Comparison of safety and effectiveness of antiretroviral therapy regimens among pregnant women living with HIV at preconception or during pregnancy: a systematic review and network meta-analysis of randomized trials

BACKGROUND

Mother-to-child transmission is the primary cause of HIV cases among children. Antiretroviral therapy (ART) plays a critical role in preventing mother-to-child transmission and reducing HIV progression, morbidity, and mortality among mothers. However, after more than two decades of ART during pregnancy, the comparative effectiveness and safety of ART medications during pregnancy are unclear, and existing evidence is contradictory. This study aimed to assess the effectiveness and safety of different ART regimens among pregnant women living with HIV at preconception or during pregnancy.

METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science. We included randomized trials that enrolled pregnant women living with HIV and randomized them to receive ART for at least four weeks. Pairs of reviewers independently completed screening for eligible studies, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool. Our outcomes of interest included low birth weight, stillbirth, preterm birth, mother-to-child transmission of HIV, neonatal death, and congenital anomalies. Network meta-analysis was performed using a random-effects frequentist model, and the certainty of evidence was evaluated using the GRADE approach.

RESULTS

We found 14 eligible randomized trials enrolling 9,561 pregnant women. The median duration of ART uptake ranged from 6.0 to 17.4 weeks. No treatment was statistically better than a placebo in reducing the rate of neonatal mortality, stillbirth, congenital defects, preterm birth, or low birth weight deliveries. Compared to placebo, zidovudine (ZDV)/lamivudine (3TC) and ZDV monotherapy likely reduce mother-to-child transmission (odds ratio (OR): 0.13; 95% CI: 0.05 to 0.31, high-certainty; and OR: 0.50; 95% CI: 0.33 to 0.74, moderate-certainty). Moderate-certainty evidence suggested that ZDV/3TC was associated with decreased odds of stillbirth (OR: 0.47; 95% CI: 0.09 to 2.60).

CONCLUSIONS

Our analysis provides high- to moderate-certainty evidence that ZDV/3TC and ZDV are more effective in reducing the odds of mother-to-child transmission, with ZDV/3TC also demonstrating decreased odds of stillbirth. Notably, our findings suggest an elevated odds of stillbirth and preterm birth associated with all other ART regimens.

The effectiveness of court-mandated compulsory treatment in promoting abstinence among people with substance use disorders in Iran

BACKGROUND

In Iran, people living with substance use disorders who engage in public drug use may be subjected to court-mandated treatment in compulsory drug detention and rehabilitation centers (CDDRC). This study aims to assess residential CDDRC's effectiveness in promoting sustained abstinence among people who use drugs (PWUD) in Kerman, Iran.

METHODS

Between October 1, 2021, and September 30, 2022, 1,083 adult male PWUD with a diagnosis of substance use disorders and a history of engagement in public drug use were admitted to the CDDRC in Kerman. They were followed-up for 12 months after discharge. The relationship between baseline variables and abstinence, assessed using rapid urine tests, was examined using crude logistic regression models.

RESULTS

Most PWUD were 30 or older (n = 876, 80.9 %) and had a history of previous CDDRC admission (n = 638, 58.9 %). At the end of the 12-month follow-up, only 2.6 % (95 % confidence intervals: 1.7-3.7) were abstinent. Individuals with limited education (Odds ratio [OR] = 3.43; 1.50-7.95) and those with a prior history of admission to the CDDRC (OR = 3.73; 1.55-9.89) had increased odds of relapse.

CONCLUSIONS

The effectiveness of CDDRC in promoting abstinence among the participants was minimal. This highlights the necessity of reassessing support and investment in these interventions and considering more evidence-informed alternative approaches in Iran.

Longitudinal polysubstance use patterns and non-fatal overdose: A repeated measures latent class analysis

BACKGROUND

Polysubstance use (PSU) is common among people who use opioids (PWUO) and has been associated with drug-related harms. We aimed to identify latent longitudinal PSU classes among a cohort of PWUO and characterize non-fatal overdose risks among different sub-classes over time.

METHODS

We used longitudinal data (2005-2018) from three ongoing prospective cohorts of people who use drugs in Vancouver, Canada. The primary outcome of interest was self-reported non-fatal overdose during the past six months. The primary exposure of interest was longitudinal PSU patterns among PWUO, obtained from repeated measures latent class analysis (RMLCA) of weekly substance use-related outcome indicators. Multivariable generalized estimating equations models were built to assess the association between latent PSU class membership and non-fatal overdose, adjusting for potential sociodemographic, behavioural, and structural confounders.

RESULTS

2627 PWUO were included in the analysis, and 1094 (41.6 %) had experienced at least one non-fatal overdose during the study period. RMLCA revealed five distinct latent longitudinal PSU classes, including low/infrequent use (Class 1; 30 %), primarily opioid and methamphetamine use (Class 2; 22 %), primarily cannabis use (Class 3; 15 %), primarily opioid and crack use (Class 4; 29 %), and frequent PSU (Class 5; 4 %). In comparison with Class 1 (low), membership in all latent PSU classes except Class 3 (cannabis) was associated with increased odds of non-fatal overdose: Class 2 (opioids + meth) vs. Class 1 (Adjusted odds ratios [aOR] = 2.20, 95 % confidence intervals [CI]: 1.51-3.22), Class 4 (opioids + crack) vs. Class 1 (aOR = 1.06, 95 % CI: 0.85-1.33), and Class 5 (frequent) vs. Class 1 (aOR = 2.39, 95 % CI: 1.92-2.97).

CONCLUSION

Our findings highlighted the heterogeneous characteristics of PWUO in terms of patterns of PSU and non-fatal overdose risk. The diverse nature of PWUO and the potential additive or multiplicative impact of using several substances on overdoses should be reflected across the substance use treatment continuum and care provision.

Pandemics, intellectual property and 'our economy': A worldview analysis of Canada's role in compromising global access to COVID-19 vaccines

Despite self-congratulatory rhetoric, Canada compromised COVID-19 vaccine equity with policies impeding a proposed global waiver of vaccine intellectual property (IP) rules. To learn from Canada's vaccine nationalism we explore the worldview - a coherent textual picture of the world - in a sample of Government of Canada communications regarding global COVID-19 vaccine sharing. Analysed documents portray risks and disparities as unrelated to the dynamics and power relations of the Canadian and international economies. Against this depoliticised backdrop, economic growth fueled by strict IP rules and free trade is advanced as the solution to inequities. Global vaccine access and distribution are pursued via a charity-focused public-private-partnership approach, with proposals to relax international IP rules dismissed as unhelpful. Rather than a puzzling lapse by a good faith 'middle power', Canada's obstruction of global COVID-19 vaccine equity is a logical and deliberate extension of dominant neoliberal economic policy models. Health sector challenges to such models must prioritise equity in global pandemic governance via politically assertive and less conciliatory stances towards national governments and multilateral organisations. Mobilisation for health equity should transform the overall health-damaging macroeconomic model, complementing efforts based on specific individual health determinants or medical technologies.

Injection cessation and relapse to injection and the associated factors among people who inject drugs in Iran: The Rostam study

BACKGROUND

Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran.

METHODS

This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome.

RESULTS

The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation.

CONCLUSION

Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

Awareness and willingness to use HIV self-testing among people who inject drugs in Iran

BACKGROUND

Most people who inject drugs (PWID) in Iran have not undergone recent HIV testing. While PWID face barriers when seeking HIV testing at health facilities, HIV self-testing (HIVST) could be a promising approach to improve HIV testing uptake. We examined the awareness and willingness to use HIVST among PWID in Iran. We also identified participants' characteristics associated with a higher willingness to use HIVST.

METHODS

PWID were recruited in 11 cities using a respondent-driven sampling method. Willingness to use HIVST was defined as a binary variable (very low/low willingness vs. high/very high willingness). We performed multivariable modified Poisson regression to examine associated factors and report adjusted prevalence ratios (aPR) and 95% confidence intervals (CI).

RESULTS

Of 2,252 PWID, 362 (16.2%; 95% CI 14.7, 17.8) had ever heard of HIVST; however, 1,658 (73.6%; 95% CI 71.7, 75.4) reported high/very high willingness to use HIVST. Willingness to use HIVST was higher among PWID who reported having a high/moderate HIV risk perception (aPR 1.22; 95% CI 1.09, 1.37), ever experiencing homelessness (aPR 1.15; 95% CI 1.03, 1.28), > 10 years of injecting history (aPR 1.16; 95% CI 1.00, 1.34), and high injection frequency in the last three months (aPR 1.18; 95% CI 1.05, 1.32).

CONCLUSION

Most PWID in Iran, particularly those experiencing homelessness, have a longer injecting history, engage in more frequent injection practices, and possess a heightened perception of HIV risk would be willing to adopt HIVST. Enhancing HIVST awareness through increased access to HIVST and health education programs are needed. Additionally, conducting implementation science studies to effectively design and run HIVST programs in Iran can also increase PWID's access to HIV testing.

Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis

BACKGROUND

Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase.

METHODS

We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research.

RESULTS

We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models).

CONCLUSIONS

Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.

Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression

PURPOSE

Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs.

METHODS

We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023 . We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies.

RESULTS

We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8-43.7) and 21.7% (14.9-29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1-42.4), and multiple induced abortion prevalence was 23.1% (12.4-35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8-54.6), and multiple induced abortion prevalence was 19.9% (11.9-29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6-42.7) overall, 42.8% (37.2-48.5) for countries where elective abortion is illegal, and 15.6% (3.9-32.7) for countries that legally allow elective abortion.

CONCLUSIONS

Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services.

Longitudinal latent polysubstance use patterns among a cohort of people who use opioids in Vancouver, Canada

INTRODUCTION

Polysubstance use (PSU) practices are increasing among people who use opioids (PWUO). However, several aspects of longitudinal PSU patterns among PWUO remain understudied. This study aims to identify person-centred longitudinal patterns of PSU among a cohort of PWUO.

METHODS

Using longitudinal data (2005-2018) from three prospective cohort studies including people who use drugs in Vancouver, Canada, we used repeated measures latent class analysis to identify different PSU classes among PWUO. Multivariable generalised estimating equations models weighted by the respective posterior membership probabilities were applied to identify covariates of membership in different PSU classes over time.

RESULTS

Overall, 2627 PWUO (median age at baseline: 36 [quartile 1-3: 25-45]) were included between 2005 and 2018. We found five distinct PSU patterns, including low/infrequent probability of regular substance use (Class 1; 30%), primarily opioid and methamphetamine use (Class 2; 22%), primarily cannabis use (Class 3; 15%), primarily opioid and crack use (Class 4; 29%) and frequent PSU (Class 5; 4%). Membership in Class 2, 4 and 5 was positively associated with several behavioural and socio-structural adversities.

DISCUSSION AND CONCLUSIONS

Findings of this longitudinal study suggest PSU is the norm among PWUO and highlights the heterogeneous characteristics of PWUO. The diversities within the population of PWUO need to be recognised in addiction care and treatment as well as optimising resource allocation in the response to the overdose crisis.

Efficacy and Safety of a Protein-Based SARS-CoV-2 Vaccine: A Randomized Clinical Trial

Importance

The protein-based SARS-CoV-2 vaccines FINLAY-FR-2 (Soberana 02) and FINLAY-FR-1A (Soberana Plus) showed good safety and immunogenicity in phase 1 and 2 trials, but the clinical efficacy of the vaccine remains unknown.

Objective

To evaluate the efficacy and safety of a 2-dose regimen of FINLAY-FR-2 (cohort 1) and a 3-dose regimen of FINLAY-FR-2 with FINLAY-FR-1A (cohort 2) in Iranian adults.

Design, Setting, and Participants

A multicenter, randomized, double-blind, placebo-controlled, phase 3 trial was conducted at 6 cities in cohort 1 and 2 cities in cohort 2. Participants included individuals aged 18 to 80 years without uncontrolled comorbidities, coagulation disorders, pregnancy or breastfeeding, recent immunoglobulin or immunosuppressive therapy, and clinical presentation or laboratory-confirmed COVID-19 on enrollment. The study was conducted from April 26 to September 25, 2021.

Interventions

In cohort 1, 2 doses of FINLAY-FR-2 (n = 13 857) or placebo (n = 3462) were administered 28 days apart. In cohort 2, 2 doses of FINLAY-FR-2 plus 1 dose of FINLAY-FR-1A (n = 4340) or 3 placebo doses (n = 1081) were administered 28 days apart. Vaccinations were administered via intramuscular injection.

Main Outcomes and Measures

The primary outcome was polymerase chain reaction-confirmed symptomatic COVID-19 infection at least 14 days after vaccination completion. Other outcomes were adverse events and severe COVID-19. Intention-to-treat analysis was performed.

Results

In cohort 1 a total 17 319 individuals received 2 doses and in cohort 2 5521 received 3 doses of the vaccine or placebo. Cohort 1 comprised 60.1% men in the vaccine group and 59.1% men in the placebo group; cohort 2 included 59.8% men in the vaccine group and 59.9% in the placebo group. The mean (SD) age was 39.3 (11.9) years in cohort 1 and 39.7 (12.0) years in cohort 2, with no significant difference between the vaccine and placebo groups. The median follow-up time in cohort 1 was 100 (IQR, 96-106) days and, in cohort 2, 142 (137-148) days. In cohort 1, 461 (3.2%) cases of COVID-19 occurred in the vaccine group and 221 (6.1%) in the placebo group (vaccine efficacy: 49.7%; 95% CI, 40.8%-57.3%) vs 75 (1.6%) and 51 (4.3%) in cohort 2 (vaccine efficacy: 64.9%; 95% CI, 49.7%-59.5%). The incidence of serious adverse events was lower than 0.1%, with no vaccine-related deaths.

Conclusions and Relevance

In this multicenter, randomized, double-blind, placebo-controlled, phase 3 trial of the efficacy and safety of FINLAY-FR-2 and FINLAY-FR-1A, 2 doses of FINLAY-FR-2 plus the third dose of FINLAY-FR-1A showed acceptable vaccine efficacy against symptomatic COVID-19 as well as COVID-19-related severe infections. Vaccination was generally safe and well tolerated. Therefore, Soberana may have utility as an option for mass vaccination of the population, especially in resource-limited settings, because of its storage condition and affordable price.

Trial Registration

isrctn.org Identifier: IRCT20210303050558N1.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis

PURPOSE

This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs.

METHODS

We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach.

RESULTS

The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1).

CONCLUSION

SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

Hepatitis C virus prevalence, determinants, and cascade of care among people who inject drugs in Iran

BACKGROUND

People who inject drugs (PWID) continue to experience the highest burden of hepatitis C virus (HCV). We aimed to characterize HCV antibody prevalence, determinants of infection, and the cascade of engagement in HCV care among PWID in Iran.

METHODS

Participants were recruited in 11 cities of Iran using respondent-driven sampling. PWID underwent a structured interview capturing measures on socio-demographics, behaviors, and the HCV cascade of care. HCV and HIV were tested using antibody rapid tests. Multivariable logistic regression models identified characteristics associated with HCV seropositivity.

RESULTS

HCV antibody prevalence was 26.0% among 2684 PWID enrolled. Of 699 participants who were HCV antibody positive, 88 (12.6%) were aware of past infections. HCV antibody prevalence was associated with older age (adjusted odds ratio [aOR] 2.09; 95% CI 1.18, 3.71), lower education (aOR 1.31; 95% CI 1.02, 1.69), >10 years of injecting (aOR 6.03; 95% CI 4.10, 8.85), methamphetamine injection (aOR 1.46; 95% CI 1.07, 1.99), daily injection drug use (aOR 1.26; 95% CI 1.01, 1.58), needle/syringe sharing (aOR 2.04; 95% CI 1.24, 3.34), recent incarceration (aOR 1.74; 95% CI 1.30, 2.32), and HIV seropositivity (aOR 7.93; 95% CI 4.12, 15.24). Additionally, 12.0% had ever tested for HCV, 4.0% had previously tested reactive for HCV antibody, and 3.7% had received an HCV diagnosis. Of diagnosed cases, 44.4% were linked to care, 15.2% initiated treatment, and 3.0% achieved sustained virologic response.

CONCLUSION

Our data show a high prevalence of HCV antibody and low engagement in HCV care, underscoring an unmet need for HCV prevention, screening, and treatment among PWID in Iran. HCV prevention and treatment programs tailored for PWID are needed to enhance harm reduction efforts and access to HCV care in Iran.

Bayesian spatial analysis of age differences and geographical variations in illicit-drug-related mortality in the Islamic Republic of Iran

Background

Drug use disorders are significant social and public health concerns in the Islamic Republic of Iran; however, little is known about drug-related mortality.

Aims

We quantified the spatial and age distribution of direct illicit-drug-related mortality in the Islamic Republic of Iran, to inform harm reduction policies and interventions.

Methods

We modelled and mapped registered illicit-drug-related deaths from March 2016 to March 2017. Data were obtained from the Iranian Forensic Medicine Organization. Besag-York-Mollie models were fitted using Bayesian spatial analysis to estimate the relative risk of illicit-drug-related mortality across different provinces and age groups.

Results

There were 2203 registered illicit-drug-related deaths during the study period, 1289 (58.5%) occurred in people aged 20-39 years and among men (n = 2013; 91.4%). The overall relative risk (95% credible interval) of illicit-drug-related mortality in the provinces of Hamadan (3.37; 2.88-3.91), Kermanshah (1.90; 1.55-2.28), Tehran (1.80; 1.67-1.94), Lorestan (1.71; 1.37-2.09), Isfahan (1.40; 1.21-1.60), and Razavi Khorasan (1.18; 1.04-1.33) was significantly higher than in the rest of the country.

Conclusion

We found evidence of age differences and spatial variations in illicit-drug-related mortality across different provinces in the Islamic Republic of Iran. Our findings highlight the urgent need to revisit existing drug-use treatment and harm reduction policies and ensure that overdose prevention programmes are adequately available for different age groups and settings.

Sexualized Substance Use among Female Sex Workers in Iran: Findings from a Nationwide Survey

Background: Female sex workers (FSWs) are at higher risk of HIV due to high-risk sexual and drug use related behaviors. This study characterized sexualized substance use among FSWs in Iran. Methods: In 2015, 1,337 FSWs were recruited from centers for vulnerable women and through outreach efforts in 13 major cities in Iran. Data were collected via face-to-face interviews from consenting FSWs on a range of socio-demographic and behavioral characteristics. The primary outcome of interest was sexualized substance use, defined as reporting alcohol or drug use before or during sex in the past month. Bivariable and multivariable modified Poisson regression models were used to assess the correlates of sexualized substance use. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were reported. Results: The prevalence of sexualized substance use was 31.3% (95% CI: 28.7, 34.0). Inconsistent condom use during sex with clients in the past month (aPR = 1.31; 95% CI: 1.01, 1.71), regular (i.e., at least weekly in the past month) alcohol use (aPR = 2.87; 95% CI: 2.17, 3.80), regular opioid use (aPR = 2.09; 95% CI: 1.45, 3.02), regular stimulant use (aPR = 2.68; 95% CI: 2.12, 3.39), and self-reported HIV negative status (aPR= 1.88; 95% CI: 1.14, 3.10) were significantly and positively associated with sexualized substance use. Conclusions: Sexualized substance use was associated with riskier sexual behavior and self-reported HIV sero-negativity. Harm reduction messaging to FSWs needs to go beyond focusing on sexual health promotion and further highlight the risks associated with sexualized substance use.

HIV testing among incarcerated people with a history of HIV-related high-risk behaviours in Iran: Findings from three consecutive national bio-behavioural surveys

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 < 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 the 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.

CONCLUSION

HIV testing among high-risk Iranian prisoners has increased from 2009 to 2017. However, HIV testing remains considerably low, and half of the incarcerated people with a history of HIV-related high-risk behaviours had never tested for HIV inside prison. Evidence-based programs are needed to optimize HIV testing inside and outside prisons and identify those at greater risk of HIV.

Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran

BACKGROUND

Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.

METHODS

Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020. We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings. Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.

RESULTS

Of 2388 respondents, 69.6 % reported public injecting in the previous year. Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting. Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.

CONCLUSION

These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran. Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran. Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.

Shifts in substance use patterns among a cohort of people who use opioids after delisting of OxyContin in BC, Canada: An interrupted time series study

BACKGROUND

OxyContin was delisted from Canadian provincial drug formularies in March 2012 and replaced with a reformulated tamper-resistant form of oxycodone (i.e., OxyNeo). We assessed if delisting of OxyContin was associated with changes in the use of unregulated opioids and other substances among people who use opioids (PWUO).

METHODS

Data were derived from two prospective cohort studies of people who use drugs in Vancouver, BC, Canada from 2006 to 2018. PWUO who had at least one follow-up visit before and after delisting of OxyContin were included. Outcomes of interest were self-reported regular (i.e., at least weekly) use of heroin, non-prescribed prescription opioids, cannabis, methamphetamine, crack cocaine, and powder cocaine during the previous six months. Using quasi-experimental interrupted time series, we fit generalized least squares models to assess participants' immediate and long-term substance use practices after the policy change.

RESULTS

We analyzed data from 1014 participants who contributed to 17457 visits during the study. Following the delisting of OxyContin, heroin use increased immediately by 5.17% (95% confidence intervals [CI]: 0.68 to 9.67) and over time by 0.47% (0.35 to 0.58) per month. Non-prescribed prescription opioid use increased immediately by 1.80% (0.10 to 3.50) and over time by 0.16% (0.12 to 0.19) per month. Cannabis use increased immediately by 4.37% (0.88 to 7.87) and over time by 0.11% (0.02 to 0.19) per month. Methamphetamine use did not increase immediately but increased over time by 0.10% (0.01 to 0.18) per month. Crack cocaine use decreased immediately by 6.13% (-10.94 to -1.69) but not significantly over time. Lastly, powder cocaine use did not increase immediately or over time.

CONCLUSIONS

Delisting of OxyContin in BC was not associated with a reduction in unregulated opioid use among PWUO. Our findings point to a shift in substance use patterns of PWUO post-intervention and further highlight the unintended consequences of supply-reduction interventions in addressing the opioid epidemic.

Excess deaths during the COVID-19 pandemic in Iran

BACKGROUND

The actual number of deaths during the COVID-19 pandemic is expected to be higher than the reported deaths. We aimed to estimate the number of deaths in Iran during the COVID-19 pandemic from December 22, 2019 to March 20, 2022.

METHODS

We compared the number of age- and sex-specific deaths reported by Iran's Bureau of Vital Statistics with the predicted deaths estimated using an improved Lee-Carter model. We estimated the number of all-cause excess deaths in three scenarios, including the baseline scenario (without any undercounting of deaths) and 4% and 8% undercounting of all-cause deaths.

RESULTS

We estimated 282,378 (95% confidence intervals [CI]: 225,439; 341,951) excess deaths in the baseline model. This number was 303,148 (95% CI: 246,417; 357,823) and 308,486 (95% CI: 250,607; 364,417) in the 4% and 8% scenarios, respectively. During the same period, Iran reported 139,610 deaths as being directly related to COVID-19. The ratio of reported COVID-19 deaths to total excess deaths ranged from 45.2% to 49.4% in the various scenarios. Most excess deaths occurred in the baseline scenario in males (157,552 [95% CI: 125,142; 191,265]) and those aged ≥75 years (102,369 [95% CI: 93,894; 111,188]).

CONCLUSIONS

The reported number of COVID-19 deaths was less than half of Iran's estimated number of excess deaths. The results of this study will be helpful for health policymakers' planning, and call for strengthening the timeliness and accuracy of Iran's death registration systems, planning for more accurate monitoring of epidemics, and planning to provide support services for survivors' families.

Population Size Estimation of People Who Use Illicit Drugs and Alcohol in Iran (2015-2016)

BACKGROUND

Estimating the number of people using illicit drugs and alcohol is necessary for informing health policy and programming. However, it is often challenging to reliably estimate the size of these marginalized populations through direct methods. In this study, we estimated the population size of these groups using the indirect Network Scale-Up (NSU) method in Iran from 2015 to 2016.

METHODS

Using a self-administered questionnaire, we asked 15 124 individuals (54% men) about the number of people they know who used different types of drugs at least once in the past 12 months. Prevalence estimates were reported per 100 000 population. The uncertainty level (UL) was calculated using the bootstrap method.

RESULTS

The average age of the respondents was 33 years old, and 35.1% of them were unmarried. The most common drugs and their prevalence were as follows: opium (2534 [95% UL: 2467-2598]), hashish (849 [95% UL: 811-886]), stimulants (methamphetamine, ecstasy pills, cocaine, and Ritalin) (842 [95% UL: 802-879]), heroin/crack (578 [95% UL: 550-607]), and drug injection (459 [95% UL: 438-484]). Additionally, we estimated the prevalence of alcohol use as 2797 (95% UL: 2731-2861). On average, substance use was 5.23 times more prevalent among men than women. Opium use was more prevalent among individuals aged >50 years old. Moreover, alcohol use was more prevalent among participants between 18 and 30 years old (5164 per 100 000 population).

CONCLUSION

Although opium continues to be the most prevalent illicit drug in Iran, the patterns of illicit drug use are heterogeneous among different age groups, genders, and provinces. Age-gender specific and culturally appropriate interventions are warranted to meet the needs of people in different subgroups.

HIV prevalence and continuum of care among incarcerated people in Iran from 2010 to 2017

Background

Incarcerated people are at an increased risk of contracting HIV and transmitting it to the community post-release. In Iran, HIV epidemics inside prisons were first detected in the early 1990s. We assessed the HIV prevalence and its correlates, as well as the continuum of care among incarcerated people in Iran from 2010 to 2017.

Methods

We used data collected in three national bio-behavioral surveillance surveys among incarcerated individuals in 2010 (n = 4,536), 2013 (n = 5,490), and 2017 (n = 5,785) through a multistage cluster sampling approach. HIV was tested by the ELISA method in 2010 and 2013 surveys and rapid tests in 2017. Data on demographic characteristics, risky behaviors, HIV testing, and treatment were collected via face-to-face interviews. HIV prevalence estimates along with 95% confidence intervals (CI) were reported. Using data from the 2017 round, multivariable logistic regression models were built to assess the correlates of HIV sero-positivity and conduct HIV cascade of care analysis.

Results

The HIV prevalence was 2.1% (95% CI: 1.2%, 3.6%) in 2010, 1.7% (95% CI: 1.3%, 2.1%) in 2013, and 0.8% (95% CI: 0.6%, 1.1%) in 2017 (trend P value < 0.001). Among people with a history of injection drug use, HIV prevalence was 8.1% (95% CI: 4.6%, 13.8%) in 2010, 6.3% (95% CI: 4.8%, 8.3%) in 2013, and 3.9% (95% CI: 2.7%, 5.7%) in 2017. In 2017, 64% (32 out of 50) of incarcerated people living with HIV were aware of their HIV status, of whom 45% (9 out of 20) were on antiretroviral therapy, and of whom 44% (4 out of 9) were virally suppressed (< 1000 copies/ml).

Conclusions

While HIV prevalence has decreased among incarcerated people in Iran, their engagement in the HIV continuum of care is suboptimal. Further investments in programs to link incarcerated people to HIV care and retain them in treatment are warranted.

An on-site community-based model for hepatitis C screening, diagnosis, and treatment among people who inject drugs in Kerman, Iran: The Rostam study

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.

METHODS

This study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.

RESULTS

A total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.

CONCLUSION

Our integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population.

Mental disorder and opioid overdose: a systematic review

PURPOSE

This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids.

METHODS

The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique.

RESULTS

Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose.

CONCLUSION

Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

Access to Medications for Opioid Use Disorder and Associated Factors Among Adolescents and Young Adults: A Systematic Review

IMPORTANCE

The ongoing overdose crisis continues to adversely affect adolescents and young adults (AYAs) and has led to numerous preventable deaths. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have the potential to reduce opioid use and associated harms; however, there are concerns that AYAs lack access to these potentially life-saving medications.

OBJECTIVE

To systematically review peer-reviewed literature on MOUD access and associated factors to synthesize strategies that can improve MOUD access for AYAs who use opioids.

EVIDENCE REVIEW

The MEDLINE, Embase, PsycINFO, CINAHL, Sociological Abstracts, Web of Science, and Global Dissertations & Theses databases were searched from database inception until May 3, 2021. English, French, Russian, or Spanish peer-reviewed studies that evaluated the availability, prescription receipt, or initiation of MOUD were eligible for inclusion.

FINDINGS

This systematic review identified 37 cohort (n = 17), cross-sectional (n = 15), and qualitative (n = 5) studies that accounted for 179 785 AYAs (mean [SD] age, 24.4 [3.9] years; 148 779 [85%] were female; 67 771 [84%] were White) and examined access to methadone (30 studies), buprenorphine (26 studies), and naltrexone (10 studies). Findings reinforce concerns that AYAs were less likely to access MOUD and suggest that adolescents were more likely to receive naltrexone or buprenorphine-naloxone, which have a lower potential for abuse, in comparison with young adults. This review also identified other factors that were associated with MOUD access, including criminal justice involvement, residing in the US South, living in a limited-income area, Black race, and Hispanic or Latino ethnicity, suggesting ways in which treatment services may be improved to increase MOUD access and meet the treatment goals of AYAs.

CONCLUSION AND RELEVANCE

This systematic review found gaps in MOUD access between AYAs and non-AYA populations in addition to differences in MOUD access between adolescents and young adults. Considering that existing clinical guidelines recommend the use of MOUD among AYAs, and in light of the increasing number of opioid toxicity deaths, there is a need to improve MOUD access among AYAs by reducing barriers to MOUD and providing AYAs with a continuum of health and social supports alongside MOUD. Future research into ways to encourage MOUD uptake among AYAs may improve the treatment and health outcomes for this population.

Prevalence and Correlates of Sexual Violence Experienced by Female Sex Workers in Iran: Results from a National HIV Bio-Behavioral Surveillance Survey

Sexual violence increases the risk of adverse health outcomes among female sex workers (FSWs). Using data from the 2015 national bio-behavioral survey, we explored the experience of sexual violence and its associated factors among Iranian FSWs. Lifetime and recent sexual violence were reported by 40.1% and 16.9%, respectively. History of substance use, ever engaging in anal sex, engaging in group sex within the last year, a high number of clients, recent unstable housing, and incarceration increased the likelihood of experiencing recent sexual violence. These findings underscore the need for community-empowerment and policy-level interventions to address violence among FSWs in Iran.

HIV Prevalence and Related Behaviors Among People Who Inject Drugs in Iran from 2010 to 2020

Injection drug use has been the leading route of HIV transmission in Iran. We assessed HIV prevalence, risk behaviors, and uptake of prevention services among people who inject drugs (PWID) in Iran between 2010 and 2020. We also examined the individual and environmental determinants of HIV among PWID. PWID were recruited in major cities across the country in three national bio--behavioral surveillance surveys in 2010, 2014, and 2020. Participants were tested for HIV and interviewed using a behavioral questionnaire. Between 2010 and 2020, the prevalence of HIV (15.1% to 3.5%), receptive needle sharing (25.2% to 3.9%) and unprotected sex (79.4% to 65.2%) decreased. Moreover, uptake of free needle/syringe increased (57.4% to 87.9%), while uptake of free condoms remained relatively stable across the surveys (34.3% to 32.6%). Multivariable analysis for the 2020 survey showed that a history of homelessness, incarceration, and a longer injection career significantly increased the odds of HIV seropositivity. During the past decade, HIV prevalence and drug- and sexual-related risk behaviors decreased among Iranian PWID. However, individual and structural determinants continue to drive HIV among this population. HIV prevention, diagnosis, and treatment among marginalized PWID with a history of homelessness or incarceration and those who inject drugs for a longer period, should be further prioritized in HIV care planning and resource allocation in Iran.

Chronic hepatitis C infection is associated with higher incidence of extrahepatic cancers in a Canadian population based cohort

INTRODUCTION

Chronic infection with hepatitis C virus (HCV) is an established risk factor for liver cancer. Although several epidemiologic studies have evaluated the risk of extrahepatic malignancies among people living with HCV, due to various study limitations, results have been heterogeneous.

METHODS

We used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for HCV in the Province since 1990. We assessed hepatic and extrahepatic cancer incidence using data from BC Cancer Registry. Standardized incidence ratios (SIR) comparing to the general population of BC were calculated for each cancer site from 1990 to 2016.

RESULTS

In total, 56,823 and 1,207,357 individuals tested positive and negative for HCV, respectively. Median age at cancer diagnosis among people with and without HCV infection was 59 (interquartile range (IQR): 53-65) and 63 years (IQR: 54-74), respectively. As compared to people living without HCV, a greater proportion of people living with HCV-infection were men (66.7% vs. 44.7%, P-value <0.0001), had comorbidities (25.0% vs. 16.3%, P-value <0.0001) and were socially deprived (35.9% vs. 25.0%, P-value <0.0001). The SIRs for liver (SIR 33.09; 95% CI 29.80-36.39), anal (SIR: 2.57; 95% CI 1.52-3.63), oesophagus (SIR: 2.00; 95% CI 1.17-2.82), larynx (SIR: 3.24; 95% CI 1.21-5.27), lung (SIR: 2.20; 95% CI 1.82-2.58), and oral (SIR: 1.78; 95% CI 1.33-2.23) cancers were significantly higher among individuals living with HCV. The SIRs for bile duct and pancreatic cancers were significantly elevated among both individuals living with (SIR; 95% CI: 2.20; 1.27-3.14; 2.18; 1.57-2.79, respectively) and without HCV (SIR; 95% CI: 2.12; 1.88-2.36; 1.20; 1.11-1.28, respectively).

DISCUSSION/CONCLUSION

In this study, HCV infection was associated with increased incidence of several extrahepatic cancers. The elevated incidence of multiple cancers among negative HCV testers highlights the potential contributions of screening bias and increased cancer risks associated with factors driving acquisition of infection among this population compared to the general population. Early HCV diagnosis and treatment as well as public health prevention strategies are needed to reduce the risk of extrahepatic cancers among people living with HCV and potentially populations who are at higher risk of HCV infection.

Prevalence of Symptom-based Sexually Transmitted Infections and Related Factors among Incarcerated Men in Iran, 2013

Background: Prisoners are at higher risk for sexually transmitted infections (STIs) than the general population. This study reported the prevalence and correlated factors of STI-related symptoms among male prisoners in Iran.

Methods: Participants were selected from 27 prisons across 16 Iranian provinces in 2013 using a multistage cluster sampling (N = 5490). Men aged ≥18 years who spent at least one week in prison and self-reported having had sex during the previous year were eligible and asked if they have had penile discharge (PD) or genital ulcers (GU) within the last year. Demographic variables, HIV/STIs-related knowledge, STIs care-seeking practices, HIV self-perceived risk, history of substance use, and sexual behaviors were collected by face-to-face interviews. HIV tests were completed using the ELISA method. Factors associated with STIs-related symptoms were examined using logistic regression models, and adjusted odds ratios (AOR) along with their 95% confidence intervals (CI) were reported.

Results: Of 2,620 eligible male prisoners (mean age ± SD = 35.7 ± 8.9), 6.9% reported symptoms for PD, GU, or both; of whom 36.2% had not sought STIs care inside prison. A history of injection drug use (AOR = 2.14; 95% CI: 1.45, 3.14), having access to condoms inside prison (AOR = 1.57, 95% CI: 1.08, 2.82), self-perceived risk of HIV (AOR = 1.52, 95% CI: 1.03, 2.24), and HIV-seropositivity (AOR = 3.30, 95% CI: 1.02, 10.61) were positively and having sufficient STIs-related knowledge (AOR = 0.63, 95% CI: 0.44, 0.89) was negatively associated with reporting STIs-related symptoms.

Conclusion: Despite the low prevalence of STIs among Iranian prisoners, initiation of screening among high-risk prisoners, including people who inject drugs and prisoners living with HIV, may prevent subsequent health effects. Current HIV/STIs prevention policies across Iranian prisons to help improve prisoners' HIV/STIs knowledge and encourage their HIV/STIs preventive practices should be reinforced.

Willingness to utilize supervised injection facilities among people who inject drugs in Iran: Findings from 2020 national HIV bio-behavioral surveillance survey

BACKGROUND

Supervised injection facilities (SIFs) have not yet been integrated into Iran's harm reduction programs. This study aimed to report the extent to which people who inject drugs (PWID) in Iran are willing to use SIFs.

METHODS

Participants were recruited from 11 major cities using respondent-driven sampling. Willingness to use SIFs was defined as a three-level categorical variable: low, moderate, or high.

RESULTS

Of 2,490 PWID, 52.8% and 23.8% reported high and moderate willingness to use SIFs, respectively. PWID with a history of homelessness (relative-risk ratio (RRR): 2.22, 95% CI: 1.76-2.80), incarceration (1.86 [1.48-2.35]), hepatitis C infection (1.49 [1.13-1.97]), and non-fatal overdose (2.30 [1.69-3.13]) were more likely to be willing to utilize SIFs. Willingness to use SIFs was also higher among PWID who reported recent public injecting (2.24 [1.70-2.97]), daily injection (1.82 [1.35-2.45]), stimulants injection (2.39 [1.41-4.07]), syringe sharing (3.09 [1.23-7.74]), harm reduction services utilization (2.80 [2.13-3.68]), and food insecurity (8.28 [5.43-12.63]).

CONCLUSION

The majority of PWID in Iran expressed willingness to use SIFs, in particular, those who were involved in higher-risk injection practices, dealing with structural risks, and had experienced drug-related harms. SIFs represent critical opportunities to deliver comprehensive harm reduction services to improve the health and well-being of PWID in Iran.

Opium tincture-assisted treatment for opioid use disorder: A systematic review

BACKGROUND

Some countries have used opioid agonist medications other than methadone and buprenorphine as a strategy to increase treatment diversity. In Iran and other countries where opium use is common and culturally tolerated, opium tincture (OT) has gained growing popularity and been approved to treat opioid use disorder (OUD). Given the increasing interest in this intervention, we conducted a systematic review of the literature to evaluate the safety and efficacy of OT-assisted treatment for OUD.

METHODS

We systematically searched international (MEDLINE, Embase, CINAHL, PsychInfo, Google Scholar, and clinicaltrials.gov) and Iranian (Scientific Information Database (SID), Iranmedex, IranDoc, digital library of Iran's Drug Control Headquarters and the Iranian Registry for Clinical Trials) databases on November 04, 2020 without any language or publication date limitations. Two reviewers screened the titles, abstracts, and full-text of the retrieved records to find clinical trials or observational studies that assessed the safety and efficacy of OT-assisted treatment for OUD.

RESULTS

We screened 1301 records and included 21 unique studies on assisted withdrawal (n = 5), maintenance (n = 9), and gradual dose reduction (n = 7) treatment regimens. Most studies included men and people with opium use disorder. We found only six randomized controlled trials (RCT). Our results showed that OT-assisted treatment is associated with comparable outcomes with methadone treatment in both assisted withdrawal and maintenance treatment regimens. We also found promising results for using gradual dose reduction regimen of OT-assisted treatment from observational studies. The overall quality of scientific evidence was low due to the limited number RCT and high risk of bias in the included studies.

CONCLUSIONS

The body of evidence supporting the safety and efficacy of OT-assisted treatment in assisted withdrawal, maintenance, and gradual dose reduction regimens is limited but somewhat promising, in particular among people with opium use disorder. Our review calls for higher-quality studies to investigate the comparative efficacy of these treatment methods with standard pharmacotherapies for OUD.

Crystal methamphetamine use in British Columbia, Canada: A cross-sectional study of people who access harm reduction services

INTRODUCTION

Increased use of crystal methamphetamine ("crystal meth") has been observed across North America and international jurisdictions, including a notable increase in the presence of methamphetamines in illicit drug toxicity deaths in British Columbia (BC), Canada. We used data from a cross-sectional survey and urine toxicology screening to report the prevalence, correlates, and validity of self-reported crystal meth use among clients of harm reduction sites in BC.

MATERIALS AND METHODS

Survey data were collected from 1,107 participants across 25 communities in BC, through the 2018 and 2019 Harm Reduction Client Survey. We described reported substance use and used a multivariate logistic regression model to characterize crystal meth use. Urine samples provided by a subset of participants were used to derive validity of self-reported three-day crystal meth use compared to urine toxicology screening.

RESULTS

Excluding tobacco, crystal meth was the most frequently reported substance used in the past three days in 2018 and 2019 (59.7% and 71.7%, respectively). Smoking was the dominant route of administration for crystal meth, crack, heroin, and fentanyl. Multivariate analysis determined significantly higher odds of crystal meth use among those who used opioids (Adjusted Odds Ratio [AOR] = 3.13), cannabis (AOR = 2.10), and alcohol (1.41), and among those who were not regularly housed (AOR = 2.08) and unemployed (AOR = 1.75). Age ≥50 was inversely associated with crystal meth use (AOR = 0.63). Sensitivity of self-reported crystal meth use was 86%, specificity was 86%, positive predictive value was 96%, and negative predictive value was 65%.

CONCLUSIONS

Crystal meth was the most commonly used substance among clients of harm reduction sites in BC in 2018 and 2019, and was frequently used concurrently with opioids. Comparison to urine samples demonstrated high validity of self-reported crystal meth use. Understanding evolving patterns of substance use will be imperative in tailoring harm reduction and substance use services for individuals that use crystal meth.

Clinical and Epidemiological Characteristics of Postdischarge Patients With COVID-19 in Tehran, Iran: Protocol for a Prospective Cohort Study (Tele-COVID-19 Study)

Background

COVID-19 was declared a pandemic on March 11, 2020. Given that the severe shortage of hospital beds has led to early discharge and insufficient patient education on home care routines and isolation protocols, the close follow-up of patients and their immediate relatives is an integral part of transitioning from hospital care to home care for patients with COVID-19.

Objective

We designed the Tele-COVID-19 prospective cohort to follow-up with COVID-19 patients in Tehran, Iran, and improve health care delivery and the recording of postdischarge patients’ clinical profiles.

Methods

All adult patients who were admitted to the COVID-19 wards of teaching hospitals in Tehran, Iran were eligible to participate in this cohort study. At baseline, patients were recruited from 4 major hospitals from March 9, 2020 to May 20, 2020. Telephone follow-ups, which were led by volunteer medical students, were conducted on postdischarge days 1-3, 5, 7, 10, and 14. We collected data on a range of sociodemographic, epidemiological, and clinical characteristics by using a standard questionnaire.

Results

Of the 950 patients with confirmed COVID-19 who were approached, 823 (response rate: 86.6%) consented and were enrolled into the cohort. Of the 823 participants, 449 (54.5%) were male. The mean age of participants was 50.1 years (SD 12.6 years). During the initial data collection phase, more than 5000 phone calls were made and over 577 reports of critical patients who were in need of urgent medical attention were recorded.

Conclusions

The Tele-COVID-19 cohort will provide patients with sufficient education on home care and isolation, and medical advice on care and the proper use of drugs. In addition, by preventing unnecessary hospital returns and providing information on household SARS-CoV-2 transmission as early as possible, this cohort will help with effective disease management in resource-limited settings.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23316

Ocular Manifestations of COVID-19: A Systematic Review and Meta-analysis

Several studies have reported the characteristics of Coronavirus disease 2019 (COVID-19), yet there is a gap in our understanding of the ocular manifestations of COVID-19. In this systematic review and meta-analysis, we investigated the prevalence of ocular manifestations in COVID-19 patients. We searched Pubmed, Embase, Scopus, Web of Science, and medRxiv from December 1, 2019 to August 11, 2020. Two independent reviewers screened the articles, abstracted the data, and assessed the quality of included studies in duplicate. Thirty-eight studies were eligible after screening of 895 unique articles, with a total of 8,219 COVID-19 patients (55.3% female; n = 3,486 out of 6,308 patients). Using data extracted from cross-sectional studies, we performed random-effects meta-analyses to estimate the pooled prevalence of ocular symptoms along with 95% confidence interval (CI). The prevalence of ocular manifestations was estimated to be 11.03% (95% CI: 5.71-17.72). In the studies that reported the details of observed ocular symptoms, the most common ocular manifestations were dry eye or foreign body sensation (n = 138, 16%), redness (n = 114, 13.3%), tearing (n = 111, 12.8%), itching (n = 109, 12.6%), eye pain (n = 83, 9.6%) and discharge (n = 76, 8.8%). Moreover, conjunctivitis had the highest rate among reported ocular diseases in COVID-19 patients (79 out of 89, 88.8%). The results suggest that approximately one out of ten COVID-19 patients show at least one ocular symptom. Attention to ocular manifestations, especially conjunctivitis, can increase the sensitivity of COVID-19 detection among patients.

Kidney Complications of COVID-19: A Systematic Review and Meta-Analysis

Background: Some patients with coronavirus disease 2019 (COVID-19) have been reported to have developed mild to severe kidney injuries. The current systematic review and meta-analysis was carried out to estimate the prevalence and incidence of acute kidney injury (AKI) among COVID-19 patients.

Study design: A systematic review and meta-analysis

Methods: PubMed, Embase, Scopus, Web of Science, and MedRxiv databases were searched from December 1, 2019, up to July 27, 2020. Two independent co-authors completed the screening process, data extraction, and quality assessment of the retrieved records. Random-effects meta-analyses were used to determine the pooled prevalence and 95% confidence interval (CI) of AKI among COVID-19 patients.

Results: Out of 2,332 unique identified records, 51 studies were included in the review. Overall, the studies were carried out on 25,600 patients. A total of 6,505 patients (in 18 cross-sectional studies) were included to estimate the pooled prevalence of AKI, and 18,934 patients (in 27 cohort studies) were included to determine the pooled incidence of AKI. The pooled prevalence of AKI was estimated as 10.08% (95% CI: 4.59, 17.32; I ²=98.56%; P<0.001). Furthermore, the pooled incidence of AKI was 12.78% (95% CI: 7.38, 19.36; I ²=99.27%; P<0.001). The mean (95% CI) values of serum creatinine (SCr), blood urea nitrogen (BUN), potassium, and sodium were 76.10 (69.36, 82.84), 4.60 (4.04, 5.30), 3.94 (3.78, 4.11), and 139.30 (138.26, 140.36) mmol/L, respectively.

Conclusions: The AKI is a considerable complication among COVID-19 patients and should be screened for on clinical examinations. The BUN, SCr, potassium, and sodium levels were within the normal ranges.

Methadone maintenance therapy service components linked to improvements in HIV care cascade outcomes: A systematic review of trials and observational studies

BACKGROUND

The beneficial links between engagement in methadone maintenance therapy (MMT) and HIV treatment outcomes have been extensively described. Nevertheless, people who use drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. In this systematic review, we sought to identify components of MMT service provision that are associated with improvements in HIV care outcomes across the HIV care cascade.

METHODS

We searched for peer-reviewed studies in online databases. To be eligible for inclusion in this review, studies must have involved a population or sub-population of PWUD engaged in MMT; report improved uptake of HIV testing, exposure to ART, or HIV-1 RNA plasma viral load suppression; provide details on MMT services; and be published in English between 1 January 2006 until 31 December 2018.

RESULTS

Out of the 5594 identified records, 22 studies were eligible for this systematic review. Components of MMT services associated with HIV care cascade outcomes described in the studies were classified in three categories of care models: 1) standard MMT care with adequate doses, 2) standard MMT care and alongside additional medical component(s), and 3) standard MMT care, additional medical component(s) as well as informational or instrumental social support.

CONCLUSION

The few studies identified reflect a scarcity of evidence on the role of social support to increase the benefits of MMT for PWUD who are living with HIV. Further research is needed to assess the role of medical and social service components in MMT care delivery in advancing PWUD along the HIV care cascade.

Convenience and comfort: reasons reported for using drugs alone among clients of harm reduction sites in British Columbia, Canada

Background

North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC.

Methods

We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified.

Results

Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20–4.27 and AOR: 2.10; 95% CI 1.15–3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%).

Conclusions

Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Induced abortion and associated factors among female sex workers in Iran

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

The high prevalence of induced abortion among FSWs in Iran is concerning. Evidence-informed programmes targeting FSWs in Iran would improve their knowledge and encourage contraceptive use as well as promote pregnancy prevention and post-abortion care.