

Dual Unsafe Injection and Sexual Behaviors for HIV Infection Among People Who Inject Drugs in Iran.

AIDS Behav 2019 Jun;23(6):1594-1603

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.

We used two national surveys (2010: N = 1597; 2013: N = 1057) of people who inject drugs (PWID) in past-month to assess the prevalence and population size of PWID with either safe or unsafe injection and sex behaviors, overall and by HIV status. In 2013, only 27.0% (vs. 32.3% in 2010) had safe injection and sex, 24.6% (vs. 23.3% in 2010) had unsafe injection and sex, 26.4% (vs. 26.5% in 2010) had only unsafe injection, and 22.0% (vs. 18.0% in 2010) had unsafe sex only. Among HIV-positive PWID in 2013, only 22.1% (~ 2200 persons) had safe injection and sex, 14.2% (~ 1400 persons) had unsafe injection and sex, 53.1% (~ 5200 persons) had unsafe injection, and 10.6% had unsafe sex (~ 1100 persons). Among HIV-negative PWID in 2013, only 27.5% (~ 22,200 persons) had safe injection and sex, 25.9% (~ 20,900 PWID) had unsafe injection and sex, 23.2% (~ 18,700 persons) had unsafe injection, and 23.3% (~ 18,800 persons) had unsafe sex. HIV-positive and -negative PWID in Iran continue to be at risk of HIV acquisition or transmission which calls for targeted preventions services.
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http://dx.doi.org/10.1007/s10461-018-2345-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527484PMC
June 2019