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Needle and syringe sharing among Iranian drug injectors

  • Hassan Rafiey1Email author,
  • Hooman Narenjiha1, 2,
  • Peymaneh Shirinbayan1,
  • Roya Noori1,
  • Morteza Javadipour3,
  • Mohsen Roshanpajouh3,
  • Mercedeh Samiei1 and
  • Shervin Assari3
Harm Reduction Journal20096:21

https://doi.org/10.1186/1477-7517-6-21

Received: 7 April 2009

Accepted: 30 July 2009

Published: 30 July 2009

Abstract

Objective

The role of needle and syringe sharing behavior of injection drug users (IDUs) in spreading of blood-borne infections – specially HIV/AIDS – is well known. However, very little is known in this regard from Iran. The aim of our study was to determine the prevalence and associates of needle and syringe sharing among Iranian IDUs.

Methods

In a secondary analysis of a sample of drug dependents who were sampled from medical centers, prisons and streets of the capitals of 29 provinces in the Iran in 2007, 2091 male IDUs entered. Socio-demographic data, drug use data and high risk behaviors entered to a logistic regression to determine independent predictors of lifetime needle and syringe sharing.

Results

749(35.8%) reported lifetime experience of needle and syringe sharing. The likelihood of lifetime needle and syringe sharing was increased by female gender, being jobless, having illegal income, drug use by family members, pleasure/enjoyment as causes of first injection, first injection in roofless and roofed public places, usual injection at groin, usual injection at scrotum, lifetime experience of nonfatal overdose, and history of arrest in past year and was decreased by being alone at most injections.

Conclusion

However this data has been extracted from cross-sectional design and we can not conclude causation, some of the introduced variables with association with needle and syringe sharing may be used in HIV prevention programs which target reducing syringe sharing among IDUs.

Introduction

Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency disorder syndrome (AIDS) has shown a rapid increasing trend [1]. This problem is closely associated to injecting drug users (IDUs) in Iran, accounting for 67% of HIV positive cases and 85% of AIDS cases [2].

HIV studies in Iran have underscored the sharing injecting equipments as the main routes of transmission [3]. In one study, lifetime and last time needle and syringe sharing was reported by 50% and 25% of IDUs, respectively [4]. In another study, in a drug treatment sample, more than two-thirds of the IDUs had shared syringes [5].

Identifying factors associated with needle and syringe sharing among IDUs is particularly important for HIV prevention [6]. While very little is known about associated factors of needle and syringe sharing among Iranian IDUs [79], we here aimed to determine the prevalence and associates of needle and syringe sharing among a sample of IDUs in Iran.

Methods

Design and setting

This is a secondary analysis of a cross-sectional survey on 7,743 individuals as a rapid situation assessment (RSA) performed by the Darius institute. Grant was awarded by the Iranian Research Center for Substance Use and Dependence (DARIUS Institute) affiliated to the University of Social Welfare and Rehabilitation Sciences. The study was approved by the ethical review committee of the university and informed consent was obtained from all the participants after they had been verbally reassured that the information would be kept confidential, especially from correctional system. This study was conducted under the financial aid of the Drugs Control Headquarters (DCHQ). Some other manuscripts have been extracted from this database.

Samples and sampling

The participants were substance dependent persons according to DSM-IV and sampled from treatment centers (n = 1,217), prisons (n = 584) and streets (n = 5,860) of the capitals of 29 provinces in the Islamic Republic of Iran. The samples from treatment centers were selected at random from newcomers. Prisons sampling was also carried out randomly among those who were registered into the prison within previous 30 days. Snowball approach was used to take sample from streets. The number of samples taken from every province was proportional to the whole population of the province. The sampling started in April 2007 and lasted for 5 months. This sampling method is used as the main sampling strategy of drug use in DCHQ studies.

Process

The interviews were carried out by university graduates (MS, BS) with drug abuse related majors/degrees who were dispatched to the provinces after being trained through workshops in Tehran (the capital of Islamic Republic of Iran). Each interview took 1 to 1 and a half hour. Data were collected using paper-based questionnaire namely Inventory for Drug Dependency-IV, which was the modified version of the one used in the previous national RSA of Iran performed by the research center [10]. The revision was done through a series of expert panel meetings, and new items and questions were added that met the desired objectives. Sixty nine items were classified in 9 different parts including: 1) socioeconomic data (at the time of data collection), 2) family data, 3) first use data, 4) lifetime drug use, 5) current drug of dependency, 6) injection data, 7) high risk behavior, 8) treatment data, and 9) social network.

Independent data

Data included in this study included the following parts:
  1. I)

    socio-demographic data: Data consisted age, age of beginning addiction, age of beginning injection, duration of injection, gender, educational level, marital status, living place, status of home, status of employment, alone living, income, legal income, illegal income, drug sell income, monthly family income, cigarette smoking, family history of cigarette smoking, family history of drug use

     
  2. II)

    Drug related data consisted monthly money that IDUs used for dominant substance, first place of drug use, first situation of drug use, most reason for first drug use, first pesrson that who suggested drug use, dominant drug that current injectors was used(type of drug), poly drug use and history of drug problems treatment.

     
  3. III)

    Injection related data consisted first place of injection, situation of first injection, cause of first injection, frequency of injection in the past years, usual place of injection and alone injection.

     
  4. IV)

    Non-sexual high risk behaviors consisted of history of arrest, and history of imprisonment.

     

To make the final costs internationally comparable, the costs which were registered in Iranian Rials were converted to purchase power parity or international Dollar (PPP$). The conversion rate for PPP$ was based on a recently published Iranian study, which had reached at an estimation of PPP$ equal to 2727 Rials according to the information from the Central Bank of Iran and the World Bank database [11].

Outcome

Lifetime needle and syringe sharing was defined as borrowing or lending syringe, needle or other injection equipments at least once in their life [1214]. The most important cause for needle and syringe sharing was also included, with a multiple choice question. Answers included "no access to sterile syringes", "to get more pleasure", "quick injection", "being sure at the shared syring", "financial limitations", "not aware of possible risk", "easy injection" and "peer pressure" [1517].

Statistical analysis

The data obtained in the SPSS for Windows 13 statistical package. In order to present quantitative data, median (percentile 25% = Q1 and percentile 75% = Q3), mean and standard deviation was used. In order to compare the qualitative variables between those with and without "needle and syringe sharing", chi-square test was used. The comparison of age between two groups was done with t-test and expenditures of drug use between two groups with Mann-Whitney. Multivariate stepwise logistic regression was used to determine the predictors of lifetime syring sharing. P value < 0.05 was considered significant.

Results

Mean age at study, age at first drug use, age at first injection, and duration of injection of the participants were 31.3 ± 8.3, 18.6 ± 5.4, 25.9 ± 6.7 and 7.4 ± 6.3, respectively. Most participants were Muslim, lived in urban area, single, with a lower diploma educational level.

Needle and syringe sharing

From all 2091 IDUs, 749(35.8%) reported lifetime experience of needle and syringe sharing. Most frequent causes for needle and syringe sharing included "no access to sterile syringes" (n = 437; 20.9%), "to get more pleasure" (n = 274; 13.1%), "quick injection" (n = 164; 7.8%), "being sure at the shared syring" (n = 128; 6.1%), "financial limitations" (n = 128; 6.1%), "not aware of possible risk" (n = 99; 4.7%), "easy injection" (n = 94; 4.5%) and "peer pressure" (n = 61; 2.9%).

Associates of Needle and syringe sharing

Socio-demographic data

IDUs with lifetime syring sharing had a higher mean age (32.3 ± 8.9 vs. 31.4 ± 8.1; p = 0.02), lower age of first drug use (17.9 ± 5 vs. 18.6 ± 5.4; p = 0.005), higher duration of injection (6.5 ± 6.3 vs. 5.4 ± 5.5; p < 0.001). Age at first injection was not linked to lifetime syring sharing (25.8 ± 6.8 vs. 26.1 ± 6.7; p = 0.28). IDUs with lifetime syring sharing had lower monthly family income (733 ppp$, Q1 = 330 ppp$, Q3 = 1283 ppp$ vs. 807 ppp$, Q1 = 476 ppp$, Q3 = 1466 ppp$; p < 0.001). Overall monthly paiment on drugs were not linked to lifetime syring sharing (586 ppp$, Q1 = 330 ppp$, Q3 = 1063 ppp$ vs. 550 ppp$, Q1 = 366 ppp$, Q3 = 1100 ppp$; p = 0.44). Bivariate analysis showed that needle and syringe sharing was significantly higher in females, those who lived in rural area, those who were illiterate, those who were separate/divorce/widow, homeless, those who lived alone, those jobless, those with illegal income, those with drug related income and those with drug use family members (Table 1).
Table 1

The comparison of syringe sharing between socio-demographic variables

  

Syringe sharing

 
  

Count

Percent

P value

Sex

Male

713

35.4%

0.029

Female

35

47.9%

 

Religious type

Muslim

737

36.0%

0.164

other

2

16.7%

 

Living place

Urban

640

35.0%

0.004

Rural

62

47.7%

 

Education level

Illiterate or were barely able to read and write

94

43.7%

0.002

Under diploma

607

36.0%

 

Upper diploma

35

25.0%

 

Marital status

single

421

38.0%

<0.001

Married

166

26.4%

 

Separate, divorce and widow

153

46.8%

 

Status of home

Having home

575

32.4%

0.000

Homeless

144

62.1

 

Alone Living

No

567

32.8%

<0.001

Yes

182

50.6%

 

Occupation

No

353

28.5%

<0.001

Yes

396

46.5%

 

Boss type

State

13

25.0%

0.591

Private

114

30.9%

 

khisfarrma

126

28.5%

 

Drug Income

No

462

30.2%

<0.001

Yes

267

52.0%

 

Job Income

No

409

43.1%

<0.001

Yes

320

29.3%

 

Illegal Income

No

412

28.5%

<0.001

Yes

317

53.0%

 

Legal Non Job Income

No

345

35.3%

0.775

Yes

384

36.0%

 

Furniture sell Income

No

683

35.5%

0.483

Yes

46

38.7%

 

Lifetime smoking

Never smoking

23

34.3%

0.636

Current smoking

690

36.1%

 

Past smoking

36

31.9%

 

cigarette smoking by parents

No

296

29.8%

<0.001

Yes

453

41.3%

 

cigarette smoking by other members of family

No

178

26.8%

<0.001

Yes

571

40.0%

 

Substance use by parents

No

475

31.3%

<0.001

Yes

274

47.7%

 

Substance use by members of family

No

337

29.0%

<0.001

Yes

412

44.3%

 

Substance-related and injection-related data

Needle and syringe sharing was higher in IDUs who used heroin (331,41.3% vs. 418,32.4%; p < 0.001), was lower in those who used opioium (47,23.6% vs.702,37.1%; p < 0.001) and was lower in those who used Amphetamines (12,15.6% vs. 737,36.6%; p <0.001). Poly drug users was associated with needle and syringe sharing (321, 40.5% vs. 415, 33.3%; p = 0.001). (Table 2).
Table 2

The comparison of syringe sharing between drug use-related variables

   

Syringe sharing

P value

   

Count

Percent

 

Dominant drug usage

Opioium

Yes

47

23.6%

<0.001

 

No

702

37.1%

 

Amphetamines

Yes

12

15.6%

<0.001

 

No

737

36.6%

 

Heroin

Yes

331

41.3%

<0.001

 

No

418

32.4%

 

Purified Heroin

Yes

202

35.9%

0.943

 

No

547

35.8%

 

Norjesic

Yes

109

35.6%

0.937

 

No

640

35.9%

 

First place of drug use

Own home, home of friends, student home

 

338

32.1%

0.003

 

Roofless public places

 

225

40.7%

 
 

Roofed public places

 

95

36.3%

 

First situation of drug use

Specific situations(family party, friends party, mourning ceremony, gatherings with friends)

 

559

35.5%

0.524

Without Specific situation

 

187

37.1%

 

What was the most important event that leaded you to first use?

Specific events(work related, familial/domestic, educational)

 

360

38.6%

0.029

Without Specific event

 

376

34%

 

Most important reason for beginning drug use

Pleasure/enjoyment, recreation, Konjkavi

 

402

34%

0.033

Without pleasure/enjoyment

 

343

38.6%

 

First person who suggested you to use substance

Family or relatives

 

149

42.2%

0.015

Friends

 

377

35.5%

 

Assistants

 

45

31.5%

 

Others

 

52

29.5%

 

Without mover

 

96

32.0%

 
Needle and syringe sharing was lower in those who alone inject (most of times) and home as first place of injection (Table 3).
Table 3

The comparison of syringe sharing between injection-related variables

   

Syringe sharinge

 
   

Number

Percent

P value

First place of injection

Own home, home of friends, student home

 

382

31.6%

0.003

Roofless public places

 

206

41.4%

 

Roofed public places

 

88

50%

 

Frequency of injection

Lower than once per day

 

145

31%

0.001

Once and higher per day

 

573

38.2%

 

Site of injection

Hand

No

76

34.4%

0.639

 

Yes

673

36.0%

 

Foot

No

393

29.9%

<0.001

 

Yes

356

45.8%

 

Groin

No

393

29.9%

<0.001

 

Yes

160

58.4%

 

Testis

No

575

32.1%

<0.001

 

Yes

174

57.6%

 

Neck

No

622

33.4%

<0.001

 

Yes

127

56.2%

 

Other

No

725

35.6%

0.316

 

Yes

24

42.1%

 

Cause of first injection

Speed of effect

No

446

32.9%

<0.001

 

Yes

303

41.2%

 

pleasure/enjoyment

No

404

30.7%

<0.001

 

Yes

345

44.5%

 

Effect less of before mode of drug use

No

526

33.3%

<0.001

 

Yes

223

43.6%

 

Pry

No

589

35.9%

0.864

 

Yes

160

35.5%

 

Relief of use

No

573

35.2%

0.265

 

Yes

176

38.0%

 

Pressure of friends

No

610

35.2%

0.208

 

Yes

139

38.7%

 

Substance was not out of reach

No

668

35.0%

0.007

 

Yes

81

45.0%

 

Low quality of present drugs

No

665

34.5%

<0.001

 

Yes

84

52.2%

 

Lower cost of injection

No

603

32.7%

<0.001

 

Yes

146

59.6%

 

Treatment of addiction

No

736

36.2%

0.031

 

Yes

13

22.4%

 

Where do you usually inject?

Own's home

No

375

39.8%

0.001

 

Yes

374

32.6%

 

Park

No

575

33.3%

<0.001

 

Yes

174

48.1%

 

School

No

743

35.8%

0.436

 

Yes

6

46.2%

 

Street and lane

No

554

32.2%

<0.001

 

Yes

195

52.2%

 

"Kharabe"

No

385

26.2%

<0.001

 

Yes

364

58.4%

 

Student's house

No

740

35.7%

0.208

 

Yes

9

50%

 

Soldiers' camp

No

737

35.5%

<0.001

 

Yes

12

80%

 

Prison

No

663

33.5%

<0.001

 

Yes

86

76.8%

 

Work place

No

661

35.5%

0.44

 

Yes

88

38.1%

 

Friend's home

No

473

34.6%

0.096

 

Yes

276

38.2%

 

With whom do you usually inject?

Alone

 

493

33.0%

<0.001

With others(friends, relatives)

 

256

43.0%

 

High risk behaviors

Lifetime needle and syringe sharing was significantly higher in those IDU who reported extramarital sexual relation) 480,64.1% vs. 269,35.9%; p < 0.001), history of being arrested by police in the past year(507,67.7% vs. 242,32.3%; p < 0.001) and history of imprisonment in the past year(455,60.7% vs. 294,39.3%; p < 0.001).

Logistic regression

Multivariate logistic regression showed that the likelihood of lifetime needle and syringe sharing was increased by female gender(OR = 2.68, 95%CI = 1.25–5.72, p = 0.01), being jobless (OR = 1.87, 95%CI = 1.41,2.47, p = 0.001), having illegal income (OR = 1.61, 95%CI = 1.21–2.15, p < 0.001), drug use by family members (OR = 1.47, 95%CI = 1.12–1.92, p = 0.005), first drug use in roofless public place (Odds Ratio = 1.55, 95%CI = 1.15–2.09, p = 0.003), first drug use in roofed public place (Odds Ratio = 1.62, 95%CI = 1.08–2.42, p = 0.01), pleasure/enjoyment as causes of first injection (OR = 1.58, 95%CI = 1.2–2.07, p = 0.001), usual injection at groin(OR = 1.64, 95%CI = 1.11–2.42, p = 0.01), usual injection at scrotum (OR = 1.57, 95%CI = 1.06–2.31, p = 0.02), lifetime experience of nonfatal overdose (OR = 1.68, 95%CI = 1.28–2.21, p < 0.001), and history of arrest in past year (OR = 1.38, 95%CI = 1.04–1.82, p = 0.02) and was decreased by being alone at most injections (OR = 0.51, 95%CI = 0.38–0.68, p < 0.001). (Table 4).
Table 4

Logestic regression for having syringe sharing between socio-demographic, drug use and injection-related variables in intravenous drug users (IDUs)

   

95% Confidence Interval for odds

 

P value

OR

Lower

Upper

Gender(female)

  

1.259

5.725

Jobless

<.001

1.870

1.412

2.478

Illegal Income

.001

1.617

1.217

2.150

Substance use of family members

.005

1.471

1.125

1.925

pleasure/enjoyment as cause of first injection

.001

1.583

1.209

2.074

First place of drug use (Roofless public places)

.003

1.558

1.157

2.097

First place of drug use (Roofed public places)

.019

1.621

1.084

2.424

Alone injection

<.001

.515

.388

.682

Groin injection

.013

1.642

1.111

2.427

Testis injection

.022

1.573

1.068

2.318

Nonfatal overdose

<.001

1.686

1.282

2.216

Arresting in past year

.022

1.385

1.049

1.829

Discussion

In Iran, 1 of 3 IDUs report the history of lifetime needle and syringe sharing. The likelihood of lifetime needle and syringe sharing was increased by female gender, being jobless, having illegal income, drug use by family members, pleasure/enjoyment as causes of first injection, first injection in roofless and roofed public places, usual injection at groin, usual injection at scrotum, lifetime experience of nonfatal overdose, and history of arrest in past year and was decreased by being alone at most injections.

Regarding the literature on syring sharing, according to a study in Mexico, 2005, 80% of the IDUs reported that they share syringes regularly with other IDUs [18]. In another study in Canada 27.6% of the participants reported sharing needles during the past 6 months [12].

Our study showed that needle and syringe sharing was increased in female IDUs. In line with our finding, one study of gender effect on needle and syringe sharing bahavior of IDUs showed that females were more likely to share injecting equipment [1921]. A recently qualitative study of Iranian female IDUs reported sharing syringes as a typical behavior [8]. Different risk profile of HIV among male and female IDUs is in line with these reports [22]. So, gender should be addressed as an important variable in needle exchange programs [23].

In our study, jobless IDUs and those who had illegal income had higher rate of needle and syringe sharing. Review of literature shows a link between unemployment of IDUs and needle and syringe sharing behavior [24, 25]. Similarly, syringe has been reported to be linked to not having a legal income [26] or engaging in illegal jobs [27]. These may be due to the financial strains to buy stril syrings, and free syrings should be given to these IDUs.

In our study, drug injectors with drug user family members were at higherrisk for needle and syringe sharing. Needle and syringe sharing is reported to be higher in IDUs with a familial network for drug use [28]. Oe study reported that the role of family network on the needle-sharing behavior is more severe in women in comparison with men [29].

In our study, first drug use at public places was linked to more syringe sharering. According to the literature, IDUs who usually inject in public places have oppurtunity for needle and syringe sharing [30, 31]. A qualitative study in Iran also confirms this association [8].

Alone injection in compare to injection with someone else, is linked to the lack of oppurtiunity of needle and syringe sharing. In one study in US, markedly lower rates of needle and syringe sharing was observed in IDUs who injecting alone [32]. Injection in the context of social and familial networks is known to be associated with higher needle and syringe sharing [28]. Those who try to keep their injecting hidden, may benefit of a reduced risk of syring sharing [32].

We found that injection in groin and linked to higher needle and syringe sharing in IDUs. However we did not find any study in this regard, studies of bodily injection sites of IDUs have reported a clear progression in sites used, from the upper extrimities, at initial injection to the use of sites such as the groin and scrotum the years after [33, 34]. Unjection in sites such as the groin and scrotum were linked to a greater number of injection-related problems. One study showed a link between more severe drug injecting and share needles [25].

We found a link between needle and syringe sharing and nonfatal overdose, which are both high risk behaviors. One study in USA showed that overdosing may be associated with borrowing syringes [35] but in another study in England in1994 to 1995 self-reported overdose was not linked to syring sharing [36]. We also found arrest in the past year as a associated factor with needle and syringe sharing. Similar results have been reported by two studies in Pakistan and Australia [37, 38]. Other Risk Behavior Surveys have shown a Co-occurrence of health-risk behaviors among differerent populations [39, 40]. These studies have explained their findings with the gateway theory.

In Iran, evidences show that access to a needle and syringe program (NSP) will reduce the needle and needle and syringe sharing practices. The authors suggested NSPs to be intensified in settings with concentrated HIV epidemics among IDUs in Iran [13].

There are some limitations to this study. First, this study is one of a series of secondary analyses [41] and we did not have data on detail of needle and syringe sharing behaviors. Second, the results rely on participants' self-report data, because self-reports are affected by response bias. Respondents may tend to deny or underreport their syring sharing due to social disirability [41]. Third, because of the cross-sectional design of this study, it is not possible to draw a conclusion on the direction of the associations. Endly, in this study we asked lifetime syring sharing, and we did not limit it by asking sharing during past year or last injection.

Conclusion

In designing interventions for HIV prevention in Iran, through decrease of needle and syringe sharing among IDUs, the introduced variables must be considered. Further studies in this regard are needed.

Declarations

Acknowledgements

We are thankful for all our collaborators who participated in the acquisition of data. We acknowledge Mohammad Mahdi Naghizadeh who supervised the data analysis.

Authors’ Affiliations

(1)
Iranian Research Center for Substance Abuse and Dependence (IRCSAD), University of Social Welfare and Rehabilitation Science
(2)
Drug Control Head Quarters (DCHQ)
(3)
Medicine and Health Promotion Institute

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