Publications by authors named "Mahin Jamshidi-Makiani"

14 Publications

  • Page 1 of 1

Infliximab and Intravenous Gammaglobulin in Hospitalized Severe COVID-19 Patients in Intensive Care Unit.

Arch Iran Med 2021 Feb 1;24(2):139-143. Epub 2021 Feb 1.

Department of Internal Medicine, Firoozgar Medical and Educational Hospital, Iran University of Medical Sciences, Tehran, Iran.

Background: Severe coronavirus disease 2019 (COVID-19) may lead to the cytokine storm syndrome which may cause acute respiratory failure syndrome and death. Our aim was to investigate the therapeutic effects of infliximab, intravenous gammaglobulin (IVIg) or combination therapy in patients with severe COVID-19 disease admitted to the intensive care unit (ICU).

Methods: In this observational research, we studied 104 intubated adult patients with severe COVID-19 infection (based on clinical symptoms, and radiographic or CT scan parameters) who were admitted to the ICU of a multispecialty hospital during March 2020 in Tehran, Iran. All cases received standard treatment regimens as local protocol (Oseltamivir + hydroxychloroquine + lopinavir/ritonavir or sofosbuvir or atazanavir ± ribavirin). The cases were grouped as controls (n = 43), infliximab (n = 27), IVIg (n = 23) and combination (n = 11).

Results: There was no significant difference between controls and treatment groups in terms of underlying diseases or the number of underlying diseases. The mean age (SD) of cases was 72.42 (16.06) in the control group, 64.52 (12.965) in IVIg, 63.40 (17.57) in infliximab and 64.00 (11.679) in combination therapy; ( = 0.047, 0.031 and 0.11, respectively). Also, 37% in the infliximab group, 26.1% in IVIg, 45.5% in combination therapy, and 62.8% in the control group expired (all < 0.05). Hazard ratios were 0.31 in IVIg (95% CI: 0.12-0.76, = 0.01), 0.30 in infliximab (95% CI: 0.13-0.67, = 0.004), 0.39 in combination therapy (95% CI: 0.12-1.09, = 0.071).

Conclusion: According to the findings of this study, it seems that infliximab and IVIg, alone or together, in patients with severe COVID-19 disease can be considered an effective treatment.
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http://dx.doi.org/10.34172/aim.2021.22DOI Listing
February 2021

Effect of Arbidol (Umifenovir) on COVID-19: a randomized controlled trial.

BMC Infect Dis 2020 Dec 14;20(1):954. Epub 2020 Dec 14.

Department of Infectious Disease, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.

Background: Treatment of patients with COVID-19 has included supportive care to mainly relief symptoms of the disease. Although World Health Organization (WHO) has not recommended any effective treatments for COVID-19, there are some reports about use of antiviral drugs. The aim of this study is to determine the effect of Arbidol (ARB) on COVID-19 disease.

Methods: Using an open-label randomized controlled trial, we examined the efficacy of ARB in patients with COVID-19 in a teaching hospital. One hundred eligible patients with diagnosis of COVID-19 were recruited in the study and assigned randomly to two groups of either hydroxychloroquine followed by KALETRA (Lopinavir/ritonavir) or hydroxychloroquine followed by ARB. The primary outcome was hospitalization duration and clinical improvement 7 days after admission. The criteria of improvement were relief of cough, dyspnea, and fever. Time to relief from fever was also assessed across the two groups. Without any dropouts, 100 patients were entered into the study for the final analysis at significance level of 0.05.

Results: The mean age of patients was 56.6 (17.8) years and 56.2 (14.8) years in ARB and KALETRA groups, respectively. Majority of patients were male across two groups (66 and 54%). The duration of hospitalization in ARB group was significantly less than KALETRA arm (7.2 versus 9.6 days; P = 0.02). Time to relief fever was almost similar across two groups (2.7 versus 3.1 days in ARB and KALETRA arms, respectively). Peripheral oxygen saturation rate was significantly different after 7 days of admission across two groups (94% versus 92% in ARB and KALETRA groups respectively) (P = 0.02). Based on multiple linear regression analysis, IHD, Na level, and oxygen saturation at the time of admission and type of therapy were the independent adjusted variables that determined the duration of hospitalization in patients with COVID-19.

Conclusion: Our findings showed that Arbidol, compared to KALETRA, significantly contributes to clinical and laboratory improvements, including peripheral oxygen saturation, requiring ICU admissions, duration of hospitalization, chest CT involvements, WBC, and ESR. We suggest further studies on ARB against COVID-19 using larger sample size and multicenter design.

Trial Registration: IRCT20180725040596N2 on 18 April 2020.
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http://dx.doi.org/10.1186/s12879-020-05698-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734453PMC
December 2020

Guillain-Barré syndrome as a parainfectious manifestation of SARS-CoV-2 infection: A case series.

J Clin Neurosci 2021 Jan 14;83:119-122. Epub 2020 Nov 14.

Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran; Department of Neurology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.

The global SARS-CoV-2 pandemic posed an unprecedented challenge to almost all fields of medicine and Neurology is not an exception. Collecting information about its complications and related conditions will help clinicians to become more confident in managing this disease. Guillain-Barre Syndrome (GBS) is mostly described as a post-infectious phenomenon and its occurrence during acute phase of illness is of interest. GBS has recently been reported during the active phase of COVID-19 for the first time. Severity and fast progression of GBS associated with COVID-19 have also been shown in recent studies. Here we report three cases of GBS during the active phase of COVID-19 with severe symptoms and fast progression to quadriplegia and facial diplegia over 2 days, which led to death in one case due to severe autonomic dysfunction. We suggest SARS-CoV-2 might be associated with rather a severe, rapidly progressive and life-threatening phenotype of GBS.
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http://dx.doi.org/10.1016/j.jocn.2020.11.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666532PMC
January 2021

Angiotensin Converting Enzyme Inhibitors, A Risk Factor of Poor Outcome in Diabetic Patients with COVID-19 Infection.

Iran J Kidney Dis 2020 12 5;14(6):482-487. Epub 2020 Dec 5.

Firoozgar Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.

Introduction: Diabetes mellitus and hypertension are described as the most common comorbidities among COVID-19 patients. We investigated the adverse effect of ACEIs in diabetic and nondiabetic patients with COVID-19.

Methods: This prospective study consisted of 617 RT-PCR-confirmed COVID-19 inpatients. Demographic and baseline characteristics, underlying comorbid diseases, and antihypertensive drugs were evaluated. Study outcome (in-hospital death) was evaluated with the Kaplan-Meyer method and Cox regression model. Statistical analyses were performed with SPSS software for Windows. P values < .05 were considered significant.

Results: Mean ± SD age was 58.49 ± 15.80 (range: 18 to 94) years old. Cox regression analysis revealed that age (adjusted hazard ratio [HR] = 1.04, 95% CI: 1.03 to 1.06), diabetes mellitus (adjusted HR = 2.07, 95% CI: 1.32 to 3.26), immunocompromised patients (adjusted HR = 2.33, 95% CI: 1.29 to 4.21), acute kidney injury (AKI) (adjusted HR = 3.23, 95% CI: 2.01 to 5.19), ICU admission (adjusted HR = 2.48, 95% CI: 1.46 to 4.21), Asthma and COPD (adjusted HR = 2.13, CI:1.6 to 4.28) and ACEI (adjusted HR = 3.08, 95% CI: 1.56 to 6.06), respectively were associated with in-hospital death. Among diabetic patients, ACEI (adjusted HR = 3.51, 95% CI: 1.59 to 7.75), AKI (adjusted HR = 3.32, 95% CI: 1.76 to 6.45) and ICU admission (adjusted HR = 3.64, 95% CI: 1.530 to 8.65) were associated with increased mortality. The Kaplan-Meier survival curve showed a lower survival rate in diabetic patients with ACE inhibitor (adjusted HR = 3.36, 95% CI: 2.25 to 7.71).

Conclusion: ACEIs may harm the diabetic patient's outcome with COVID-19. Further studies can confirm if ACE inhibitors have an adverse effect on COVID-19 diabetic patient's mortality.
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December 2020

Recombinant Production of a Novel Fusion Protein: Listeriolysin O Fragment Fused to S1 Subunit of Pertussis Toxin.

Iran Biomed J 2021 01 10;25(1):33-40. Epub 2020 Feb 10.

Infectious Disease Center for Communicable Disease Control, Ministry of Health and Medical Education, Iran.

Background: Some resources have suggested that genetically inactivated pertussis toxoid (PTs) bear a more protective effect than chemically inactivated products. This study aimed to produce new version of PT, by cloning an inactive pertussis toxin S1 subunit (PTS1) in a fusion form with N-terminal half of the listeriolysin O (LLO) pore-forming toxin.

Methods: Deposited pdb structure file of the PT was used to model an extra disulfide bond. Codon-optimized ORF of the PTS1 was used to make recombinant constructs of PTS1 and LLO-PTS1 in the pPSG-IBA35 vector. The recombinant PTS1 and LLO-PTS1 proteins were expressed in BL21 DE3 and SHuffle T7 strains of E. coli and purified by affinity chromatography. Cytotoxic effects of the recombinant proteins were examined in the MCF-7 cell line.

Results: The purity of the products proved to be more than 85%, and the efficiency of the disulfide bond formation in SHuffle T7 strain was higher than BL21 DE3 strain. No cytotoxicity of the recombinant proteins was observed in MCF-7 cells. Soluble recombinant PTS1 and LLO-PTS1 proteins were produced in SHuffle T7 strain of E. coli with high efficiency of disulfide bonds formation.

Conclusion: The LLO-PTS1 with corrected disulfide bonds was successfully expressed in E. coli SHuffle T7 strain. Due to the safety for human cells, this chimeric molecule can be an option to prevent pertussis disease if its immunostimulatory effects would be confirmed in the future.
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http://dx.doi.org/10.29252/ibj.25.1.33DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7748116PMC
January 2021

Toward an Alum Free Mono-Component Monovalent Pertussis Vaccine: A Cytokine Response Assay.

Iran J Immunol 2020 Jun;17(2):111-120

Antimicrobial Resistance Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran.

Background: Current evidence indicates the resurgence of whooping cough despite high coverage of whole-cell (wP) and acellular (aP) pertussis vaccines.

Objective: To investigate the cytokine response to a genetically inactivated protein containing the S1 subunit of pertussis toxin (PTS1) with and without the Listeriolysin O (LLO-PTS1), in comparison with current wP and aP vaccines in the mice model.

Methods: Thirty-six female NMRI mice aged 8 to 12 weeks (25 ± 5 g) were divided into six groups, including control (n=6) and five treated groups (n=6/each). Treated groups received intraperitoneal injection of recombinant PTS1, recombinant fusion LLO-PTS1, aP, wP, and sham (phosphate-buffered saline), whereas the control group did not receive anything. After 60 days, the serum levels of IFN-γ, IL-4, and IL-17 cytokines were evaluated by ELISA method.

Results: Our findings showed LLO-PTS1 significantly increased IL-17 and IL-4 cytokines compared with wP and aP vaccines. IFN-γ failed to increase substantially in the LLO-PTS1 group compared to others, but it was non-inferior to standard vaccines.

Conclusion: Our alum free mono-component monovalent recombinant fusion protein (LLO-PTS1) could bear the capacity to stimulate the release of IFN-γ similar to wP and aP vaccines in the mouse model. Besides, it showed better results in stimulating the release of IL-17 and IL-4 response. This study can be regarded as a platform for further probes in booster pertussis vaccine development.
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http://dx.doi.org/10.22034/iji.2020.86199.1749DOI Listing
June 2020

SARS-CoV-2 Molecular and Phylogenetic analysis in COVID-19 patients: A preliminary report from Iran.

Infect Genet Evol 2020 10 30;84:104387. Epub 2020 May 30.

Department of Virology, Iran University of Medical Sciences, Tehran, Iran; Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran. Electronic address:

Background: The aim of the current study was to investigate and track the SARS-CoV-2 in Iranian Coronavirus Disease 2019 (COVID-19) patients using molecular and phylogenetic methods.

Methods: We enrolled seven confirmed cases of COVID-19 patients for the phylogenetic assessment of the SARS-CoV-2 in Iran. The nsp-2, nsp-12, and S genes were amplified using one-step RT-PCR and sequenced using Sanger sequencing method. Popular bioinformatics software were used for sequences alignment and analysis as well as phylogenetic construction.

Results: The mean age of the patients in the present study was 60.42 ± 9.94 years and 57.1% (4/7) were male. The results indicated high similarity between Iranian and Chinese strains. We could not find any particular polymorphisms in the assessed regions of the three genes. Phylogenetic trees by neighbor-joining and maximum likelihood method of nsp-2, nsp-12, and S genes showed that there are not any differences between Iranian isolates and those of other countries.

Conclusion: As a preliminary phylogenetic study in Iranian SARS-CoV-2 isolates, we found that these isolates are closely related to the Chinese and reference sequences. Also, no sensible differences were observed between Iranian isolates and those of other countries. Further investigations are recommended using more comprehensive methods and larger sample sizes.
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http://dx.doi.org/10.1016/j.meegid.2020.104387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832360PMC
October 2020

Impact of hepatitis B virus and hepatitis C virus infection on sperm parameters of infertile men.

Int J Reprod Biomed 2019 Aug 3;17(8):551-556. Epub 2019 Sep 3.

Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Tehran Iran.

Background: Viral hepatitis is one of the health problems which have the effects on the health issues. It seems that hepatitis B virus (HBV) and hepatitis C virus (HCV) infection have negative impacts on the semen quality and male infertility rate.

Objective: In this study, we aimed to evaluate the effects of HBV and HCV on sperm quality among Iranian infertile men referred to Royan Institute Reproductive Biomedicine Research Center between 2003 and 2014.

Materials And Methods: This retrospective case-control study included 112 HBV positive infertile men and 47 HCV positive infertile men as case group and 112 HBV negative and HCV negative matched infertile men as a control group. All semen analysis and viral parameters assessment was performed in the central laboratory with the same method and instruments.

Results: Sperm count among infertile men with HBV and HCV infection was significantly lower than control group [the mean of the total sperm count 100.95░±░118.59, 118.22░±░141.18, 166.27░±░151.25 (p░<░0.001)]. Sperm motility was significantly decreased in HBV and HCV positive men in comparison to the control group [30.97░±░25.88, 31.09░±░28.72, 40.87░±░23.37, respectively (p░<░0.007)]. The percentage of normal sperm morphology was significantly higher in control group in comparison to HBV and HCV infected group [the mean of the normal semen morphology 3.23░±░3.27, 3.70░±░3.83, 4.51░±░3.15 p░<░0.015]. Although there is a significant decline in liquefaction time in the case group but the viscosity, semen volume, and PH of semen samples were similar in the both case and control groups.

Conclusion: Our results suggest that HBV and HCV infection are associated with poor sperm quality.
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http://dx.doi.org/10.18502/ijrm.v17i8.4820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745080PMC
August 2019

The prevalence of HBV, HCV and HIV infections among Iranian infertile couples referring to Royan institute infertility clinic: A cross-sectional study.

Int J Reprod Biomed 2018 Sep;16(9):595-600

Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran.

Background: The role of the screening protocol for viral hepatitis and human immuunodeficiency virus (HIV) infections among infertile couples were seldom investigated.

Objective: The present study was performed to assess the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV infections among infertile couples referring to infertility clinic of Royan Institute.

Materials And Methods: This analytical cross-sectional study was performed on 21673 infertile couples referring to infertility clinic of Royan Institute between 2009 and 2014. Serological findings for viral hepatitis B, C and HIV infection were gathered herewith demographic data of the study participants through the study checklist. Ultimately, 302 couples who had at least one positive result in their serological tests were included in the statistical analysis.

Results: The HBV and HCV infections prevalence among study participants were 0.57% and 0.148% respectively; only two cases had HIV infection. HBV and HCV infections prevalence had significant association with the gender of participants, but there was no significant relationship between these infections and infertility types.

Conclusion: Viral hepatitis infections screening among infertile couples undergoing assisted reproductive techniques needs more attention.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6312715PMC
September 2018

Prevalence of cryptococcal antigen positivity among HIV infected patient with CD4 cell count less than 100 of Imam Khomeini Hospital, Tehran, Iran.

Iran J Microbiol 2017 Apr;9(2):119-121

Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran.

Background And Objectives: Cryptococcal meningitis is one of the main opportunistic infections associated with human immunodeficiency virus (HIV) infection. Despite the present and increasingly availability of specific treatment for cryptococcosis, the mortality rate of this infection is still high, particularly in patients with advanced immunsupression and advanced cryptococcal diseases.

Materials And Methods: This Prospective Cohort study was conducted at Imam Khomeini hospital in Tehran, Iran. Serum cryptococcal antigen was detected using the Lateral Flow Assay (LFA) There were 86 HIV-infected patients included in this study.

Results: There were 86 HIV-infected patients in this study. The prevalence of positive serum cryptococcal antigen was 0% (0 of 86).

Conclusion: The prevalence of cryptococcal infection among patients with advanced acquired immunodeficiency syndrome (AIDS) in the Iran is very low (<3%) thus the screening test for cryptococcal antigenemia dose not save lives and is not cost-effective in Iranian population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715277PMC
April 2017

Relative frequency of human papillomavirus genotypes and related sociodemographic characteristics in women referred to a general hospital in Tehran, 2014-2015: A cross-sectional study.

Int J Reprod Biomed 2017 May;15(5):305-310

Department of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Background: Human papilloma virus (HPV) is one of the major public health problems and the main causes of cervical cancer. The prevalence HPV infection in developing countries with low financial resources is high.

Objective: This study aimed to determine the relative frequency of HPV genotypes and its sociodemographic characteristics in women referred to a general hospital in Tehran, Iran from 2014-2015.

Materials And Methods: This cross-sectional study was performed in 400 women with Pap smear samples, referring to to a general hospital in Tehran, Iran from 2014-2015. The detection of 28 HPV genotypes was performed by using the Multiplex PCR technique. The sociodemographic survey was conducted for each HPV positive woman.

Results: HPV-positive infection was detected in 155 (38.75%) women aged 17-85 years. HPV 16 (19.1%) was the most prevalent type, followed by HPV 39 (12.5%) and HPV 18 (8.9%). The highest rate of HPV infection was observed at the age of 36 years (7.7%). The level of education and economic situation of each woman were showed most of HPV-positive women had a high school diploma (34.6%) and average economic situation (67,9%). 60.9% of these women were a housewife, and 67.3% lived in the capital .

Conclusion: Determination of HPV genotype and risk factor related to HPV infection in each geographical region can lead to the production of effective vaccines against the HPV virus. It can also be useful for disease management and high sensitivity diagnosis of cervical intraepithelial neoplasia.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510584PMC
May 2017

Drug-drug Interactions: The Importance of Medication Reconciliation.

J Res Pharm Pract 2017 Jan-Mar;6(1):61-62

Antimicrobial Resistance Research Center, Iran University of Medical Sciences, Tehran, Iran.

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http://dx.doi.org/10.4103/2279-042X.200992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5348861PMC
March 2017

Urine-Based Nested PCR for the Diagnosis of : A Comparative Study Between HIV-Positive and HIV-Negative Patients.

Jundishapur J Microbiol 2016 Aug 26;9(8):e35634. Epub 2016 Jul 26.

Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, IR Iran.

Background: While tuberculosis (TB) can be diagnosed by microscopy and culture, the sensitivity of Ziehl-Neelsen staining is variable and culture results require 4 - 8 weeks to be determined. Polymerase chain reaction (PCR) and its modifications, including nested PCR, might be promising methods for the rapid diagnosis of TB.

Objectives: This study aimed to evaluate the performance of nested PCR on urine samples of human immunodeficiency virus (HIV)-positive and -negative patients with different manifestations of clinical TB.

Methods: In a prospective study, three early-morning urine samples from 100 patients with pulmonary TB (PTB) or extrapulmonary TB (EPTB) were evaluated using a molecular target with insertion element IS6110, specific to the genome, and nested PCR was performed. The results were analyzed with SPSS version 22.

Results: A total of 100 patients, including 74 (74%) with PTB and 26 (26%) with EPTB, were enrolled. Positive smears were seen in 38 patients (38%). Lymph nodes were the most commonly involved organ in 14 of the 26 (53.8%) EPTB patients (13.5%). Seven (23.1%) of the EPTB patients were HIV-positive. Urine PCR was positive in only 28 patients (28%). Seven HIV-positive patients with PTB showed positive urine PCR results. Moreover, PCR results were positive in only one of the seven HIV-positive subjects with EPTB. Positive PCR results were found in 20 of the 73 HIV-negative patients (27.4%) and in 8 of the 27 HIV-positive patients (29.6%). Therefore, there was no significant difference between the HIV-negative and HIV-positive patients for urine PCR (sensitivity 29.6%, specificity 72.6%; positive and negative predictive values 28% and 72%, respectively; P = 0.138).

Conclusions: Nested PCR showed the same sensitivity in HIV-positive and HIV-negative patients. It can be applied as a rapid technique for the diagnosis of TB.
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http://dx.doi.org/10.5812/jjm.35634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5080847PMC
August 2016

AIDS and hepatitis B and C high risk behaviors among 15 to 45 years old individuals in Bandar Abbas (Iran) in 2012.

Electron Physician 2014 Jul-Sep;6(3):884-9. Epub 2014 Jul 1.

Medical Doctor, Infectious Disease Research Centre, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.

Background: AIDS and hepatitis are two of the most important health issues in the world. Adolescents and individuals in their reproductive years are important population for interventions in order to reduce high risk behaviors for transmission of sexually transmitted disease. However the prevalence of AIDS and hepatitis B and C is high in Bandar Abbas, no study is available about high risk behaviors related to these diseases in Bandar Abbas. The aim of the current study was to investigate high risk behaviors related to AIDS and hepatitis B and C among 15- to 45 year old individuals in Bandar Abbas, Southern Iran.

Method: In this analytical study, 1938 participants between 15- and 45 years of age in Bandar Abbas in 2012 were selected to participate in this study. For each individual, the following information was sought: shared syringes, phlebotomy, tattoos, prisoning, drug abuse, amphetamine, alcohol, smoking, unsafe sexual contacts, as well as demographic information including age, sex, marital status, and education level. Data were analysed using SPSS version 16 (SPSS Inc. Chicago, Illinois, United States) using descriptive statistics and chi-square tests.

Results: A total of 8.4% reported having had tattoos; 10.3% reported previous phlebotomy. Individuals with prison history included 7.3% of our study population and their mean age was 31.4 years. Unsafe sexual contact was reported in 10.7% of the study sample. High risk behaviors were more common among individuals with a low educational level, and in alcohol users and amphetamine users (P<0.05).

Conclusion: High risk behaviors are more common among individuals in their reproductive years. Increasing educational level and knowledge translation are effective in preventing AIDS and hepatitis high risk behaviors.
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http://dx.doi.org/10.14661/2014.883-889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324297PMC
March 2015