HIV Seroprevalence among High-Risk Groups in Kohgiloyeh and Boyerahmad Province, Southwest of Iran, a Behavioral Surveillance Survey

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1 AIDS Behav (2012) 16:86 90 DOI /s x ORIGINAL PAPER HIV Seroprevalence among High-Risk Groups in Kohgiloyeh and Boyerahmad Province, Southwest of Iran, a Behavioral Surveillance Survey Orang Ilami Bahador Sarkari Abdolmajid Khosravani Mehdi Akbartabar Tori Zahra Hosseini Published online: 29 December 2010 Ó Springer Science+Business Media, LLC 2010 Abstract We conducted a survey to assess the seroprevalence and risk behaviors for HIV infection in 2,009 individuals in Kohgiloyeh and Boyerahmad province, in Southwest of Iran. Blood samples were drawn from each participant and tested for anti-hiv1/2 antibodies. HIV antibodies were detected in 36 (1.8%) blood samples among a total of 2,009 participants. The rate of infection in inmates was 2.7% while this rate was 9.9% in injection drug users. Correlation between HIV infection and sex, age, marital status, history of imprisonment, injection drug use, and place of residence were significant. Improving of the surveillance in this community through supervision and monitoring of infected people is needed. Keywords Seroprevalence HIV High-risk group Prevalence Iran Introduction HIV is a challenging health problem in the new century. According to WHO report there were 33.4 million cases of HIV infection at the end of year 2008 and 2.7 million new O. Ilami A. Khosravani Z. Hosseini Faculty of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran B. Sarkari (&) Center of Basic Researches in Infectious Diseases, Shiraz University of Medical Sciences, Shiraz, Iran sarkarib@sums.ac.ir M. Akbartabar Tori Faculty of Health, Yasuj University of Medical Sciences, Yasuj, Iran cases of HIV have been reported in These reports show that there is an emerging incidence of HIV infection in Asia, the Indian subcontinent and a few of Middle East countries including Iran [1]. HIV-infected people serve as a reservoir for transmission of the infection to their partners and also other people including health care workers. It is essential to assess the magnitude of the problem in any region in each country. This will help the health authorities in improving the surveillance and prevention of the infection in the community through management and monitoring of infected individuals. In Iran, the infection is emerging mostly due to the problem of intravenous drug abuse and needle-sharing in the country. Iran has experienced two waves of the AIDS epidemic. The first wave was between 1986 and 1996, and those at risk of the epidemic were those who received contaminated blood or blood products. The second and new wave of the epidemic began within the last 15 years and the populations at risk have remained injection drug users and those who are engaged in unprotected sexual activities. More than 4.5 million people in Asia are estimated to inject drugs. Injection drug users (IDUs) constitute a large group of persons at high-risk for acquiring HIV infection [2]. The range of HIV infection in intravenous drug users in Iran has been reported to be over 10% and injecting drug users account for over two-thirds (67.5%) of reported HIV cases in Iran [3, 4]. HIV infection rates among high-risk groups are on the rise around the world. The high-risk populations for HIV infection are individuals who are involved in activities including blood transfusions, medical or dental practice, acupuncturing and tattooing, injection drug users, men who have sex with men (MSM), sex workers, prison inmates,

2 AIDS Behav (2012) 16: and health workers. HIV positive individuals might endanger their friends and families and also the general community to HIV infection. In this study we evaluated the epidemiological and behavioral characteristics of populations at a high-risk of HIV infection in high-risk groups in Kohgiloyeh and Boyerahmad province, southwest of Iran. Given the concentration of epidemic, the study was justified by the lack of information about HIV infection and HIV-related risk behavior in this area. Findings of this study might be used for better implementation of HIV surveillance and control programs not only in Iran but also in the region as it appears that the nature of the epidemic is similar across affected countries within the region. Materials and Methods The current study was conducted from 2009 to 2010 in Kohgiloyeh and Boyerahmad province. Kohgiloyeh and Boyerahmad is one of the 31 provinces of Iran. It is in the south west of the country (Fig. 1) and its capital is Yasuj. The province covers an area of 15,563 sq km, and in 2006 had a population of 634,000. The province is mostly mountainous in terrain, part of the Zagros range. High-risk groups for HIV in Iran (those who are involved in activities including blood transfusions, medical or dental practice, acupuncturing and tattooing, injection drug users, prison inmates, and health workers) were recruited for this study. After getting approval from the ethics committee of Yasuj University of Medical Sciences, blood samples were taken from 2,009 individuals at risk of HIV including, inmates, injection drug users, health care workers, patients on maintenance haemodialysis, hemophilic patients and people with a history of blood transfusion from Yasuj, Gachsaran, and Dehdasht (three main townships in the province). Participation in this study was voluntary and all participants were counseled about the study and they were requested to provide signed informed consent. Confidentiality of the details of the participants was guaranteed. A questionnaire was used to record the demographic features of participants during sample collecting. Moreover the questionnaire contained detailed questions concerning HIV-related risk behaviors such as intravenous drugs injection, history of imprisonment, having received blood and/or blood products, unsafe sexual activities, and history of other risk factors such as tattooing, body piercing, and history of surgery or dental practice. Five milli litres of blood was taken from each subject and sera were tested for anti-hiv1/2 antibodies, using an enzyme-linked immunosorbent assay (ELISA, DIALAB, Austria). Collected data were analyzed by SPSS version 13 software. Standard x 2 test was used to assess the correlation of demographic and behavioral variables and HIV seropositivity. Results Of 2,009 participants, 802 (39.9%) were from Yasuj, 803 (40%) were from Gachsaran and 404 (20.1%) were from Dehdasht Townships. Males constituted 66.4% of subjects whereas 33.4% of participants were female. Most of the subjects (39.6%) were in the age group years and majority of the study subjects were married (60.3%). Details of recruited high-risk groups are depicted in Table 1. HIV antibodies were detected in 36 (1.8%) of subjects. Rate of infection was higher in males (2.4%) compared to females (0.5%). The highest rate of infection (3.5%) was seen in Gachsaran Township. Rate of infection in inmates was 2.7% while this rate was 9.9% in injection drug users. The highest prevalence of HIV (3.2%); 15/472 was found Fig. 1 Location of Kohgiloyeh and Boyerahmad within Iran (Y Yasouj, D Dehdasht, G Gachsaran)

3 88 AIDS Behav (2012) 16:86 90 Table 1 High-risk groups and frequency of participant in each group High-risk groups Frequency Percent Inmates Health care workers Injection drug users Thalassemic Hemophilic History of transfusion Others a a Tattooing, history of surgery, dental practice, having HIV positive patients in the family Table 2 Risk factors associated with HIV infection in Kohgiloyeh and Boyerahmad province, southwest of Iran Risk factor in the years age group while no HIV infection was found in the 166 subjects 20 years or younger. Rate of infection was quite high (7.8%) in unemployed individuals. Health care workers constituted 0.6% of infected individuals. Table 2 represents the risk factors associated with HIV infection in this study. Correlation between HIV infection and sex, age, marital status, history of imprisonment, injection drug use, unprotected sex activities, level of education and place of residence were statistically significant (P \ 0.05). Multiple risk factors were noticed in some of the subjects and a significant correlation was found between the number of risk factors and positive HIV serostatus. Discussion HIV positive HIV negative Total P value History of P \ 0.05 imprisonment History of drug using P \ 0.05 History of transfusion P [ 0.05 History of needle stick P [ 0.05 Thalassemia P [ 0.05 Hemophilia P [ 0.05 Unprotected sex P \ 0.05 activities Others a P \ 0.05 a Tattooing, history of surgery, dental practice, having HIV positive patients in the family The Middle East stands as a region where knowledge of the epidemic continues to be very limited and subject to much controversy [5]. The cultural values in this region, in terms of prohibitions against premarital sex, homosexuality and alcohol and drug use, might contribute to a decline in the spread of HIV in this region. Nevertheless the recent data shows that the number of newly infected cases in these regions is increasing [1]. HIV infection rates among high-risk groups are on the rise in this region and around the world. The high-risk populations for HIV infection are those involved in activities such as blood transfusions, medical or dental practice, acupuncturing and tattooing, injection drug users, MSM sex workers, prison inmates, and health care workers. HIV positive individuals might put their friends and families as well as the general members of the community at risk of HIV infection. With the lack of data and information on the epidemiology of HIV in this area, the purpose of this study was to evaluate the seroprevalence of HIV and HIV-related risk behavior in high-risk groups in Kohgiloyeh and Boyerahmad province, southwest of Iran. Prevalence of HIV among all participants of this study was 1.8%. Findings of this study demonstrated that highrisk groups in Kohgiloyeh and Boyerahmad province are at great risk of HIV infection. Since the recruited subjects of this study are among the high-risk population, therefore the rate of HIV infection in the general population of the province might be different. Moreover, because of religious beliefs and the inconvenience of questions about sex behaviors, many individuals could not suitably answer these questions. Such data was not considered in statistical analysis. Self-reporting of behaviors such as sexual activity and drug use which resulted in underreporting of the risk factors are other limitations of this study. A significant correlation was found between sex and HIV infection where male were more likely to be infected than females. This is consistent with other studies in Iran and the rest of the region [6 8]. Considering the main route of HIV infection in Iran which is injecting drug use and the fact that the majority of IDU are males, the high rate of HIV infection in males is predictable. Higher rates of infection were found in Gachsaran in comparison with the other two townships. This might be due to the diversity of ethnic groups in this township and also to the geographical location of this township which is situated between three provinces with a relatively high trafficking of passengers. A correlation was found between imprisonment and HIV seropositivity. Similar connection has been shown in other studies in Iran. Rate of infection in prison inmates in the current study confirmed that the rate of HIV infection among inmates is relatively high. HIV infection in prison inmates might be a real challenge in controlling for HIV infection in the community since this group serves as a source of infection where they transfer the virus to their families upon release. The behavior of inmates that makes the HIV prevalence high among this population needs further investigation although

4 AIDS Behav (2012) 16: intravenous drug using might contributed to this high HIV prevalence. Findings of this study, as have been shown in previous studies, demonstrate a significant link between HIV infection and injection drug use [2]. In Rahimi-Movaghar [4] study in Tehran, prevalence of HIV was reported to be 10.7% in injecting drug users. Lower rate of HIV infection, however, has been reported in Imani [7] study in Shahr-e-Kord in intravenous drug users, where only one out of 1,333 IDU have been positive for HIV. Aceijas et al. [8] estimated that, in 2004, four of five IDUs worldwide lived in developing countries. The countries in which the majority of HIV infections have been attributed to injection drug use in 2005 included Russia, Ukraine, the central Asian republics, Iran, China, Indonesia, Nepal, and Vietnam. Although needle stick injury is a route of HIV infection and cases of HIV due to needle stick injury have been reported among health workers, our study shows no connection between a history of this route of transmission and HIV infection in health care workers. Receiving blood or blood products might endanger the recipient to HIV, although its probability in recent years is quite low with comprehensive testing of blood for HIV in blood transfusion centers. This study did not find a correlation between a history of blood transfusion and HIV infection. This is in keeping with the fact that nowadays the risk of transmission of HIV through blood or blood product is low. On the other hand, the rate of HIV infection in blood donors in Iran, which mainly voluntarily donate blood, is low. Khedmat et al. [9] reported a HIV prevalence of 0.003% (11 out of 318,029) for Iranian volunteer blood donors attending to Tehran blood transfusion service from 2005 to The prevalence of HIV in blood donors in neighboring countries is more or less the same. Khattak et al. [6] reported a prevalence of 0.007% for HIV in northern Pakistan in 103,858 blood donors. Thalassemic and hemophilic patients are at high-risk of acquiring HIV infection. No cases of HIV prevalence were found among the hemophilic and thalassemic patients in our study. This might be due to the low number of such cases in our study. Moreover, the risk of receiving contaminated blood is too low these days in many blood transfusions setting around the world as well as in Iran. Decrease in the rate of blood borne infection has been documented in Iran, e.g. for hepatitis C infection. It has been demonstrated that the prevalence of HCV in hemodialysis patients in Iran is decreasing from 14.4 in 1999 to 4.5% in 2006 [10]. Seroprevalence of HIV antibodies among multitransfused thalassemic and haemophiliac children in Shiraz was found to be zero (in 466 patients) and 0.36%, respectively [11, 12]. In Mirmomen study samples from patients with beta thalassemia from five provinces of Iran including Tehran, Kerman, Qazvin, Semnan and Zanjan were tested for HIV seropositivity. None of 732 samples were positive for HIV [12]. A consistent correlation was found between levels of education and HIV prevalence among the participants. Individuals with higher levels of education experience lower rates of infection. Individuals with relatively high levels of education are more likely to know how to prevent HIV infection and to take measures to protect themselves. In conclusion, findings of the present study provided epidemiologic features of HIV in Kohgiloyeh and Boyerahmad Province in Southwest of Iran and behavioral factors that characterize the epidemiology of HIV infection in the country. Moreover, findings of this study may help in improving the surveillance and prevention of the infection in the community through management and monitoring of infected individuals. Acknowledgments This study was financially supported by governor of Kohgiloyeh and Boyerahmad province. Authors would like to thank all of those who provided the blood samples for this study. References 1. UNAIDS epidemic update Available at: unaids.org/pub/report/2009/jc1700_epi_update_2009_en.pdf. 2. Mathers BM, Degenhardt L, Ali H, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet. 2010; 375: Kheirandish P, Seyedalinaghi SA, Hosseini M, et al. Prevalence and correlates of HIV infection among male injection drug users in detention in Tehran, Iran. J Acquir Immune Defic Syndr. 2010;53: Rahimi-Movaghar A, Razaghi EM, Sahimi-Izadian E, Amin- Esmaeili M. HIV, hepatitis C virus, and hepatitis B virus co-infections among injection drug users in Tehran, Iran. Int J Infect Dis. 2010;14: Abu-Raddad LJ, Hilmi N, Mumtaz G, et al. Epidemiology of HIV infection in the Middle East and North Africa. AIDS. 2010; 24(Suppl 2):S Khattak MF, Salamat N, Bhatti FA, Qureshi TZ. Seroprevalence of hepatitis B, C and HIV in blood donors in northern Pakistan. J Pak Med Assoc. 2002;52: Imani R, Karimi A, Rouzbahani R, Rouzbahani A. Seroprevalence of HBV, HCV and HIV infection among intravenous drug users in Shahr-e-Kord, Islamic Republic of Iran. East Mediterr Health J. 2008;14: Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 2004;18: Khedmat H, Fallahian F, Abolghasemi H, et al. Seroepidemiologic study of hepatitis B virus, hepatitis C virus, human immunodeficiency virus and syphilis infections in Iranian blood donors. 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5 90 AIDS Behav (2012) 16: Karimi M, Ghavanini AA. Seroprevalence of HBsAg, anti-hcv, and anti-hiv among haemophiliac patients in Shiraz, Iran. Haematologia (Budap). 2001;31: Mirmomen S, Alavian SM, Hajarizadeh B, et al. Epidemiology of hepatitis B, hepatitis C, and human immunodeficiency virus infections in patients with beta-thalassemia in Iran: a multicenter study. Arch Iran Med. 2006;9: