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Outcome assessment of a triangular clinic as a harm reduction intervention in
Rajaee-Shahr Prison, Iran
Harm Reduction Journal 2013, 10:41 doi:10.1186/1477-7517-10-41
Rahim Taghizadeh Asl (firstname.lastname@example.org)
Babak Eshrati (email@example.com)
Colleen Anne Dell (firstname.lastname@example.org)
Kelli Taylor (email@example.com)
Parviz Afshar (firstname.lastname@example.org)
Mohammad Kamali (email@example.com)
Ali Mirzazadeh (firstname.lastname@example.org)
Article type Research
Submission date 19 October 2011
Acceptance date 3 December 2013
Publication date 26 December 2013
Article URL http://www.harmreductionjournal.com/content/10/1/41
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Outcome assessment of a triangular clinic as a harm
reduction intervention in Rajaee-Shahr Prison, Iran
Rahim Taghizadeh Asl1†
Colleen Anne Dell3*†
* Corresponding author
1 World Health Organization, Tehran, Iran
2 Arak University of Medical Science, Arak, Iran
3 Department of Sociology & School of Public Health, University of
Saskatchewan, Saskatoon, Saskatchewan, Canada
4 Faculty of Medicine/Medical School, University of Calgary, Calgary, Alberta,
5 Ministry of Welfare, Tehran, Iran
6 Iran University of Medical Science, Tehran, Iran
7 Institute for Health Policy Studies, School of Medicine, University of
California, San Francisco, USA
† Equal contributors.
Transmission of the human immunodeficiency virus (HIV) among incarcerated injection drug
users (IDU) is a health epidemic in the Islamic Republic of Iran. Triangular clinics (TCs)
were established in prisons as a harm reduction measure to decrease the risk of HIV
transmission and other blood-borne infections. The objective of this study was to assess the
immediate outcomes of one TC among male IDUs in Iran’s Rajaee-Shahr prison.
This study was conducted in two stages between 2003 and 2005. In the preparatory stage,
focus group data was collected to update the prison’s TC education and medical interventions
and construct the self-report questionnaire. In stage two, 150 male IDUs were recruited in a
closed cohort study design to assess the immediate outcome of the TC. Participants were
measured at baseline and followed up to six months to measure their drug use, attitude toward
and knowledge of high risk behaviours, serological conversion for HIV, HBV and HCV, and
engagement in risky behaviors. The TC outcomes were determined through random urine
analysis testing, a self-administered questionnaire and behaviour report cards, and viral
The findings of the urine analyses indicated a minimal yet consistent decrease in drug use
over the six months. The pre and post- self-administered questionnaire data relayed a modest
change in IDU risky behaviours associated with sexual practices; this was greater in
comparison to the knowledge and attitude measures. It was determined that age may have a
detrimental effect as may viral infections (HIV and HBV) on knowledge, attitude and
behavior change. Both education and employment may have a protective effect. Data
collected from the self-report behaviour cards similarly showed a modest reduction in high
risk practices. At the six month follow-up, only one case became HIV positive, 9 HCV and
Considering that HIV is concentrated among Iranian prisoners who inject drugs at a high
level, the results of this study indicate that TCs are a possible effective intervention.
However, many prisoners continued with risky behaviors even if they were participating in
harm reduction measures, such as methadone maintenance therapy.
Triangular clinic, Injection drug use, HIV/AIDS, Health belief model
To address the IDU and HIV epidemic we need “to break the silence and change attitudes of
prisoners and policy makers and [have] collaboration all around”.
-Dr. Afshar, Director General of Health Services for the Iranian Prison Organization at the
2004 International AIDS Conference.
With a population of over 75 million people in Iran, the number of individuals abusing drugs
is estimated to be over one million, with approximately 200,000 to 300,000 injection drug
users (IDU) [1,2]. At present, the human immunodeficiency virus (HIV) is highly
concentrated among IDUs . Over the past several years there has been an increase in HIV
cases originating from sexual transmission in the general population , however, the large
majority of new cases (65-79%) remain among IDU’s sharing needles [3-5]. With a growing
proportion of young people making up the Iranian population and an increase in the
availability of drugs, including a mounting relationship between amphetamine-type stimulant
use and high risk sexual practices, the country is vulnerable to an increase in the number of
new drug users, including those engaged in injecting and other high risk behaviours . In
turn, there is potential for a dramatic increase in the prevalence of HIV, as well as the
hepatitis B virus (HBV) and hepatitis C virus (HCV) . The most recent (2012) United
Nations AIDS progress report by the Islamic Republic of Iran acknowledged that if the
current HIV epidemic among IDUs is left unattended, it has the potential to turn into a
generalized population epidemic .
Acknowledging the direct linkage between IDU and the spread of HIV, Iran committed to
attempts to control the spread of the disease at the 2003, 2008 and 2011 United Nations
General Assembly Special Sessions on HIV/AIDS. The latest data relay that “[m]easures
taken over the past ten years have successfully slowed the progression of the epidemic among
injection drug users”, but the HIV rate among IDUs remains at around 15% and varies across
the country . A surveillance survey in 2010 in Iran further revealed that “among those who
had injected drugs over the last month, 36.9% had used a non-sterile needle, and 12.6% had
practiced shared injection” . Controlling the spread of HIV within Iranian penitentiaries is
a particular concern with their concentration of IDUs as well as high risk behaviours.
Foremost, the majority of incarcerated IDUs, some HIV positive, will reintegrate back into
their communities, and this is a particular concern for the spread of HIV and other transmitted
A 2006 study by Zamani et al. reported that 94% of IDUs in Iran have been incarcerated at
least once in their lifetime. Among them, 28% reported using injection drugs at least once
within the prison; of these, 82% reported using a shared injection device, with 36% of these
individuals being HIV-positive . A 2007 study by the same authors found that in their site-
specific study of Karaj Central prison  in Iran, 42% of prisoners reported to use
intravenous drugs before their incarceration. A more recent 2013 study, reporting on 2009
data from a sample of 27 Iranian prisons, concluded that the prevalence of HIV among the
prisoner population is 2.1%, and 8.1% among those who have a history of IDU . They also
found that only 24% of prisoners reported condom use during their last vaginal/anal sexual
encounter in prison, 12.9% reported being tattooed while incarcerated, and only one in five
had sufficient knowledge of the routes of HIV transmission and preventative measures .
Such high risk behaviours among prisoners both before and during their incarceration have
turned Iranian prisons into highly prospective environments for acquiring HIV.
In response, triangular clinics (TCs) surfaced in Iranian prisons at the turn of the 21st century
 as part of a coordinated, country-wide approach to the dual epidemic of HIV and IDU
. Iran has a long-standing commitment to supply reduction efforts, that is, largely
enforcement efforts that aim to disrupt the manufacturing and distribution of drugs, with a
history of severe punishment for drug dealing. This coincides with the correctional system’s
harsh and overcrowded prison conditions, detainment of political dissidents, and carrying out
of prisoner executions. However, with a high rate of IDU and an emerging HIV health
epidemic, coupled with lessons learned from other countries, demand reduction efforts that
focus on treatment and prevention were introduced to reduce individuals’ needs for drugs.
Harm reduction clinics initiated in the community; these are drop-in centres in drug-ridden
neighborhoods where former drug abusers assist with offering “needles, methadone,
treatment for sexually transmitted diseases, AIDS tests and other medical care to their peers”
. The clinics transitioned into triangular clinics in the prison environment and similarly
offer harm reduction measures. Both clinic types were embraced as both pragmatic and
progressive in consideration of the country’s general conservative social climate [11,14]. In
fact, Iran’s concept of the TC is largely unique across the globe . In Canada and the
United states, for example, the prison systems do not offer needle exchange even though IDU
in these systems too is a concern; it is frequently a part of the fabric of prison life .
In line with Iran’s promotion of a participatory and proactive approach to control the HIV
epidemic , TCs acknowledge the mutual role of the prisoner, the staff and the prison
environment. Triangular Clinics aim to: (1) improve information to affected groups regarding
HIV/AIDS/drug abuse; (2) improve information to staff regarding HIV/AIDS/drug abuse, (3)
provide access to facilities regarding harm reduction, and (4) improve the quality of life and
empowerment of affected citizens . These aims support the Health Belief Model (HBM)
and its focus on informing beliefs (knowledge) and attitudes to eventually change behaviour,
and specifically within the HV/AIDS field. “Within a harm reduction context, the HBM
provides a systematic framework for examining the reasoning behind an individual’s choice
to decrease, maintain or increase their high risk behaviour” . It is well established in the
prevention and treatment literature that handing out clean needles in isolation from other
support services, for example, is inadequate for sustainable behaviour change .
The TCs provide a variety of harm reduction services including counseling, education,
referral services, and treatment such as methadone maintenance therapy (MMT) . For
example, MMT is currently available to opioid-dependent prisoners in over half of the 230
prisons and correctional settings in Iran . With the introduction of TCs and MMT, the
total number of prisoners taking part in methadone therapy increased from 100 in 2002 to
more than 25,000 in 2009 [1,20]. Since their introduction they have also expanded to address
STIs in addition to HIV/AIDS. However, still, relatively little research has been undertaken
to assess the outcome of TC’s on behavior change. The aim of this study is to assess the
immediate outcome of a TC on behavior change among injection drug users incarcerated in
Rajaee-Shahr prison in Iran. Drawing on available data, the outcome indicators include (1)
drug use, (2) change in attitude toward and belief about (knowledge) high risk behaviours, (3)
serological conversion (HIV, HCV and HBV), and (4) engagement in risky behaviors (e.g.,
syringe exchange, condom use).
Setting and sample
In order to assess the immediate outcome of the TC as a health intervention in an Iranian
prison, this study funded by the World Health Organization was undertaken in Rajaee-Shahr
prison between 2003 and 2005. The lapse in time between the data collection and publication
of this paper in part reflects the detailed process for data release in the country. Ethics for the
study was granted from the World Health Organization, Special Programme for Research and
Training in Tropical Diseases, and the Iran Prisons Organization ethics committee. Rajaee-
Shahr prison is located 70 km northwest of Tehran (Iran’s capital) in the city of Karaj, has an
inmate population of approximately 3,200 individuals, and is one of the most crowed and
harsh prison environments in the country [12,20].
The study sample was a closed cohort of 150 incarcerated male injection drug users; the first
150 prisoners who voluntarily registered in the study were included. Given the conservative
environment of the Iranian correctional facility, this was deemed the best method to solicit
participation and is similar to how other topic sensitive studies have been carried out in the
prison system . In order to be eligible for selection, individuals must: (1) have been
imprisoned for more than four months, (2) not have been diagnosed with a psychiatric
disorder, (3) not have previously accessed the TC or other harm reduction services in the
prison, and (4) be an injection drug user and willing to take part in MMT. Verbal informed
consent was acquired from all study participants. For individuals with low literacy, a
designated and trained staff member was available to confidentially assist with the prisoners’
participation in the study.
The study was conducted in two stages: (1) the qualitative preparatory stage, and (2) the
quantitative outcome testing stage. The first stage is addressed in detail in this paper and sets
the necessary context for understanding the operation of a TC. In this preparatory stage, three
focus groups were held. The groups were comprised of eight to ten men imprisoned in
Rajaee-Shahr prison who were involved in high risk drug and sexual behaviors (e.g., needle
sharing); all focus groups were held in Farsi language and lasted approximately two hours.
The aim of this initial step in the study was to gather baseline understanding about the target
group’s knowledge, attitude, and practices related to IDU, HIV/AIDS, HBV, HCV, unsafe
sexual practices, and other risky behaviors. These three foci reflect the Health Belief Model,
which focuses on individuals’ attitudes and beliefs in an attempt to explain and predict health
behaviors, in particular sexual and other high risk taking to prevent the transmission of HIV
[19,21,22]. This data was used to review and revise the existing TC educational and medical
interventions in Rajaee-Shahr prison as well as to construct the questionnaire for the second
step of the study – measuring immediate outcomes.
The second stage of the study collected data from all participants at baseline and six months
following their first attendance at the TC. The questionnaire was designed to address the key
components of the Health Belief Model: (1) perceived risk (measuring knowledge and
attitude), (2) perceived severity (measuring knowledge and attitude), (3) perceived benefits
(measuring attitude), (4) perceived barriers (measuring attitude), and (4) cues to action
(measuring behaviors). The questionnaire included 75 questions, measuring knowledge (39
questions), attitude (26 questions), and practices (10 questions). The content validity of the
questionnaire was assessed through six expert reviews in the areas of health education,
infectious disease, and psychology. The self-administered questionnaire was then tested for
reliability among 40 randomly selected prisoners representative of the study target group
imprisoned at Rajee-Shahr. With 34 responses, internal consistency of the questionnaire was
measured with Cronbach’s Alpha test, and the outcome was greater than 74%.
In addition to the questionnaire, at pre-test each participant completed a personal history
survey, a physical examination, testing for HIV, HBV and HCV viral infection, STI testing,
and urine analysis for drug residue. From this, physicians determined the medical needs of
each participant and suggested various treatment options, including detoxification, STI
counseling, and MMT. A health and education counseling session was held with each
All 150 participants started MMT in groups of 5 to10 (referred to as the attack phase).
Throughout this phase, participants were closely monitored for several weeks in an isolated
ward of the prison to minimize any unanticipated effects of withdrawal and risks due to other
drug use. The prescribed methadone dosage for each participant was determined by a
physician and accounted for the participant’s health status, drug use history, and other
personal indexes. The daily dosage of methadone was between 80–125 mg. Following the
attack phase, participants were relocated to the common ward of the prison where they
received a maintenance dose of methadone (referred to as the loading phase). This phase was
undertaken for a 6-month period, during which all participants received their daily dosage of
methadone under the direct supervision of a trained health staff member. This marked the
beginning of the outcome testing of the TC intervention.
After 6 months, the participants completed: (1) random urine analysis for opium/heroin
residuals via thin-layer chromatography (TLC) to measure drug use, (2) the follow-up study
questionnaire (to measure practice, knowledge, and attitude change), and (3) HIV, HBV,
HCV viral infection testing. The study also issued and collected self-report behavior cards at
four equal intervals over the 6 month period (at the end of months 2, 3, 4 and 5). The study
benefited from applying these cards in two ways: to remind participants of the high risk for
contracting viral infections (i.e., HIV, HBV, HCV) with risky behaviors (e.g., sharing sharp
instruments such as a razor, tattooing, injecting drugs, sexual contact without using a
condom), and to collect self-reported engagement in risky behaviours.
Of the 150 participants enrolled in the study, all reported to be of Iranian and Muslim
descent, with 62% born in the province of Tehran. The mean age was 31.4 years (SD = 8.2).
Only 21% graduated from high school or attended university, while 14% identified
themselves as illiterate. Eleven percent of participants reported being unemployed at their
time of their incarceration. Fifty percent were single and had never been married, and of
those that were married, 65 had children. The mean years of drug abuse was 10.97 (SD = 7.6)
and the mean years of injection drug use was 5.39 (SD = 5.21). This translates into
participants reporting to have spent, on average, a third of their lives abusing drugs (32% of
lifetime, SD = 17.08%), with engagement in injection drug use for approximately one-
seventh of their lives (15.98% of lifetime, SD = 12.75%). A total of 103 participants
completed the full study.
More than 88% of the participants agreed to be tested for viral infections at the start of the
study, of which 42.5% tested positive for HIV, 18.9% for HBV, and 75.9% for HCV. Ninety
percent of participants were screened for sexually transmitted infections (gonorrhea and
syphilis) and all were negative. A urinalysis was performed on 81% of participants; only one
participant tested positive and for a urinary tract infection. Although the findings of this study
are unique to Rajaee-Shahr prison and therefore not directly transferable to other TCs in the
Iranian correctional system, given the comparable context of HIV, IDU and incarceration
across the country, they can provide important insight.
The data collected in the qualitative preparatory stage of the study was systematically
reviewed to recommend revisions to the current TC educational and medical interventions for
high risk groups, primarily IDUs, in the prison (e.g., cultural adaption). They were originally
developed based on the best available knowledge at the time and this study was the first
attempt to review the prisoner, staff and prison context for their implementation. Attention
was placed during this stage on prisoner behavior change. This stage was time intensive
because all interventions needed to be compatible with prison rules and required staff
The amended interventions offered through the TC included: counseling and testing for
HIV/AIDS and Hepatitis; STI and disease examination (i.e., Venereal Disease Research
Laboratory test for syphilis, Fluorescent Treponemal Antibody-Absorption and Gram
Staining for Gonorrhea, and Urine Analysis for Urinary Tract Infections), treatment, and
care; harm reduction and related drug abuse services, including MMT, syringe exchange, and
care and treatment of injection sites; education regarding HIV/AIDS, STIs, and harm
reduction; and other related services, such as condom distribution, medication, and treating
other diseases such as Tuberculosis. The inclusion of MMT was based on the finding that
heroin was the most popular and commonly injected drug among the prison population due to
its ease of access, low cost, and efficiency.
Drawing on available data, the outcome indicators include: (1) drug use, (2) change in
attitude toward and belief about (knowledge) high risk behaviours, (3) serological conversion
(HIV, HCV and HBV), and (4) engagement in risky behaviors (e.g., syringe exchange,
Throughout the TC intervention, random urine analysis using TLC was conducted to detect
opium and heroin residuals, a strong indicator of injection drug use. Compliance was limited
with only 64% of participants providing samples at the four points. Positive drug results for
opium and heroin were high, ranging from 78.9% to 81.6% of participants (see Table 1). The
data does indicate a minimal yet consistent decrease over time (from 81.6% to 78.9%),
however, this was not significant (p = 0.982).
Table 1 Opium and/or heroin use during TC intervention
1 Negative 7 4.7 18.4
Positive 31 20.7 81.6
Total 38 25.3 100.0
2 Negative 5 3.3 18.5
Positive 22 14.7 81.5
Total 27 18.0 100.0
3 Negative 16 10.7 19.5
Positive 66 44.0 80.5
Total 82 54.7 100.0
4 Negative 20 13.3 21.1
Positive 75 50.0 78.9
Total 95 63.3 100.0
Practice, knowledge and attitude change
Analysis of the pre and post- self-administered questionnaire data relayed that a change in
IDU risky behaviours and associated sexual practices, although modest, was greater in
comparison to knowledge and attitude (see Table 2) and also had the least respondent
variability among the three components of the HBM. The results of a paired t-test (see Table
3) similarly revealed reduced engagement in risky practices following respondents’ TC
attendance (.000). Neither knowledge nor attitude appeared to be affected—positively or
Table 2 Practice, knowledge and attitude change
N Mean (% of
Percentage of mean score to
maximum achievable score
Knowledge pre-test 104 46 27.17 (0.69.6) 6.30 0 0.92
Knowledge post-test 53 97 27.63 (0.70.8) 5.29 0.45 0.89
Attitude pre-test 149 1 76.44 (0.73.5) 9.51 0.40 1.01
Attitude post-test 92 58 75.51 (0.72.6) 13.60 0.30 1
Practice pre-test 148 2 11.85 (0.59.2) 3.19 0.05 0.9
Practice post-test 91 59 13.69 (0.68.4) 3.09 0.21 0.95
Table 3 Pre and post-test impact of TC on practice, knowledge and attitude
Knowledge pre and post-test .937
Attitude pre and post-test .687
Behaviour pre and post-test .000
Combined knowledge, attitude and behavior pre and post-test .419
Applying multiple linear regression to examine a combined knowledge, attitude and behavior
(KAB) score, the only significant determinant was the degree of knowledge, attitude and
behaviour pre-test, adjusting for age, employment, addiction history, viral infection status,
and education. This may be partially explained by the size of the study population and the
loss of follow-up participants. It can, however, be tentatively hypothesized that based on the
coefficients a larger sample size may produce statistical significance.
Additional data analyses relayed that post-intervention KAB is significantly related to KAB
at baseline (P = 0.05) (see Table 4). Further, individuals with positive test results in HIV
(Beta −5.36) and HBV (Beta −4.48) and also older in age (Beta −0.16 per 1 year increase in
age) had acquired scores in KAB, although it was not statistically significant. Age may have
an inverse effect on the KAB score as may viral infections (HIV and HBV). Both education
and employment may have a positive effect.
Table 4 Knowledge, attitude and behaviour post-test association with independent
KAB pretest 0.31 0.052
Age −0.16 0.719
Employment 4.48 0.76
Addiction history 0.27 0.521
HIV + infection −5.36 0.383
HBV + infection −4.48 0.483
Education 1.45 0.75
HIV, HBV and HCV conversion
The findings of the questionnaire relaying a slight reduction in IDU-related risky behaviour
and this is consistent with the viral infection test results, which showed an increase in 1 HIV
conversion, 21 HBV, and 9 HCV (see Figure 1). Although comparison data on conversions
prior to the TC are not available, these findings are encouraging among a high risk group of
IDUs. Recall that at baseline 43% of respondents tested positive for HIV, 19% HBV and 76%
Figure 1 Viral Infection Status of Study Participants Before and After TC Intervention.
The completion rate for the self-report behaviour cards documenting the participants’ high
risk drug and sexual-related practices during the TC intervention was limited (see Table 5).
Nonetheless, the data relay that over the course of the 6 month study, 53% of the study
participants remained free of any risky behaviour after two months of involvement in the
intervention. Engagement in risky behavior increased throughout the 6 month period, with
only 1.4% of the participants reporting being risk-free after the total period of the study (i.e.,
6 months) (see Table 6).
Table 5 Frequency of high risk practices on self-report behaviour cards
Time 1 72 78 150
Time 2 57 93 150
Time 3 41 109 150
Time 4 68 82 150
*Includes individuals who did not complete the study.
Table 6 Timing of prisoners’ practicing of risky behaviour
Interval End of
Engaged in Risky
Lost Survival Std. Error [95% Conf. Int.]
1 2 110 52 0 0.527 0.047 0.43 0.615
2 3 58 14 0 0.40 0.046 0.308 0.489
3 4 44 31 0 0.118 0.030 0.066 0.186
4 5 13 9 4 0.014 0.014 0.004 0.067
More specifically, focusing on HCV converted status because it had the highest initial viral
infection rate among the prison population and therefore the greatest availability and
accuracy of immediate test results, when risky practices at any of the four time points during
the 6 month TC intervention were tested among participants who became HCV positive, the
data collected on the self-report behavior cards showed that there was no significant
difference between the risky behavior of converted cases and others (fisher’s exact test:
2sided = 1.00) (see Table 7).
Table 7 Practicing of risky behaviors among participants who became HCV positive
during the study
Converted HCV test
Risky behavior Yes 90 5 95
No 0 0 0
Missing 34 1 35
Total 124 6 130
Although not identified in the initial study design, two additional indicators of high risk
behavior emerged as the study progressed. These were the frequency of abscess formation at
the injection site, and the number of drug-related quarrels. According to informal clinical
observations and security records, there was no evidence of either of these issues among the
study participants. This again suggests that there was some reduction in risky behaviors.
Risky practices index
In acknowledgement of the cultural taboo associated with intoxicant use in Iran and its
potential impact on full disclosure in the study, an index for participating in risky practices
related to IDU was created through a combining of reported shared drug injection equipment
and positive urine analysis. The findings relayed that 71% of participants engaged in at least
one high risk behaviour during the TC intervention, despite receiving the TC harm reduction
services. With 29% of the sample missing, it is unknown if any participants were totally free
from risky behavior during the 6 month study period. Overall, participation in risky
behaviour varied between 93% and 86% at the four reporting points over the course of the TC
intervention (see Figure 2).
Figure 2 Proportion of Participants Engaging in Risky Practices Index over the 6
Month TC Intervention.
The documented number of HIV cases in Iran increased 87% between 2001 and 2007 .
The vast majority of new cases were identified among IDUs [24-26]. The two key risk factors
are imprisonment and the use of contaminated injection equipment while incarcerated .
Likewise, recent studies of HCV among men incarcerated in Tehran, Iran identified a history
of incarceration to be independently associated with HCV infection . The same was
found of HBV and sexually transmitted diseases [27,45]. The same cannot necessarily be
applied to female prisoners in Iran . A recent study of TCs in Hamadan province in Iran
concluded that the establishment of TCs is a starting point for organizing IDUs infected with
HIV/AIDS to detect and address their disease . It is well established that there is a high
prevalence of high risk behaviors among IDUs , but there remains limited understanding
about how to change the high risk behaviours of incarcerated individuals who inject drugs,
including the immediate and long-term outcomes of TCs.
Although time consuming, it was critical that the first step in this study focused on generating
knowledge about the prisoner population so that the existing Rajaee-Shahr TC educational
and medical interventions could be appropriately modified. For example, it was established
that the low literacy level among the majority of prisoners who would access the TC needed
to be considered in the available written material. Offering services at the TC that are tailored
to respond foremost to client needs is foundational to a harm reduction philosophy. It was
also essential that baseline characteristics of the prisoner population were established to
undertake step two of the study and the identification of outcome indicators, such as HIV,
HCV and HBV status, which have been identified as particularly problematic among
individuals who inject drugs in Tehran, Iran .
The findings of this study relay that the immediate outcome of the TC in Rajaee-Shahr prison
on behaviour change among injection drug users is modest. The premise of the Health Belief
Model – that individuals’ attitudes and beliefs explain and predict health behaviors – did not
support behaviour change over the six-month period. This does not mean, however, that the
TC is ineffective. In fact, evidence to the contrary was concluded. It should also be kept in
mind that Rajaee-Shahr prison is an institution in which individuals are sentenced for serious,
long-term crimes and the volunteer sample for this study represents long-term, high risk
IDUs. Consequently, the impact of harm reduction measures on knowledge and attitude may
be minimal in the sort-term, even though some behavior was modified. A study by Shams et
al. (2011) examined the impact of harm reduction approaches in Iranian prisons over a two
year period and found there was not an immediate reduction (after one year/2007) in social
behavior across the provincial institutions (e.g., self-harm, drug abuse, bullying), but that
over the long-term (2 years/2008) there was .
Examining this study’s outcome indicators, it was concluded that introducing the TC
intervention led to a minimal decrease in drug use (i.e., opium and heroin), although it did
consistently decrease over the 6 month period. Once again, the high risk IDU prisoner
population needs to be considered in interpreting this finding. This is a particularly important
finding given that all participants in the study were prescribed MMT. Reasons for the
participants’ continued drug use while on MMT requires exploration, including whether it is
in the individual’s best interest to be prescribed methadone. Future studies should investigate
MMT dosage guidelines, means of distribution to combat diversion, and the source of
problematic drug use within the prison environment in order to provide the most effective TC
harm reduction intervention.
Although the majority of participants continued their drug use, there was still some reported
decrease in associated risky practices, although this was not sustained by the vast majority of
participants over the six month intervention. With participants reporting long-term drug use,
including IDU, it should not be expected that a swift change in behavior would occur.
Although, a recent study of prisoners in Ghezel Hesar prison in Tehran, Iran found that “the
rate of injecting in the prison unit … decreased drastically since introducing the MMT
program” . Further examination into the specifics of this intervention would be useful.
The corresponding absence of change in knowledge and attitude in the current study may in
part be explained by the primary focus of the TC being on behaviour change, and the fact that
individuals enrolled in the study may have already had altered beliefs and attitudes based on
the preparatory stage of the study/at baseline. This finding may also suggest that access to
harm reduction services, including MMT, has the potential to motivate prisoners to change
their behavior without altering their current knowledge or attitude. This is an important
consideration to follow-up on, given that long-term change in high risk behaviors, according
to the Health Belief Model, requires change among all three components. This may in fact
help to explain the lack of sustained behaviour change across the 6 month study period.
There was no difference found in engagement in risky behaviour among participants who
became HCV positive during the study and those that did not. This implies that a ‘one size
fits all’ approach to practice change may not be warranted, which underpins the harm
reduction philosophy of a TC. There is a need for much greater understanding about the
intricacies of prisoners’ lives and their high risk drug use and sexual practice related
It was also found that HIV and HBV positive status as well as older age may diminish change
in knowledge, attitude and practices. This may be explained by the feeling of hopelessness
that may accompany a positive viral status and pessimism with older age. This is supported
by the finding that the effect was stronger for HIV infection. The opposite may be the case
for participants with higher education and employment status. A 2010 survey of injection
drug users in Iran similarly found that education greater than high school and permanent
employment were protective factors for HIV transmission .
The results of the current study suggest that existing interventions may not be as effective for
extremely high risk groups like drug injecting prisoners who already are affected with viral
infections and are well informed given their compromised health status; hence this may
indicate the need for targeted interventions for specific groups .
It is well established that not enough is known about the high risk behaviors of IDUs in Iran,
both generally and particularly within prison sub-populations [31,34]. A baseline study of
prisoners in Karaj Central prison, for example, found that injecting, in comparison to non-
injecting drug-using prisoners, were more likely to have been tested for HIV infection ;
this is useful information. In measuring the outcome of the TC, the current study only
considered injection drug use and related risky practices. To further develop the TC, it would
be useful to know more context-specific information, such as if the TC stimulates change in
the extent to which drug users organize their lives around drug use, how much drug use is
integrated into their lives, and the ways in which drug use negatively impacts other aspects of
their health . Related, it was determined that the most frequent viral infection among the
participants was Hepatitis C. This is consistent with other studies of incarcerated groups ,
and should be given equivalent attention to HIV in the reduction measures being
implemented within TCs.
Given the complex nature of this study, it has four key limitations. These may in part explain
the absence of concrete findings. First, the attempt to measure both sex and non-sex related
high risk behaviors in the conservative social environment of a prison setting in Iran has
extreme cultural and religious taboos. This may have translated into decreased levels of
accuracy and compliance with reporting in the study. One means to address this was the
development of a risky practices index (combined indicator of reported shared drug injection
equipment and positive urine analysis results at the same sequence). In the future, the
development of a less complex and lengthy questionnaire may want to be considered, as well
as observational reporting. Related, focus was paid to measuring prisoner behavior to the
exclusion of considering the mutual role of staff in the TC and the prison environment (other
than in the preparatory phase) in this study. Third, participant retention was a limitation of the
study; it is anticipated that with an increased, non-punitive presence of the TC clinic within
the prison environment as time progresses, prisoners may be willing to report their IDU and
associated risky practices. And fourth, the use of thin-layer chromatography as the form of
urine analysis in this study has potential problems in that it may produce incorrect
conclusions; it can produce both a false positive and a false negative for various reasons,
including the presence of drug metabolite-like chemicals in urine and human error. Although
more expensive, more accurate tests may want to be applied in future studies.
Although the findings of this study are specific to Rajaee-Shahar prison in Tehran, Iran, it
remains that the Iranian prisoner “population is under-served by HIV prevention services, as
are the prison populations of many countries in the Middle East and Eastern Mediterranean
regions” . This recognition is transferable to other countries in the world. As the Iranian
working group on drug treatment and rehabilitation in prison settings shared: “We believe
that Iran with the unfortunately large addiction affliction has much to offer and in return is
eager to learn when it comes to clinical interventions in drug abuse” . Thus this study
makes a contribution to both understanding harm reduction practices within an Iranian prison
and the international literature. As correspondent Ian Tanner writes for The Majalla, an Arab
magazine, “Despite the draconian policy towards punishing trafficking and the fact that
treatment is not universally available, Iran’s drug policy is at the very least surprising, and
perhaps even inspiring” .
The results of this study relay that the TC in Rajaee-Shahr prison had modest immediate
impact (i.e., 6 months) in reducing high risk harmful behaviors among incarcerated IDUs. In
its current form, it is unknown if the TC would bring about a sustainable, long-term reduction
in harmful behaviors. This is particularly important considering the lack of significant change
in knowledge and attitude related to high risk practices; the three together comprise the
Health Belief Model. Also, considering the large number of missed cases at follow-up, it may
further indicate the clinic’s benefits were either not evident or relevant to the participants.
Past studies have shown that harm reduction initiatives are most effective when perceived
benefit is high among participants . Future research is required to determine the specific
gaps in the current TC model.
In order to combat the HIV/AIDS epidemic in Iran, the results of this research must be
considered not only in the context of the prison environment, but beyond to the general
Iranian population . The majority of the prisoners in Rajaee-Shahr prison will be released
and will reintegrate into the general population where they have the potential to spread HIV
and other viral infections . We know from other studies that injection drug users engage
in high risk behaviors outside the prison environment . We also know that there is a need
for practice and research-focused attention to be placed on the transition from prison to the
community, and keeping up safe practices such as MMT. A recent study of HIV/AIDS in Iran
emphasized “the need for intensified HIV prevention efforts with men who use drugs via
injection and strengthened efforts to encourage the individual at risk to get tested for HIV”
. With a large number of IDUs filtering through the prison system in Iran, and the high
rates of HIV, HBV and HCV, this may be an ideal catchment area. This is supported in other
studies [36,37]; in the general Iranian community, people who wish to determine their HIV
status are oftentimes prevented from doing so because of the sociocultural context. As a
result, the impacts of the triangular clinic examined in this study should be supported as one
part of a broad, multi-faceted HIV/AIDS and other health behaviour prevention strategy in
the Islamic Republic of Iran.
The authors declare that they have no competing interests.
RTA and BE participated in the design of the study, collection of data, analysis and
interpretation of data, drafting the article, and final approval of this version. CAD and KT
participated in contextualizing the data, drafting the article, and final approval of this version.
PA, MH and AM participated in reviewing drafts of this paper and final approval of this
version. All authors read and approved the final manuscript.
This study was part of a larger study funded by the World Health Organization (IDNO:
SGS03/67). The authors would like to acknowledge the World Health Organization for its
financial support of the project. They would also like to acknowledge the cooperation of the
Health Bureau of Iran Prisons Organization and personnel of the heath office of Rajaee-Shahr
prison who made the prison and prisoners accessible to us, and kindly provided us with
access to assess their interventions. Dr (Ms) Marzieh Farnia, Director General of Health
Bureau in Iran Prisons Organization and Dr (Ms) Joumana Hermes, Medical Officer of
WHO-EMOR are specifically thanked for their review and comments on this article.
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