1. Minoo Mohraz, M.D., M.P.H. Parastoo Khairandish, M.D.,M.P.H. Gholamreza Akbari, M.D. Houssien Malekafzali, M.D., Ph.D. Mohsen Malekinejad M.D., M.P.H. Nooshin Razani, M.D., M.P.H. Willi McFarland, M.D., Ph.D. George Rutherford, M.D., A.M. HIV and related risk behaviors of injecting drug users (IDU) in Iran: findings from the first respondent-driven sampling (RDS) survey of IDU in Tehran in 2006-2007

2. Objectives To assess feasibility and usefulness of RDS being integrated into Iran’s HIV surveillance system To estimate HIV prevalence and related risk behaviors among IDU To identify key areas for HIV prevention interventions among IDU population

3. Parallel epidemics of HIV and drug-use Iranian Center for Disease Management (March 2007) HIV confirmed cases Iranian Ministry of Health and Medical Education, 2007 -Prior drug treatment-based and prison-based studies have estimated prevalence to be 15.2%-23.2% (Zamani, 2005, 2006) and 1.2%-25.0% (Asghri, 2006 unpublished) -Estimated size of IDU population: 200,000 (Razaghi 2006) Opiate trafficking routes

4. Methods: overall design Design: cross-sectional Sampling technique: RDS Target population: active IDU in Tehran HIV serological assessment: HIV antibody testing using EIA with Western blot confirmation Interview: Face-to-face using a pre-structured questionnaire Calculated sample size: 726 subjects

5. Methods: RDS implementation Implementation ComponentsWeek (1 - 14)Week (15 - 44) Recruitment sites1 4 (3 added) Allowable number of referral (coupon given out) 3 3 (no change) Coupon expiration30 days 30 days (no change) Primary incentive 1000 Tooman ($1.07) 2000 Tooman ($2.14) Secondary Incentive 500 Tooman ($0.54) 1000 Tooman ($1.07) Seeds1424 (10 added)

6. Geographical distribution of participants 22 (5%) 23 (7%) 151 (35%) 200 (40%) 63 (12%) 3 Seeds 6 Seeds(25%) 8 Seeds(33%) 1 Seed(4%)

7. Results Recruitment duration: 44 weeks Total seeds: 24 (14 initial + 10 after adjustments) Maximum waves generated by one seed: 34 Number of coupons distributed: 1726 Number of coupons returned: 645 – 90% of ineligible referrals were non-injectors Number of eligible and enrolled: 553 – Number included in final analysis: 426 Demographics: 98% male, 27% <30 years old, 39% Fars, 12% homeless, 8% illiterate, 45% unemployed, 9% married

8. Prevalence of HIV and selected risk behaviors HIV: 25.0% (18.0% - 28.3%) Never heard of HIV: 18.1% (14.8%-22.8%) Ever tested for HIV: 28.6% (22.9%- 34.6) Ever used non-sterile needle: 74% (67.4-79.6) Ever shared a needle - last 12 months: 28.0% (22.7%- 32.9%), last 30 days: 20% Shared drug paraphernalia for all injections: 15.7% (11.2%- 19.6%) Ever incarcerated: 84.1% (79.2%- 88.1%)

9. Prevalence of HIV sexual risks among male IDU Ever had sex with FSW: 40.8% (30.9%-42.6%) History of sex with other men: 7.6% (4.9%- 11.1%) Ever exchanged sex for money/drugs: 8.4% (4.9%-11.15%) 45% previously married, 9% currently married

10. Conclusion HIV prevalence is high even in community-based sample of IDU in Tehran RDS is an effective sampling tool to reach “male” IDU for surveillance surveys in Iran RDS enabled us to reach certain sub-populations for prevention who may not be reached otherwise Some IDU sub-populations might not be networked with others: females, Afghani, more affluent

11. Acknowledgment Participants, field workers, IRCHA staff, Kayvan Laboratory Funding agencies: Eastern Mediterranean Regional Office of World Health Organization, Tehran University of Medical Sciences, Iranian Ministry of Health and Medical Education, Center for Disease Management, University of California, Berkeley, School of Public Health

13. Discussion: Comparison of RDS Result with Zamani (2005) CharacteristicsZamani (N=170) Prevalence (%) RDS Study ( N= 546) Prevalence (95% CI) HIV Positive15.225 (18.8-28.0) Age < 3049.327 (N/A) Male97.098.7 (N/A) Never married56.345.8 (38.8 –51.9) Fars ethnicity63.038.7 (31.4 – 43.5) Unemployed58.755.3 (50.1 – 61. 8) Ever incarcerated58.784.1 (979.2- 88.1) Ever test for HIV29.628.6 (22.9-34.6) Ever exchange sex for money or drug 31.58.4 (4.9-11.1)