The majority of prisoners in our study were knowledgeable about how HIV is transmitted. Their high level of understanding may be due in large part to recent credible HIV training efforts in Iranian prisons. The need and positive impact of training on awareness of HIV transmission has been documented in other international studies [13–15]. However, the vast majority of prisoners in our study still believed that HIV could be transmitted through kissing or hand shaking. This is consistent with a study conducted with prisoners in Nigeria . A study of Iranian high school students in Tehran similarly found that the majority of respondents answered knowledge questions about HIV/AIDS correctly, but that there still existed misconceptions about the routes of transmission . So, even with recent awareness training at Rajaei-Shahr prison, there is evidence of some inaccurate information about HIV transmission among the prisoner population.
Using the Health Belief Model (HBM) as the framework to help understand individuals' health related behaviors, specifically high-risk behaviors for the transmission of HIV, our results show that the only component of the model significantly associated with the reduction of high-risk behavior is perceived benefit. That is, prisoners decreased their HIV high-risk behaviours (e.g., used clean syringes) when they believed in the effectiveness of strategies designed to reduce the risk or seriousness of impact of the health condition. This does not mean that the other two components of the HBM are not effective in explaining health related behaviour, only that they did not show to be for the prisoner population in our study. Clearly, further research is required.
Similar to the findings in our study, a 2006 comparative study conducted in six cities in Eastern Europe, Asia and Latin America found that the promotion of and advocacy surrounding the health benefits of needle exchange for injection drug users positively affected HIV high-risk taking behaviors . Another 2006 study, this one focussing on the feasibility of offering late-night harm reduction services for a hard to reach group of Methamphetamine-using men who have sex with men, concluded that providing needle exchange, condoms, sexually transmitted infection testing and harm reduction education together may positively impact the high-risk behaviors of individuals at risk for acquiring or transmitting HIV . In other studies it has been shown that relaying the benefits of harm reduction strategies, as conceived in a HBM framework, may influence high-risk behaviors with drugs other than opiates, such as ecstasy or tobacco [20, 21]. And in two studies examining the awareness of condom use to prevent the spread of HIV among non-injection drug using based samples (hotel workers in Madrid, adolescents in the United States), both showed that belief in the effectiveness of condoms contributed to more likely use [22, 23]. The effectiveness of condom use education and provision in reducing the risk of HIV transmission has been widely supported in the research literature among various populations [24, 25].
The international literature by and large supports the effectiveness of harm reduction programming in prison settings . The benefit of needle exchange programs, for example, in the reduction of risk behaviour and the transmission of blood-borne infection in correctional facilities in such places as Germany, Spain and Switzerland has been supported through research . More specific, the importance of informing prisoners about the effectiveness of harm reduction initiatives for changing their HIV high-risk behavior has received some support in this study, and as reviewed, in others as well. Considering these findings and our understanding of the prison environment, prisoners need to be viewed as individuals who are capable of making health informed choices, and not simply criminals who are incarcerated to be punished [28, 29]. This damaging ideology is one of many barriers globally that must be overcome if a harm reduction approach, in particular among a prison population, is to be fully embraced and implemented. In Iran, triangular clinics are suggested to be a very viable and possible step toward ensuring this.
The integrated concept of triangular clinics (sexually transmitted infections, HIV/AIDS, drug abuse) in Iran prisons, including Rajaei Shahr prison, attempt to reduce the threat of HIV transmission that prisoners face while incarcerated. Triangular clinics are well-established complex clinics serving a wide range of prisoner health needs, including counseling and testing, harm reduction interventions (e.g., needle exchange) and medical diagnosis and treatment for sexually transmitted infections . According to the findings of this study, to improve the value of these services, it may be wise to widely educate the prison population about their effectiveness. Once again, this suggests that it is necessary that prisoners be viewed as individuals with the capacity and desire to make informed decisions about their own health.