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Harm reduction is a health-centred approach that seeks to reduce the health and social harms associated with high-risk behaviors, such as illicit drug use. The objective of this study is to determine the association between the beliefs of a group of adult, male prisoners in Iran about the transmission of HIV and their high-risk practices while in prison. A cross-sectional study was conducted in 2004. The study population was a random selection of 100 men incarcerated at Rajaei-Shahr prison. The data were collected through a self-administered questionnaire. Focus group discussions were held at the prison to guide the design of the questionnaire. The relationship between components of the Health Belief Model (HBM) and prisoners' risky HIV-related behaviors was examined. Calculating Pearson's correlation coefficient, a significant, positive association was found between the benefit component of the HBM and prisoners not engaging in HIV high-risk behaviors. Educational harm reduction initiatives that promote the effectiveness of strategies designed to reduce the risk of HIV transmission may decrease prisoners' high-risk behaviors. This finding provides initial support for the Iran prison system's current offering of HIV/AIDS harm reduction programming and suggests the need to offer increased education about the effectiveness of HIV prevention practices.
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BioMed Central
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Harm Reduction Journal
Open Access
Research
Preventing HIV transmission among Iranian prisoners: Initial
support for providing education on the benefits of harm reduction
practices
Babak Eshrati
1
, Rahim Taghizadeh Asl
2
, Colleen Anne Dell*
3
, Parviz Afshar
4
,
Peggy Margaret E Millson
5
, Mohammad Kamali
6
and John Weekes
7
Address:
1
Arak University of Medical Science, Arak, Iran,
2
United Nations Development Programme, Tehran, Iran,
3
Department of Sociology,
University of Saskatchewan, Saskatchewan, Canada,
4
Health and Correction Deputy of Prison Organization, Tehran, Iran,
5
Department of Public
Health Sciences, University of Toronto, Toronto, Canada,
6
Iran Medical University, Tehran, Iran and
7
Institute of Criminology and Criminal
Justice, Carleton University, Ottawa, Canada
Email: Babak Eshrati - eshratib@sina.tums.ac.ir; Rahim Taghizadeh Asl - taghizadehasl@yahoo.com;
Colleen Anne Dell* - colleen.dell@usask.ca; Parviz Afshar - afshar_pmd@yahoo.com; Peggy Margaret E Millson - p.millson@utoronto.ca;
Mohammad Kamali - kamali@mkamali.com; John Weekes - WeekesJR@CSC-SCC.GC.CA
* Corresponding author
Abstract
Background: Harm reduction is a health-centred approach that seeks to reduce the health and
social harms associated with high-risk behaviors, such as illicit drug use. The objective of this study
is to determine the association between the beliefs of a group of adult, male prisoners in Iran about
the transmission of HIV and their high-risk practices while in prison.
Methods: A cross-sectional study was conducted in 2004. The study population was a random
selection of 100 men incarcerated at Rajaei-Shahr prison. The data were collected through a self-
administered questionnaire. Focus group discussions were held at the prison to guide the design of
the questionnaire. The relationship between components of the Health Belief Model (HBM) and
prisoners' risky HIV-related behaviors was examined.
Results: Calculating Pearson's correlation coefficient, a significant, positive association was found
between the benefit component of the HBM and prisoners not engaging in HIV high-risk behaviors.
Conclusion: Educational harm reduction initiatives that promote the effectiveness of strategies
designed to reduce the risk of HIV transmission may decrease prisoners' high-risk behaviors. This
finding provides initial support for the Iran prison system's current offering of HIV/AIDS harm
reduction programming and suggests the need to offer increased education about the effectiveness
of HIV prevention practices.
Background
Injection drug use and high-risk sexual behaviors are key
contributing factors to the transmission of the human
immunodeficiency virus (HIV). These behaviours have
been identified in international research as two of the
most common modes of HIV transmission in the prison
setting [1,2]. They have also been identified as main con-
tributing factors to increasing rates of HIV infection in
Published: 9 June 2008
Harm Reduction Journal 2008, 5:21 doi:10.1186/1477-7517-5-21
Received: 3 October 2007
Accepted: 9 June 2008
This article is available from: http://www.harmreductionjournal.com/content/5/1/21
© 2008 Eshrati et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Harm Reduction Journal 2008, 5:21 http://www.harmreductionjournal.com/content/5/1/21
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Iran generally [3]. The opium ban in Iran has led to greater
heroin use and injecting, and hence elevated rates of HIV
infection through the sharing of injection equipment [4].
Alongside this, the government's focus on illicit drug sup-
ply-reduction has resulted in the prison becoming pro-
gressively more populated with individuals serving
sentences for drug-related crimes and using drugs. HIV
transmission in Iranian prisons has become a major con-
cern for the country [5].
Harm reduction is a health-centered approach that seeks
to reduce the health and social harms associated with
high-risk behaviors [6,7]. Harm reduction initiatives are
commonly targeted toward specific high-risk populations,
including prisoners. A key component of such initiatives
is taking a non-judgemental approach to the choices indi-
viduals make (e.g., decreased use of illicit drugs). There
are various, although intermittent, forms of HIV-related
harm reduction programs available to injection drug users
within the Iranian prison system, ranging from metha-
done maintenance therapy to the provision of sterile
equipment to inject drugs. Likewise, harm reduction initi-
atives such as condom distribution exist for individuals at
risk of HIV due to their sexual practices. Although the con-
temporary Iranian prison system response to HIV trans-
mission among its prisoner population has been very
progressive, there remains considerable room for
improvement [3,8].
In order to increase harm reduction programming across
the Iranian prison system, the effectiveness of its applica-
tion needs to be empirically established. The objective of
this study is to determine the association between the
beliefs of a group of adult, male prisoners in Iran about
the transmission of HIV/AIDS and their high-risk practices
while in prison. We begin by establishing the beliefs pris-
oners' hold about how HIV is transmitted. We then iden-
tify the types of behaviours prisoners engage in that have
the potential for HIV transmission. Using the Health
Belief Model (HBM) framework, and calculating statistical
measures such as Pearson's correlation coefficient, we
examine the association between prisoners' beliefs and
practices. Based on the findings, it is suggested that educa-
tional harm reduction initiatives that promote the effec-
tiveness of strategies designed to reduce the risk of HIV
transmission may decrease prisoners' high-risk behaviors.
The Health Belief Model (HBM) focuses on the attitudes
and beliefs of individuals and attempts to explain and pre-
dict their health behaviors [9,10]. The HBM is a widely
used framework to help explain health related behaviors,
including sexual risk taking and the transmission of HIV/
AIDS [11]. The HBM is comprised of three key compo-
nents: threat (believed susceptibility to and severity of a
health condition), benefits (believed effectiveness of strat-
egies designed to reduce the risk or seriousness of impact
of a health condition), and barriers (believed negative
consequences that may result from taking particular
health actions because of a health condition). Stated sim-
ply, a person is believed to take part in preventative health
related behavior (e.g., use a condom) if they feel the neg-
ative health condition can be avoided, if they feel their
particular action can avoid the negative health condition,
and if they are able to put the recommended health action
into practice. Within a harm reduction context, the HBM
provides a systematic framework for examining the rea-
soning behind an individual's choice to decrease, main-
tain or increase their high-risk behaviour. This is
important in a prison context as educating individuals
about the health risks of their behaviors through training
and counselling is a widely-supported form of health pro-
motion and disease prevention.
Methods
A cross-sectional study design was undertaken to deter-
mine the beliefs and associated high-risk behaviors con-
nected with the transmission of HIV among a group of
adult males incarcerated in Rajaei-Shahr prison. This max-
imum-security prison is located in Karaj city, which is
approximately 70 km North West of Tehran, the capital
city of Iran. The study sample is 100 adult males who were
incarcerated in March, 2004. The total incarcerated popu-
lation at the time was approximately 3,200 males and 300
females. The participants in our study were randomly
selected from a roster prepared by the prison authorities.
This roster was developed based on an existing list of
incarcerated cases provided by the prison authority and
who were deemed accessible (i.e., not in solitary confine-
ment or have specific reservations associated with them).
Our sample is representative of the majority of male pris-
oners incarcerated at the prison at the time of the study. At
the time, the design did not allow us to consider the types
of crimes individuals were jailed for. It can be stated
though that the Iran Prisons Organization tends to incar-
cerate like individuals together (e.g., type of crime).
Participation in the study was voluntary and required ver-
bal informed consent, with the guarantee of anonymity.
The collected data is securely maintained by the research-
ers. The questionnaire consisted of 75 items and was avail-
able in Farsi (Persian). For those prisoners with low
literacy levels, a designated and trained health staff mem-
ber was available to read the questions out loud without
influence on the confidential responses. The response rate
was 100%, and all questionnaire data were completed.
This high rate is explained in part by the support prisoners
have for the health programs offered by the prison, as well
as the opportunity to engage in an activity that is outside
their regular routines. There was no incentive (e.g., gift)
for participating. This study was part of a larger research
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project conducted between 2003 and 2005; this study
examined the impact of harm reduction interventions in
prison. The study was funded by the World Health Organ-
ization (WHO) and ethics was granted from the WHO –
Special Programme for Research and Training in Tropical
Diseases, and the Iran Prisons Organization ethics com-
mittee.
Among the 100 randomly selected participants who took
part in the study, the mean age was 32.06 (SD = 8.54,
Range = 20–53 years). The mean duration of incarceration
was 5.30 years (SD = 5.14, Range = 1–17 years) and the
median was 3.0 years. Nearly 47% of the sample reported
illicit drug use during their lifetime, including while incar-
cerated. This is not surprising given that drug related
offences comprise a large proportion of Iran's prison pop-
ulation. We did not ask specifically about drug use while
incarcerated at Rajaei-Shahr prison because such a direct
question could elicit mistrust and fear in the initial stage
of a multi-part study.
Data were collected using self-report questionnaires. In
order to design a valid, culturally competent and stand-
ardized questionnaire, we drew upon the results of our
review of the literature, and held focus group discussions
with 3 groups of prisoners, each consisting of 8–10 partic-
ipants in Rajaei-Shahr prison in January, 2004. The partic-
ipants were selected with the assistance of the prison
health staff and key prisoners who knew individuals that
would be interested, cooperative and represented varied
reasons for their incarceration and belief systems. All
focus group participants were informed about the objec-
tive of the discussion and their confidentiality was guaran-
teed. All focus group discussions were held in Farsi
(Persian). Policy regarding confidentiality and anonymity
in research at the prison prevented us from determining
whether the participants in the focus groups also partici-
pated in completing a self-report questionnaire. Drawing
on the results of the focus group discussions and literature
review, a bank of questions was designed for the larger
study, of which 75 were selected for our survey. Using the
HBM as a framework, we classified prisoners' beliefs
about the risk of HIV transmission as a consequence of
various behaviours.
A limitation of our research methodology is that our use
of a cross-sectional design did not allow us to identify any
causal relationship due to the lack of time sequence con-
firmation between the cause and the outcome [12]. That
is, we were not able to confirm the temporal sequence of
the prisoners' beliefs and behaviours. Further, given the
particularly challenging nature of the context of this study
(e.g., cultural and social factors), it is difficult to make
generalizations from our study to other settings.
Results
Beliefs about modes for HIV transmission
The majority of participants in this study have considera-
ble knowledge about modes of HIV transmission. On
average, 79.5% of responses to 14 suggested modes of HIV
transmission were answered correctly. Awareness was
greatest for sharing a razor (1 incorrect, 1 do not know)
and needle sharing (1 incorrect, 1 do not know). How-
ever, 95 of the 100 prisoners incorrectly reported that
shaking hands and kissing with an HIV infected individ-
ual can cause them to be infected. See Table 1.
Applying the Health Belief Model
Considering the three components of the HBM (perceived
threats [susceptibility and severity], benefits, barriers),
Cronbach's alpha was calculated for every question com-
bination, and it was consistently greater than 70%. From
here, a single variable for each component of the HBM
was calculated through the summation of questions spe-
cific to each. However, as there were only 2 questions for
perceived severity, each was considered separately.
Table 1: Prisoner beliefs about modes of HIV transmission
Incorrect answer Do not known Correct answer
Males having sex with males 5 5 90
Males having sex with females 18 13 69
Insect sting 21 14 65
Louse sting 10 14 76
Scabies 12 10 78
Eating with shared dishes 17 8 75
Shaking hands and kissing 95 0 5
Blood transfusion 3 3 94
Sharing a razor 1 0 99
Needle sharing for drug use 1 1 98
Tattooing with shared needle 4 0 96
Dentistry with infected instruments 12 2 86
Barber with infected tools 13 2 85
Hejamat (venesection and cupping) 1 2 97
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The prevalence of responses to various preventive and
high-risk behaviors for HIV transmission is shown in
Table 2. In order to combine the HBM with the results of
the behavior questions, we calculated a Cronbach's alpha
of 77.4%. All 9 questions documenting the prevalence of
HIV high-risk behaviours were summed to achieve a com-
mon score for each respondent showing high scores with
respect to safer behaviours for the prevention of HIV
transmission. The mean, standard deviation, minimum
and maximum possible achievable score for each compo-
nent of the HBM other than perceived severity are shown
in Table 3.
Considering the least-harmful behaviour for each ques-
tion (always, sometimes, never) as a correct answer, we
associated a score and then calculated a total behavior
score for each respondent. The mean for the correct
behavior score was 22.29 (SD = 2.89, Min = 13, Max =
27). The maximum behavior score was 27. The calculated
Pearson's correlation coefficient and the related p value
for the three components of the HBM and associated
behaviors showed a significant positive correlation only
between the benefit component of the HBM and behavior
(r = .29, p < .003). It should be noted that this is a weak to
moderate range correlation.
In order to determine the association of behaviors with
perceived severity we performed an analysis of variance
with regard to the two questions. There was no statistically
significant association between these two variables (p >
.05).
Discussion
The majority of prisoners in our study were knowledgea-
ble about how HIV is transmitted. Their high level of
understanding may be due in large part to recent credible
HIV training efforts in Iranian prisons. The need and pos-
itive impact of training on awareness of HIV transmission
has been documented in other international studies [13-
15]. However, the vast majority of prisoners in our study
still believed that HIV could be transmitted through kiss-
ing or hand shaking. This is consistent with a study con-
ducted with prisoners in Nigeria [16]. A study of Iranian
high school students in Tehran similarly found that the
majority of respondents answered knowledge questions
about HIV/AIDS correctly, but that there still existed mis-
conceptions about the routes of transmission [17]. So,
even with recent awareness training at Rajaei-Shahr
prison, there is evidence of some inaccurate information
about HIV transmission among the prisoner population.
Using the Health Belief Model (HBM) as the framework to
help understand individuals' health related behaviors,
specifically high-risk behaviors for the transmission of
HIV, our results show that the only component of the
model significantly associated with the reduction of high-
risk behavior is perceived benefit. That is, prisoners
decreased their HIV high-risk behaviours (e.g., used clean
syringes) when they believed in the effectiveness of strate-
gies designed to reduce the risk or seriousness of impact of
the health condition. This does not mean that the other
two components of the HBM are not effective in explain-
ing health related behaviour, only that they did not show
to be for the prisoner population in our study. Clearly,
further research is required.
Similar to the findings in our study, a 2006 comparative
study conducted in six cities in Eastern Europe, Asia and
Latin America found that the promotion of and advocacy
surrounding the health benefits of needle exchange for
injection drug users positively affected HIV high-risk tak-
ing behaviors [18]. Another 2006 study, this one focuss-
ing on the feasibility of offering late-night harm reduction
services for a hard to reach group of Methamphetamine-
using men who have sex with men, concluded that pro-
viding needle exchange, condoms, sexually transmitted
infection testing and harm reduction education together
may positively impact the high-risk behaviors of individ-
uals at risk for acquiring or transmitting HIV [19]. In other
studies it has been shown that relaying the benefits of
harm reduction strategies, as conceived in a HBM frame-
work, may influence high-risk behaviors with drugs other
than opiates, such as ecstasy or tobacco [20,21]. And in
two studies examining the awareness of condom use to
Table 2: Reported prevalence of HIV high-risk behaviours in prison
Always Some times Never
Using a condom when having sex 29 51 20
Needle sharing 6 23 71
Having sex with a male 1 20 79
Having extra-marital sex (with a female) 7 58 35
Tattooing with shared needles 4 37 59
Having history of Hejamat (cupping, venesection) 6 3 91
Victim of a sexual assault 3 4 93
Being raped by other prisoners 2 66 32
Using a shared razor 37 52 11
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prevent the spread of HIV among non-injection drug
using based samples (hotel workers in Madrid, adoles-
cents in the United States), both showed that belief in the
effectiveness of condoms contributed to more likely use
[22,23]. The effectiveness of condom use education and
provision in reducing the risk of HIV transmission has
been widely supported in the research literature among
various populations [24,25].
The international literature by and large supports the
effectiveness of harm reduction programming in prison
settings [26]. The benefit of needle exchange programs,
for example, in the reduction of risk behaviour and the
transmission of blood-borne infection in correctional
facilities in such places as Germany, Spain and Switzer-
land has been supported through research [27]. More spe-
cific, the importance of informing prisoners about the
effectiveness of harm reduction initiatives for changing
their HIV high-risk behavior has received some support in
this study, and as reviewed, in others as well. Considering
these findings and our understanding of the prison envi-
ronment, prisoners need to be viewed as individuals who
are capable of making health informed choices, and not
simply criminals who are incarcerated to be punished
[28,29]. This damaging ideology is one of many barriers
globally that must be overcome if a harm reduction
approach, in particular among a prison population, is to
be fully embraced and implemented. In Iran, triangular
clinics are suggested to be a very viable and possible step
toward ensuring this.
The integrated concept of triangular clinics (sexually
transmitted infections, HIV/AIDS, drug abuse) in Iran
prisons, including Rajaei Shahr prison, attempt to reduce
the threat of HIV transmission that prisoners face while
incarcerated. Triangular clinics are well-established com-
plex clinics serving a wide range of prisoner health needs,
including counseling and testing, harm reduction inter-
ventions (e.g., needle exchange) and medical diagnosis
and treatment for sexually transmitted infections [30].
According to the findings of this study, to improve the
value of these services, it may be wise to widely educate
the prison population about their effectiveness. Once
again, this suggests that it is necessary that prisoners be
viewed as individuals with the capacity and desire to make
informed decisions about their own health.
Conclusion
For many reasons, Iran has a large and growing prison
population. Of great concern is the high rate of HIV/AIDS
among prisoners, and the need to stop transmission of the
disease. Within the Iranian prison environment, it is most
commonly spread through injection drug use and sexual
contact. This is similar to the global situation [1,2,31,32].
According to the results of this study, HIV high-risk behav-
iors are common among a sample of adult males incarcer-
ated at the Rajaei-Shahr prison in Iran, despite the fact
that they are well informed about the potential for HIV
transmission. For risky behaviors related to sexuality, this
may be due to the fact that sexual behavior is still a taboo
in Iran and is not openly discussed. For example, in our
study it is where there was the highest misperception
about HIV, that is, that it can be transferred through shak-
ing hands and kissing with an HIV infected individual
(95% incorrectly reported this). Consequently, miscon-
ceptions prevail and individuals may be unwilling to seek
services within the prison system. For various reasons,
including stigma, prisoners also are known to be hesitant
to access related harm-reduction services for their injec-
tion drug use. This study suggests the need to educate pris-
oners on the effectiveness of harm reduction measures for
all HIV-related risky behaviours, as it may lead to a reduc-
tion in high-risk behaviours. Given that Iran is progressive
in its offering of services, this is even more important.
As mentioned, a limitation of our research methodology
is our use of a cross-sectional design did not allow us to
identify any causal relationship between the cause (pris-
oners' beliefs) and the outcome (prisoners' behaviours).
An important next step in this research is to conduct mul-
tivariate analyses to permit some statistical control of
important factors.
We suggest that work in the area of education needs to
ensure that a cultural approach that accounts for the reli-
gious and social norms of Iran be explored [33]. For exam-
ple, according to Islamic belief any activity which
endangers an individual's life is strictly prohibited (e.g.,
illicit drug use). As we know from other work, education
efforts must also address the mistrust between prisoners
and correctional administration, as well as low levels of
prisoner literacy [1]. We suggest as well the need to
explore various venues to provide education on the effec-
Table 3: Statistical measures for 3 components of the Health Belief Model
Mean SD Minimum Maximum Maximum Score
Benefits 11.39 3.81 7 22 32
Barriers 14 4.71 6 24 24
Susceptibility 12 3.5 7 25 28
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tiveness of HIV harm reduction interventions. For exam-
ple, consideration could be given to having peer
educators, counselors, support groups, targeting specific
populations, creating videos and offering drama lessons
to address the knowledge, attitudes and behaviours
toward HIV/AIDS among prisoners. An important role in
such initiatives is having prisoners participate in their
design to ensure that specific populations receive the
information in the most valuable and applicable way pos-
sible. Such initiatives have been implemented elsewhere
with success [34,1]. Knowledge assessment studies would
be beneficial for monitoring the effectiveness of such
training and educational efforts.
And finally, it is important that the findings of this study
be considered beyond the walls of the prison environ-
ment, because the majority of HIV infected prisoners will
be released from prison and will reintegrate into the gen-
eral Iranian population and potentially contribute to the
spread of HIV in their home communities. AIDS aware-
ness still remains limited among many sectors of Iranian
society, including the wives and partners of ex-prisoners.
Censorship exists in some sectors of society and HIV/AIDS
is still highly stigmatized as a social taboo. It follows that
the prison education efforts suggested in this study need
to be part of a strong, comprehensive and large-scale HIV/
AIDS education and communication strategy in Iran.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
BE and RTA participated in the design of the study, collec-
tion of data, analysis and interpretation of data, drafting
the article, and final approval of this version, CAD partic-
ipated in contextualizing the data, drafting the article, and
final approval of this version, PM, MK and JW reviewed
and suggested revisions on the research methodology and
the approach to data analysis and presentation of the
results, and final approval of this version.
Acknowledgements
This study was part of a larger study funded by the World Health Organi-
zation (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 Rejayee
Shahr prison who made the prison and prisoners accessible for us, and
kindly provided us with access to make planned assessments on their per-
formed interventions.
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Harm Reduction Journal 2008, 5:21 http://www.harmreductionjournal.com/content/5/1/21
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... Harm reduction programs (15) lead to a reduction in infectious diseases (16,17,18) criminal activities, recidivism, and drug use (19). So, the most critical measures in jails is to formulate health policies in order to implementing and scaling up harm reduction and addiction treatment programs (20,21). ...
Preprint
Full-text available
Background. Substance use disorder is one of the most prevalent health issues among prison populations. In this regard, the Department of Health and Treatment of the Iranian Prisons has implemented treatment and harm reduction programs in prisons since 2002. The purpose of the present study was to describe the practical experience of implementation of addiction treatment and harm reduction programs in Iran's prisons. Methods. A qualitative cross-sectional study was designed in the present study. Further to library sources, we used face-to-face semi-structure interviews with 11 key informants with question about the evolution of treatment and harm reduction programs in Iranian prisons. We analyzed the data using content analysis method by MAXQDA-10 software. Results. The HIV outbreaks was a challenge in Iranian prisons in the late 18th-century (1999). Policy makers had different responses ranging from denying the issue to solving it according to the abstinence paradigm that was prevailed among the majority of drug experts and politicians, and finally to issuing a legal amendment based on evidence-based health literature. Although, at first, financial problems and lack of human resources hindered the implementation of large scale harm reduction measures, the extent and quality of these programs rapidly improved. Recently, these programs in Iranian prisons are a unique model of health in the Persian Gulf region. The main treatment and harm reduction programs in Iranian prisons were methadone maintenance treatment and setting up triangular clinics. Also, the national program for diagnosing HIV/AIDS and tuberculosis in prison were provided by the collaboration of medical sciences universities. Conclusion. One of the main measures to provide evidence-based health interventions in prisons is the advocating for policy reform to implementation and expand harm reduction-based approaches. Providing evidence-based treatment and harm reduction programs in prisons and after inmates’ release into the community can significantly reduce health costs.
... Missed visits to the clinic was accounted as an important obstacle to ART initiation in a study of patients at 1917 HIV/AIDS Clinic, University of Alabama, Birmingham [8]. The triangular clinic is an innovative and programmatic concept that deals with three frequently overlapping issues; drug abuse, sexually transmitted infections, and HIV/AIDS [9]. The triangular clinic utilizes the services of medical doctors as well as paramedical staff and counselors. ...
Article
Background: High rate of adherence to antiretroviral therapy (ART) is critical for the optimized outcome. The present study aimed to determine the rate of retention in ART programs and its’ associated factors in a triangular clinic. Materials and Methods: The present retrospective cohort study was conducted on people living with HIV receiving care in a triangular clinic affiliated with Iranian research center for HIV/AIDS, Tehran, Iran, from 2003 to 2008. Baseline variables, duration of ART, and cause of treatment discontinuation were gathered using patients’ profile and analyzed by SPSS 21 and STATA 11. Results: Three hundred and seventeen cases with the mean age of 37.69 ± 10.63 (2–76) years were included (83.9% male). Treatment discontinuation had happened in 142 (45.2%) cases. Cause of treatment discontinuation was death in 20 (13.7%) cases and personal preference in 126 (86.3%) individuals. 6, 12, 18, 24, 36, and 60 months retention rates were 81.1%, 58.4%, 48.3%, 35.6%, 22.9%, and 6.3%, respectively. The results of multivariate logistic regression analysis showed a significant association between treatment retention and female sex (OR: 4.10; 95% CI: 1.59–10.56, P=0.003), addiction/drug use (OR: 0.39; 95% CI: 0.21– 0.77, P=0.007), and lamivudine+ zidovudine+ indinavir treatment regimen (OR: 0.63; 95% CI: 0.46 -0.87, P= 0.005). Conclusion: Based on the findings, male sex, addiction/drug use, and type of treatment regimen were among the most important risk factors for ART attrition in HIV-infected patients. [GMJ.2017;6(2):110-117]
... Harm reduction is conceptually formulated and empirically investigated as perceived benefits in prevention studies (Bonar & Rosenberg, 2011;Eshrati et al., 2008;Winer et al., 2022). Considerable evidence has demonstrated that smokers, in higher proportions, perceive e-cigarettes as less harmful than non-smokers. ...
... As a response to the growing HIV epidemic among incarcerated people in Iran, harm reduction programs and triangular clinics were initiated in 2002 and scaled up across several major prisons in the country [16,17]; interventions that helped curb the epidemic and reduce the HIV prevalence among incarcerated people to 2.1% in 2009 [12,18]. Harm reduction services inside prisons in Iran include methadone maintenance therapy (MMT), free condoms for conjugal visits, and HIV testing and counseling [17,19,20]. Incarcerated people who report a history of HIV-related high-risk behaviours are provided with a voluntary HIV test upon entrance to the prison. ...
Article
Full-text available
Abstract Background Incarcerated people are at a disproportionate risk of contracting HIV. We estimated the prevalence and correlates of HIV testing among incarcerated people with a history of HIV-related high-risk behaviours in Iran. Methods Data for this analysis were obtained from three consecutive nationwide bio-behavioural surveillance surveys of a random sample of incarcerated people in 2009 (n = 5953), 2013 (n = 5490), and 2017 (n = 5785). History of testing for HIV in the last 12 months was the primary outcome variable. HIV testing was examined among those with a history of HIV-related high-risk behaviours (i.e., having multiple sex partnerships, injection drug use practices, or a history of having a tattoo). The outcome variable was divided into three categories: Never tested for HIV, ever tested for HIV inside the prison in the last 12 months, and ever tested for HIV outside the prison in the last 12 months. We used multivariable multinomial logistic regression models to examine factors associated with HIV testing. Results Overall, 8,553 participants with a history of HIV-related high-risk behaviors with valid responses to the HIV testing question were included in the analysis. Although HIV testing inside prison has increased (23% [2009], 21.5% [2013], and 50.3% [2017]: P-value
... Sampling strategies were census in five studies, multi-stage random sampling in six studies, stratified random sampling in three studies, and simple random sampling in two studies. Questionnaires were completed by face-to-face interview except one (Eshrati et al., 2008) done by self-administration. Seven studies reported the reason for incarceration, with five being drugrelated or robbery (Fakhrzadegan et al., 2017;Haghdoost et al., 2012Haghdoost et al., -2013Haji-Maghsoudi et al., 2014;Khajedaluee et al., 2016;Sharifi et al., 2016Sharifi et al., -2017. ...
Article
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Drug use is common among people who live in prisons (PWLP) worldwide. This systematic review and meta-analysis aimed to summarize the prevalence of drug use among PWLP in Iran. We searched PubMed, Embase, Web of Science, Scopus, PsycINFO, as well as Farsi-language databases including Iran Psych Magiran, IranMedex, Scientific Information Database (SID), and Irandoc for studies published from January 2003 to January 2021. We included studies that reported the prevalence of drug use among PWLP. We performed a random-effects meta-analysis to pool prevalence estimates. Point estimates and 95% confidence intervals (CI) are reported. Among 1107 publications and reports screened, 16 studies reported the prevalence of drug use and were included. The pooled prevalence of lifetime non-injection drug use was 73.8% (95% CI 70.9, 76.6). The pooled prevalence of lifetime injection drug use was 16.0% (12.6, 19.7). Needle/syringe sharing among those with a lifetime injection drug use history was 14.0% (6.4, 24.0). Non-injection and injection drug use was found to be prevalent among PWLP in Iran. Continued evidence-based prevention, harm reduction, and treatment programs should address drug use among this population.
... An interesting point in Fig. 3 is an implicit relationship between IDUs and MSM; while the trend of IDUs has been dropping since 2007, the trend of MSM has been accelerating instead. Although programs such as safe syringe distribution and methadone maintenance treatment have been relatively effective for IDUs [34]- [37], due to social sensitivity to addressing sexual intercourse the strategies toward controlling unsafe sex have not been so effective [38]. Studies show that the primary role of contribution to HIV transmission is in a transition from unsafe injection to unprotected sexual contact [33]. ...
Article
In this study we look into the socio-political trends emerging after the 1979 revolution in Iran. The development of democracy, education, and health network system are remarkable achievements in the Islamic government. However, since economic factors in a society work in harmony, an integrated view about emerging trends results in more achievements and better future planning. This study seeks to bring a set of relevant trends to attention and present a multidimensional picture of Iranian society.
... Specific policies are made to prevent and control HIV infection in the prisons of Iran. Examples are screening the newly admitted prisoners, distributing condoms for safe sexual activities [10], initiating and expanding the administration of methadone maintenance therapy, setting up triangular clinics in prisons and exchanging needle/syringe regularly [9,11]. ...
Article
Full-text available
Background The present research explored the effect of an educational program based on the health belief model (HBM) on prisoners’ HIV preventive behaviors in the south of Iran. Methods The present quasi-experimental research was conducted in 2019–20 on 280 prisoners, 140 in the control group (CG) and 140 in the intervention group (IG). The sampling was simple randomized. The data were collected using a questionnaire in two parts, one exploring the demographic information and the other the HBM constructs. The final follow-up was completed 3 months after the educational intervention (8 sessions long) in November 2020. Results After the intervention, statistically significant between-group differences were found in the healthy behavior score and all HBM constructs except for the perceived barriers ( p < 0.001). Perceived severity and susceptibility were found to be the strongest predictors of HIV preventive behaviors. Conclusion The educational intervention showed to positively affect the adoption of preventive behaviors mediated by the HBM constructs. To remove barriers to HIV preventive behaviors or any other healthy behavior, researchers are suggested to develop multi-level interventions (beyond the personal level) to gain better findings.
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Full-text available
Background: Incarcerated people are at a disproportionate risk of contracting HIV. We estimated the prevalence and correlates of HIV testing among incarcerated people with a history of HIV-related high-risk behaviours in Iran. Methods: Data for this analysis were obtained from three consecutive nationwide bio-behavioural surveillance surveys of a random sample of incarcerated people in 2009 (n = 5,953), 2013 (n = 5,490) and 2017 (n = 5,785). History of testing for HIV in the previous 12 months was the primary outcome variable and was examined among those with a history of HIV-related high-risk behaviours (i.e., having multiple sex partnership, injection drug use practices, or history of having a tattoo). The outcome variable was divided into three categories: Never tested for HIV, ever tested for HIV inside the prison, and ever tested for HIV outside the prison. We used multivariable multinomial logistic regression models to examine factors associated with HIV testing. Results: Overall, 8,553 participants with a history of HIV-related high-risk behaviors with valid responses to the HIV testing question, were included in the analysis. Although HIV testing inside prison has increased (23% [2009], 21.5% [2013], and 50.3% [2017]: P-value <0.001), the prevalence of HIV testing outside prison has decreased (7.7% [2009], 7.5% [2013], 4.1% [2017]: P-value <0.001) over time. Our multivariable multinomial regression model showed older age (Relative-risk ratio [RRR]: 1.24, 95% Confidence Intervals [CI]: 1.05, 1.47), history of previous incarceration (RRR: 1.46, 95% CI: 1.24, 1.71), currently receiving methadone maintenance therapy inside prison (RRR: 2.09, 95% CI: 1.81, 2.43), having access to condoms inside prison (RRR: 1.42, 95% CI: 1.20, 1.68) and sufficient HIV knowledge (RRR: 1.74, 95% CI: 1.47, 2.05) were significantly associated with an increased probability of having an HIV test in the last 12 months inside prison. Conclusions: HIV testing among Iranian high-risk prisoners has increased from 2009 to 2017. However, HIV testing remains considerably low, and half of incarcerated people with a history of HIV-related high-risk behaviours had never tested for HIV inside prison. Evidence-based programs efforts are needed to optimize HIV testing both inside and outside prisons and identify those at greater risk of HIV.
Article
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Aims: Drug users form the main HIV-affected group in Iran. About two-third of all the individuals affected by HIV in Iran are those who use drug through injection. The aim of this study is to determine the effect of health belief model (HBM) on prevention of HIV transmission among the opiate-dependent population in Zarandieh. Methods and Materials: This is a quasi-experimental intervention study carried out on 49 addicted men in Zarandieh. was collected using a questionnaire, based on HBM and the group completed the questionnaire. According to the pre-test, the educational intervention was designed and implemented. Three months after the intervention, the post-test was performed and analyzed using the primary questionnaire and χ2, T-test. Findings: The findings indicated that the mean scores of HBM Model constructs (self-efficacy, susceptibility, severity and benefit) increased significantly after intervention and the perceived barriers decreased (p< 0.001). Also, the history of HIV testing reported 8%before intervention, while the rate increased to 48.6% after intervention. Conclusions: This finding provides initial support for designing and implementation of health education program, based on the HBM on Preventing HIV transmission among Opiate-dependent population.
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Although many behavioral research studies and public enlightenment campaigns have been undertaken by both government and non-governmental organizations in the general public, no such study has been documented on prison inmates in Nigeria. This study aimed at documenting the social characteristics, HIV/AIDS knowledge and preventive practices of selected prisoners in Nigeria. It also elicited risk factors HIV/AIDS transmission in Nigeria prisons. A cross-sectional study of prison inmates using an anonymous risk-factors identification questionnaire was undertaken in January 1997. The Kiri-kiri (maximum, medium and female) prisons were selected by balloting. Thereafter, two hundred and fifty two inmates were selected by systematic random sampling method using the full listing of all inmates as at the time of the survey. The study comprised of an interview session using a well structured questionnaire to seek information about their social data, their knowledge about HIV/AIDS including its transmission and preventive social data, and their indulgence in HIV/AIDS risky behaviour. The majority (53.6%) of the respondents were in the age group 20-29 years, 18 (7.1%) were less than 20 years old one of whom was in the maximum-security prison and three were females (table 1). The majority (52%) had secondary education while 9.9% had tertiary education and 7.1% had no formal education. About 97.2% of the study population had heard about AIDS although only 20.6% had known or seen someone with AIDS before and about 34.1% knew the causative agent of AIDS. 60.3% knew the correct mode of transmission of AIDS. 15.5% claimed fidelity and 12.7 % claimed use of condom for casual sexual contact, were measures that could help prevent AIDS but 7.9% did not know any preventive measure. Since hearing about AIDS, 59.5% claimed to have taken steps to protect themselves. 42.7% of the 89 who had not taken any protective steps against AIDS had no knowledge of how to protect themselves. About 56.3% claimed to have used condom before although only 38.7% used it for their last sexual exposure while 28.2% claimed they used it for all casual sexual intercourse. Many (42.8%) said they knew that homosexuality was the most prevalent sexual practice in the prison while 28.6% claimed there was no sexual practice and 13.1% feigned ignorance of any sexual practices in the prisons. Many (53.2%) claimed to have multiple sexual partners although 94.8% denied any sexual practice whilst still in prison. This study demonstrated that (i) almost all THE prisoners studied had heard of AIDS although only a few had seen or known a case of AIDS; (ii) despite the fact that many of them knew the correct modes of transmission, many indulged in high risk behaviours for AIDS transmission; (iii) there is a considerable proportion of receptive naïve inmates who stand the risk of being infected due to their high level of ignorance about HIV/AIDS. Well designed information, education and communication (IEC) programmes on AIDS with such formidable support structures as the provision of harm-reduction devices and risk-reduction counselling are urgently recommended for the Nigerian prisoners to effectively combat the imminent HIV/AIDS epidemic among the prison inmates.
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The prevalence of AIDS infection is approximately five times higher in state and federal prisons than among the general U.S. population. It is also apparent that high-risk HIV transmission behaviors occur inside prison; however, data validly documenting instances of intraprison HIV transmission are rare. This study validly identifies 33 inmates in a large sample of state prison inmates who contracted HIV inside prison and presents data on how they likely contracted HIV. It further compares these inmates to inmates who did not contract HIV inside prison in terms of age, race, and level of education. Documenting the burden posed by HIV transmission inside prison, providing insight into how they contract HIV inside prison, and what types of inmates are at risk will help public and correctional health officials reform their current education and prevention practices and ultimately reduce or prevent HIV transmission both inside and outside prison.
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Journal publications and conference presentations on prison-based syringe exchange (PSE) programmes were identified by a comprehensive search of electronic databases. Experts involved with development and evaluation of current PSE programmes or policy were contacted for reports, documents and unpublished material. Spanish information on PSE was translated for this review. We identified 14 papers specifically on PSE programmes in Switzerland (six papers), Germany (four) and Spain (four). The first PSE programme started in 1992 in Switzerland. As of December 2000, seven PSEs were operating in Switzerland, seven in Germany and five in Spain. There have been six evaluations of prison syringe exchange programmes and all have been favourable. Reports of drug use decreased or remained stable over time. Reports of syringe sharing declined dramatically. No new cases of HIV, hepatitis B or hepatitis C transmission were reported. The evaluations found no reports of serious unintended negative events, such as initiation of injection or of the use of needles as weapons. Staff attitudes were generally positive but response rates to these surveys varied. Overall, this review indicated that prison syringe exchange programmes are feasible and do provide benefit in the reduction of risk behaviour and the transmission of blood-borne infection without any unintended negative consequences.
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The media play an important role at the interface of science and policy by communicating scientific information to the public and policy makers. In issues of theoretical risk, in which there is scientific uncertainty, the media's role as disseminators of information is particularly important due to the potential to influence public perception of the severity of the risk. In this article we describe how the Canadian print media reported the theoretical risk of blood transmission of Creutzfeldt-Jakob disease (CJD). We searched 3 newspaper databases for articles published by 6 major Canadian daily newspapers between January 1990 and December 1999. We identified all articles relating to blood transmission of CJD. In duplicate we extracted information from the articles and entered the information into a qualitative software program. We compared the observations obtained from this content analysis with information obtained from a previous policy analysis examining the Canadian blood system's decision-making concerning the potential transfusion transmission of CJD. Our search identified 245 relevant articles. We observed that newspapers in one instance accelerated a policy decision, which had important resource and health implication, by communicating information on risk to the public. We also observed that newspapers primarily relied upon expert opinion (47 articles) as opposed to published medical evidence (28 articles) when communicating risk information. Journalists we interviewed described the challenges of balancing their responsibility to raise awareness of potential health threats with not unnecessarily arousing fear amongst the public. Based on our findings we recommend that journalists report information from both expert opinion sources and from published studies when communicating information on risk. We also recommend researchers work more closely with journalists to assist them in identifying and appraising relevant scientific information on risk.
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Findings are presented from research which attempted to test the ability of a particular decision-making framework, the health belief model (HBM), to explain mothers' differential compliance with a drug regimen prescribed for their asthmatic children. Interviews were completed with 111 mothers from a low-income, clinic population, who brought their children to a pediatric emergency facility for treatment of acute asthma episodes. Based on the HBM's sociobehavioral dimensions, the interview included questions about the mother's general health motivations and attitudes, as well as about her view regarding the child's asthma condition and its ramifications. Two measures of compliance were employed: (a) laboratory verification of the drug's presence or absence in the patient's blood and (b) a construction combining objectively determined and self-reported information if laboratory documentation was unavailable. Significant associations were obtained between the majority of HBM components and the measures of compliance. Mothers' perceptions of threat of illness (particularly the child's susceptibility to illness and the seriousness of such conditions, whether asthma-related or not) and of difficulties associated with administration of the medication were substantial predictors of adherence. An unexpected finding, that adherent mothers are both more skeptical of, yet more dependent upon, physicians and medical care is explained in terms of hypotheses specific to the condition studied. Of those variables suggested by relevant literature (but unspecified in the HBM), only mothers' marital status and level of formal education maintained significant associations with compliance. These results offer additional support for the HBM approach to understanding health-related behaviors. On the basis of the findings, it is also suggested that there are no profound changes in health beliefs when compliance 'fails'.
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To assess the incidence of infection with HIV-1 in the Maryland state prison system, inmates with excess sera stored from specified intake periods between April and June 1985 and 1986 were approached in May 1987 to volunteer for venipuncture. Of the 2286 inmates for whom intake specimens were stored, 1038 (45.4%) no longer incarcerated as of April 1987 were excluded from the study; another 319 missed the survey. Of the 929 eligible inmates approached for the study, 446 (48%) consented and 422 (94.6%) provided a specimen. Twenty-nine (6.6%) were confirmed seropositive at time of entry into prison, indicating that infection had occurred prior to incarceration. Baseline seropositives were more likely (P less than 0.05) to be non-violent offenders, committed in Baltimore City, and black. The 393 participants seronegative at baseline provided a total of 482 prison-years of potential exposure to infection. Two inmates seroconverted with baseline specimens seronegative on Western blot and follow-up sera confirmed positive; their duration of pre-incarceration detention was 69 and 146 days, respectively. No interruption of incarceration was recorded for these two inmates. The rate of infection in this prison sample, which does not include an average of 2 months of pre-incarceration detention for the study sample, was 0.41% per prison-year.
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Primary care physicians continue to play an important role in preventing HIV transmission by targeting messages to their high-risk patients. The risk of HIV transmission cannot be eliminated entirely; however, clinicians have a variety of prevention interventions at their disposal. Behavioral and therapeutic interventions offered in a client-centered environment have the greatest chance of success. Patients can benefit from individualized prevention plans that decrease risk by treating drug addiction and by modifying sexual and drug-taking behaviors. The risk of HIV infection in health care workers can be reduced by strict adherence to universal precautions and the use of postexposure antiretroviral therapy.