Revision and Implementation of "Clinical Guideline for Tuberculosis and HIV in Prisons", Great Tehran Prison, Iran.

AIM: To evaluate the feasibility of the revised "Clinical Guideline for HIV and TB" in the Great Tehran Prison during October 2013 to June 2014. METHODS: The guideline includes all aspects of HIV/TB diagnosis based on active case finding (ACF), treatment and care services. Before the implementation, a focus group discussion was conducted, and attended by experts on prison health. The objective was to identify defects and limitations of the guideline. After the discussion, the guideline was revised. The Great Tehran Prison contains three separate units; all prisoners are taken first to "reception and identification unit (quarantine)" and then send to two housing units according to their legal status. An HIV ACF strategy was employed in the quarantine, and two units through a voluntary provider-initiated HIV testing. Three staff of the triangular clinic trained the prisoners about common routes of HIV transmission and the symptoms of TB in the units. In the quarantine, all prisoners were examined for all HIV-risk factors, HIV testing and symptoms of TB. In unit one, healthcare staff continued the ACF process, while in unit two, the peers of prisoners were assigned as the healthcare communicators to proceed with the strategy. At this caring process, when the test result was positive, then the process of care, treatment and follow ups was initiated. Moreover, the use of directly observed therapy (DOT) for antiretroviral therapy (ART) and TB was applied to the sick prisoners. There was also a follow-up caring for released prisoner to refer them to care and treatment services outside the prison. RESULTS: The guideline was implemented in the prison successfully. CONCLUSION: Regarding feasibility of the guideline, the investigators of this study suggest that the guideline should be implemented in other prisons across the country.

Prevalence and Associated Factors of HIV Infection among Male Prisoners in Tehran, Iran.

BACKGROUND: This is a cross-sectional survey conducted on 6900 male prisoners in Great Tehran Prison from October 2013 to May 2014. METHODS: In order to find HIV positive prisoners in the prison's quarantine and two housing units, we used HIV active case finding (ACF) strategy by rapid screening test. In ACF, healthcare staff and trained prisoners asked inmates to answer relevant questions about history of risky behaviors related to HIV as well as to be tested voluntarily by HIV rapid test. A positive result was confirmed by ELISA screening and Western blot tests. Furthermore, to find the prevalence of specific HIV risk factors among prisoners were assessed using a questionnaire, and the results were analyzed by STATA software, providing univariate and multivariate modeling. RESULTS: There were 85 HIV positive patients. The prevalence of HIV was 1.23%. The risk factors independently associated with HIV infection were age (adjusted odds ratio of 3.46 for 35-44 yrs., 95% CI:1.01-11.92), duration of imprisonment (adjusted odds ratio of 4.22 for ≥10 yr., 95% CI: 1.92-9.24 ), history of  injection drug use (adjusted odds ratio of 5.01, 95% CI: 2.24-11.18), history of needle sharing (adjusted odds ratio of 2.28, 95% CI: 1.25-4.16) and tattooing (adjusted odds ratio of 1.84, 95% CI: 1.05-3.24). CONCLUSIONS: The prevalence and risk factors of HIV infection should be recognized by policy makers for intensifying harm reduction programs and reforming the HIV guidelines in prisons.

Methadone maintenance treatment program in prisons from the perspective of medical and non-medical prison staff: a qualitative study in Iran.

BACKGROUND: As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran. METHODS: On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons. RESULTS: This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants' views "reduction of illegal drug use and high-risk injection", "reduction of potentially high-risk behaviors" and "making positive attitudes" were the main advantages of MMT in prisons, while issues such as "inaccurate implementation", "lack of skilled manpower" and "poor care after release from prison" were among the main shortcomings of MMT program. CONCLUSION: MMT program in Iran's prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.

Injecting Drug Users Retention in Needle-Exchange Program and its Determinants in Iran Prisons.

BACKGROUND: Participation and to stay in a health program depends on many factors. One of these programs is Needle Exchange Program (NEP) in prisons. OBJECTIVES: The current study aimed to evaluate the retention of injecting drug prisoners and find the related factors in Iran. PATIENTS AND METHODS: This cohort study analyzed data about injecting drug male prisoners who were participated in NEP in three Iranian prisons. Data was collected from October 2009 to June 2010. A proper approach of survival analyses including Kaplan-Meier method, Log-Rank test, and Cox Proportional Hazard Model were used to evaluate Injecting Drug Users (IDUs) retention in NEP and its determinants. RESULTS: Out of 320 prisoners, 167 were from Isfahan Central Prison, 82 from Tehran-Ghezel-Hesar Prison, and 71 from Hamadan Central Prison. Two-hundred and fifty prisoners (78.4%) had history of drug injection; and drug injection was the most common choice for 115 persons (35.9%). Participants were followed up for 29 weeks, the mean (SD) time of retention in the program was 24.1 (0.6) weeks. There was a significant relationship between age, number of used needles per week, duration of addiction, age of addiction onset, as well as imprisonment age, main method of drug use, type of main using drug, Hepatitis B Virus (HBV) infection, job status, reason of arrestment, history of involvement in harm reduction programs, and the length of retention (P < 0.05). There was also significant relationship between the history of using harm reduction services (P = 0.007), tattooing (P = 0.01), longer durations of addiction (P = 0.048), and retention. CONCLUSIONS: Tattooing and longer duration of addiction were two important factors that significantly increased retention in the program. In contrast, history of using harm reduction services was the factor that decreased persistence. The risk of quitting the program may decrease about 68% in those who did not involve in harm reduction programs.

Drug Use among Iranian Drivers Involved in Fatal Car Accidents.

BACKGROUND: Although the problem of substance use among drivers is not limited to certain parts of the world, most epidemiological reports on this topic have been published from industrial world. AIM: To investigate pattern of drug use among Iranian drivers who were involved in fatal road accidents. METHODS: This study enrolled 51 Iranian adults who were involved in fatal vehicle accidents and were imprisoned thereafter. Data came from a national survey of drug abuse that was done among Iranian prisoners. The survey collected data at the entry to seven prisons in different regions of the country during a 4-month period in 2008. Self-reported lifetime, last year, and last month drug use was measured. Commercial substance screening tests were applied to detect recent substance use (opioids, cannabinoids, methamphetamines, and benzodiazepines). RESULTS: The commercial substance screening test showed three distinct patterns of recent illicit drug use: opioids (37.3%), cannabinoids (2.0%), opioids and cannabinoids (13.7%). 29.4% were also positive for benzodiazepines. The substance use screening test detected 23.5% of participants who had used drugs but did not disclose any substance use. CONCLUSION: Opioids are the most common illicit drugs being used by Iranian drivers who are involved in fatal car accidents. The high rate of substance use prior to fatal car accidents in Iran advocates for the need for drug use control policies and programs as major strategies for injury prevention in Iran. There is also a need for substance screening among all drivers involved in fatal car accidents in Iran, as more than 20% of users may not disclose substance use.

Trend of HIV/AIDS Prevalence and Related Interventions Administered in Prisons of Iran -13 Years' Experience.

BACKGROUND: HIV/AIDS epidemic is concentrated among injecting drug users in Iran. Like many other countries with HIV/AIDS concentrated epidemic, prisons are high risk areas for spreading HIV/AIDS. The aim of this paper was to study the trend of HIV/AIDS prevalence and related interventions administered in prisons of Iran during a 13 years period. METHODS: This cross sectional study was conducted using the data collected from the sentinel sites in all prisons in the country and it also used the data about Harm Reduction interventions which has been implemented by Iran Prisons Organization. To evaluate the correlation between the prevalence and each of administered interventions in prisons the Correlation Coefficient Test was used for the second half of the mentioned time period. RESULTS: The prevalence of HIV/AIDS in prisons had increased rapidly in the early stages of epidemic, so that in 2002 the prevalence raised to 3.83%. Followed by the expansion of Methadone Maintenance Therapy and development of Triangular Clinics, HIV/AIDS prevalence in prisons declined. There was a relationship between interventions and the prevalence of HIV/AIDS. CONCLUSION: In regions and countries where the epidemic is highly prevalent among injecting drug users and prisoners, Methadone Maintenance Therapy and development of Triangular Clinics can be utilized to control HIV/AIDS epidemic quickly.