Correlates of shared methamphetamine injection among methamphetamine-injecting treatment seekers: the first report from Iran

Abstract

Shared methamphetamine injection is an emerging route of drug use among Iranian methamphetamine injectors. It is a primary vector for blood-borne infections. The aim of the current study is to determine the prevalence and correlates of shared methamphetamine injection in a sample of Iranian methamphetamine injecting treatment seekers in the south of Tehran. We surveyed male and female methamphetamine injectors at three drop-in centres and 18 drug-use community treatment programmes. Participants reported socio-demographic characteristics, drug use, high-risk behaviours, current status of viral infections and service use for drug treatment. Bivariate and multivariate logistic regression models were used to test associations between participants’ characteristics and shared methamphetamine injection. Overall, 209 clients were recruited; 90.9% were male; 52.6% reported current methamphetamine injection without any shared injection behaviour and 47.4% reported current shared methamphetamine injection. Shared methamphetamine injection was found to be primarily associated with living with sex partners (AOR 1.25, 95% CI 1.13–1.98), reporting ≥3 years of dependence on methamphetamine injection (AOR 1.61, 95% CI 1.27–2.12), injection with pre-filled syringes in the past 12 months (AOR 1.96, 95% CI 1.47–2.42), homosexual sex without condom use in the past 12 months (AOR 1.85, 95% CI 1.21–2.25), the paucity of NA group participation in the past 12 months (AOR 0.67, 95% CI 0.41–0.99), the paucity of attending psychotherapeutic sessions in the past 12 months (AOR 0.44, 95% CI 0.28–0.96) and positive hepatitis C status (AOR 1.98, 95% CI 1.67–2.83). Deeper exploration of the relationship between shared methamphetamine injection and sexual risk among Iranian methamphetamine injectors would benefit HIV/sexually transmitted infection prevention efforts. In addition, existing psychosocial interventions for methamphetamine-injecting population may need to be adapted to better meet the risks of shared methamphetamine injectors.

Keywords

HIV AIDS sexually transmitted infections injecting drug use methamphetamine shared injection high risk behaviours sexual risk

Background

Methamphetamine (MA) and related amphetamine compounds (amphetamine-type stimulants or ATS) are among the most commonly abused substances, with an estimated 35 million users in the world.¹ Iran has a long history of drug use especially opium use. MA has recently been introduced in the Iranian illicit drug market and in a short period of time, its abuse has become epidemic among Iranian injecting drug users (IDUs).^2,3 The new emerging trend of MA injection in Iran is a completely new drug problem.⁴ MA use is associated with shared injection which is a primary vector for transmitting blood-borne infections such as HIV.⁵ In addition, MA use is associated with high-risk behaviours and the risk of being infected with HIV, hepatitis and tuberculosis.^6,7

Despite availability of sterile syringes and implementing needle and syringe programmes (NSPs), in general, shared drug injection is observed among male Iranian MA injectors and has resulted in spreading blood-borne infectious diseases.^8,9 A study on a group of male Iranian IDUs who had sex with men (MSM IDUs) showed that compared to other IDUs, MSM IDUs were more likely to report sharing needles and syringes for drug injection.¹⁰ A study on 150 Iranian HIV-positive patients (124 males and 26 females) showed that shared drug injection was one of the main routes of transmitting HIV infection.¹¹ A study on 213 Iranian IDUs showed that a history of shared drug injection inside prison and multiple incarcerations were associated with significantly higher prevalence of HIV-1 infection.¹² Another study on the patterns of drug use in a sample of 292 patients attending a general health centre in Iran showed that more than two-thirds of the IDUs reported sharing syringes.¹³ In a study on 118 Iranian IDUs, the estimated rates of HIV, HBV and HCV infections were 0.7%, 0.7% and 59.4%, respectively, and 31% reported lifetime history of sharing needle and syringe for drug injection.¹⁴ In a secondary analysis, a sample of 2091 drug-dependent patients from medical centres, prisons and streets of 29 provinces in Iran were studied; 749 (35.8%) participants reported lifetime history of shared drug injection. Lifetime shared drug injection was associated with female gender, being jobless, having illegal incomes, drug use by family members, pleasure-seeking, lifetime experience of nonfatal overdose, history of incarceration in previous year and a number of other factors.¹⁵ Identifying the correlates of shared MA injection among Iranian MA injectors is particularly important for health implications and specifically targeting the treatment needs of this group, but very little is known about the prevalence and correlates of shared MA injection among Iranian MA injectors.

The lack of published studies on shared MA injection may be partly due to the new emerging trend of MA injection in the Iranian community. The current cross-sectional study aimed to determine the prevalence and correlates of shared MA injection in a sample of treatment seekers who mainly injected MA in the south of Tehran, Iran, in an effort to understand the dynamics of such behaviours and contribute to creating a basis for clinic-based risk-reduction interventions.

Methods

Design and setting

Between March and December 2011, we surveyed male and female treatment-seekers who were enrolled at 18 drug use community treatment centres and three drop-in centres (DICs) in the south of Tehran, a densely populated area in Tehran which is mainly inhabited by low socio-economic migrants and problematic drug users.¹⁶ The protocol of the study was approved by the Research and Ethics Committee of Tehran University of Medical Sciences (TUMS) in Tehran. After providing informed consent, participants completed the study questionnaire.

Participants

Male and female MA injectors who were treatment seekers were eligible to enter study if they were (1) ≥18 years old and (2) reported MA injection as one of their main drugs of injection in the 12 months preceding the study recruitment. Other eligibility criteria included lack of reporting severe drug intoxication, craving and/or withdrawal symptoms at recruitment. Participants were ensured that non-participation in the study would not impact their treatment or harm-reduction service utilization. Six patients were excluded because of severe medical conditions. The current analysis was restricted to the 209 participants who practiced MA injection in the past 12 months within the study baseline.

Measures

An interviewer-administered questionnaire was used for the interviews. The items of the questionnaire were elicited from the questionnaire of the “World Drug Injection Study Phase II (Version 2b, Revision 2)”¹⁴ and the Addiction Severity Index (ASI-5th).¹⁷ The questionnaire contained detailed questions on socio-demographic characteristics, drug use, high-risk injection and sexual behaviours, current status of viral infections and service use for drug treatment. Previous studies in Iran confirmed the reliability and validity of these measures for Iranian IDUs.⁹ Three psychiatrists adapted the questionnaire according to the situation in Tehran, which was followed by a pretest assessment on a sample of MA injectors in Tehran.

Statistical analysis

Statistical analyses were performed using SPSS for Windows (version 16.0, 2007; SPSS Inc., Chicago, IL, USA). Descriptive statistics characterized participants’ socio-demographic characteristics, drug use and injection, high risk injection and sexual behaviours, current status of viral infections and service use for drug treatment. We assessed bivariate and multivariable associations between participants’ characteristics and shared MA injection using logistic regression. Variables were included in the multivariable logistic regression model if associated with shared MA injection in univariate analyses (p < .20). Potential interactions were assessed. The multivariate model was used to obtain adjusted odds ratio (AOR) and confidence interval (CI) for the associated factors with shared MA injection.

Results

Of 209 participants, almost 52% were recruited from DICs and approximately 47% were recruited from drug-use community treatment programmes. The majority of participants (90.9%) were male; 110 participants (52.6%) reported regular MA injection without sharing needles and syringes (Group A) and 99 participants (47.4%) reported shared MA injection (Group B) in the 12 months preceding the study assessment. In this study, shared MA injection was defined as sharing needles and syringes with other drug injectors within the past 12 months prior to intake. The mean number of shared MA injection episodes was six times per month within the past 12 months prior to intake. Mean duration of MA injection was 4 (SD = 6.7) years in group A and 3 (SD = 7.8) years in group B. The monthly mean numbers of MA injections were 12 (SD = 9.2) in group A and 13 (SD = 10.2) in group B, which were similar between the two groups.

The ages of the two groups were similar (mean 35 years, range 18 to 54 years in group A and mean 34.9 years, range 18 to 50 years in group B). Univariate analysis showed that group A was less likely to be divorced (19.1% vs. 29.3%, p < 0.001) and separated compared with group B (9.1% vs. 21.2%, p < 0.001). In addition, participants in group A were more likely to live with their spouses (60% vs. 38.3%, p < 0.001) while participants in group B were more likely to live with their sex partners (31.2% vs. 17.3%, p < 0.001). Group B was more likely to be homeless (21.2% vs. 9.1%, p < 0.001) and jobless (59.5% vs. 38.2%, p < 0.001) while group A was more likely to have a job (61.8% vs. 40.4%, p < 0.001). Group B reported ≥3 years of dependence on MA injection (63.6% vs. 55.6%, p < 0.001). In addition, group B reported more injection with pre-filled syringes in the past 12 months (31.3% vs. 7.2%, p < 0.001) and more lifetime sharing injection equipment (33.3% vs. 10.9%, p < 0.001). Group B reported more homosexual sex without condom use in the past 12 months (24.2% vs. 10%, p < 0.001). Group A reported more Narcotics Anonymous (NA) group attendance in the past 12 months (21% vs. 6.1%, p < 0.001) and more attending individual psychotherapeutic sessions in the past 12 months (25.4% vs. 12.1%, p < 0.001). Group B reported more HCV-positive status (29.3% vs. 18.2%, p < 0.01) while group A reported more unknown serologic status (73.6% vs. 34.3%, p < 0.001) (See Table 1).

Table 1.

Bivariate analyses of the general profile of participants (n = 209).

Variable	Group A (n = 110)	Group B (n = 99)	p Value
Recruitment site
DICs	65 (59.1%)	59 (59.6%)
Drug use community treatment programmes	45 (41.9%)	40 (40.4%)
Gender
Male	99 (90%)	89 (89.9%)
Female	11(10%)	10 (10.1%)
Age (Year)	35 ± 9.6	34.9 ± 9.8	0.112
Marital status
Married	61 (55.4%)	39 (39.4%)	0.196
Divorced	21 (19.1%)	29 (29.3%)	0.001
Separated	10 (9.1%)	21 (21.2%)	0.001
Single/Never married	18 (16.4%)	10 (10.2%)	0.045
Living status
Spouses	66 (60%)	38 (38.3%)	0.001
Sex partners	19 (17.3%)	31 (31.2%)	0.001
Male peers	4 (3.6%)	1 (0.1)	0.189
Alone	11 (10%)	8 (8.1%)	0.066
Homeless	10 (9.1%)	21 (21.2%)	0.001
Job status
Jobless	42 (38.2%)	59 (59.5%)	0.001
Having a job	68 (61.8%)	40 (40.4%)	0.001
Education
<12 years	102 (92.7%)	97 (98.9%)
≥12 years	8 (7.3%)	2 (2.1%)
Duration of dependence on MA injection
<3 years	49 (44.5%)	26 (36.4%)	0.234
≥3 years	61 (55.6%)	63 (63.6%)	0.001
The monthly mean number of MA injections (past 12 months)	12 (SD = 9.2)	13 (SD = 10.2)	0.129
Injection with pre-filled syringes (past 12 months)	8 (7.2%)	31 (31.3%)	0.001
Lifetime sharing injection equipment	12 (10.9%)	33 (33.3%)	0.001
Lifetime injection in prison	19 (17.3%)	24 (24.2%)	0.168
Lifetime shared injection in prison	5 (4.5%)	9 (9%)	0.123
Number of casual sex partners (past 12 months)
None	61 (55.5%)	51 (51.5%)
One or more	49 (44.5%)	48 (48.9%)
Homosexual sex without condom (past 12 months)	11 (10%)	24 (24.2%)	0.001
Heterosexual sex without condom (past 12 months)	55 (50%)	59 (59.6%)	0.123
NA group attendance
Past 12 months	23 (21%)	6 (6.1%)	0.001
Lifetime	37 (33.6%)	31 (31.3%)	0.122
Attending psychotherapeutic sessions
Past 12 months	28 (25.4%)	12 (12.1%)	0.001
Lifetime	66 (60%)	55 (55.5%)	0.127
Serologic testing (In the past 12 months)
HIV+	1 (0.1%)	5 (5%)	0.129
HCV+	20 (18.2%)	36 (29.3%)	0.001
HBV+	8 (7.3%)	12 (12.1%)	0.133
Unknown status	81 (73.6%)	34 (34.3%)	0.001
History of drug use treatment	81 (73.6%)	74 (74.7%)	0.037

NA, Narcotics Anonymous

Multivariate logistic regression analysis confirmed the roles of some independent factors that were associated with shared MA injection. Shared MA injection was found to be primarily associated with living with sex partners (AOR 1.25, 95% CI 1.13–1.98), reporting ≥3 years of dependence on MA injection (AOR 1.61, 95% CI 1.27–2.12), injection with pre-filled syringes in the past 12 months (AOR 1.96, 95% CI 1.47–2.42), homosexual sex without condom use in the past 12 months (AOR 1.85, 95% CI 1.21–2.25), the paucity of NA group participation in the past 12 months (AOR 0.67, 95% CI 0.41–0.99), the paucity of attending psychotherapeutic sessions in the past 12 months (AOR 0.44, 95% CI 0.28–0.96) and positive HCV status (AOR 1.98, 95% CI 1.67–2.83) (see details in Table 2).

Table 2.

Correlates of shared methamphetamine (MA) injection.

Participants’ characteristics	% Shared injection	AOR	95% CI
Gender
Male	89.9	3.50	(3.25–5.72)
Marital status
Separated	21.2	4.50	(3.55–5.92)
Living status
Sex partners	31.2	1.25	(1.13–1.98)
Homeless	21.2	3.80	(3.25–6.72)
Job status
Jobless	59.5	2.98	(2.25–4.72)
Duration of dependence on MA injection
≥3 years	63.3	1.61	(1.27–2.12)
Injection with pre-filled syringes (past 12 months)	31.3	1.96	(1.47–2.42)
Lifetime sharing injection equipment	33.3	4.43	(3.25–6.22)
Homosexual sex without condom (past 12 months)	24.2	1.85	(1.21–2.25)
NA group attendance (past 12 months)	6.1	0.67	(0.41–0.99)
Attending psychotherapeutic sessions (past 12 months)	12.1	0.44	(0.28–0.96)
Serologic testing (past 12 months)
HCV+	29.3	1.98	(1.67–2.83)

Discussion

MA injection is a marker of greater addiction severity,⁹ which could have critical health and treatment implications. In this study, we investigated the factors that were correlates of shared MA injection in a group of treatment seekers who mainly injected MA in Tehran, Iran. The current study is the first study that specifically targeted Iranian MA injectors who practiced shared MA injection. We found that the rate of shared MA injection was 47.4% among participants. Considerable rates of shared drug injection have been reported among drug users in Iran and other countries.^{9,12,15,18,19} Nonetheless, further studies should be conducted on the rate of shared MA injection and its health implications.

Compared with other drugs, MA use is more associated with practicing high-risk behaviours including shared injection.²⁰ Higher rates of practicing shared MA injection should be extensively studied among Iranian MA injectors because of its health implications and the risk of transmitting blood-borne infections such as HIV. More widespread adoption of interventions demonstrated to reduce risky injection practices, and development of new, more effective interventions are urgently needed for Iranian patients enrolling at community-based treatment centres and DICs.

Participants who reported that they were shared MA injectors differed in several important behaviours compared with those participants who did not report shared MA injection. We found that marital separation, homelessness and joblessness were important correlates of shared MA injection. A study on 749 shared drug injectors in different parts of Iran showed that needle and syringe sharing was significantly higher in those respondents who reported unemployment and unstable marital, living and unemployment conditions.¹⁵ Instability in familial, residential and job conditions among our participants were likely to reduce emotional supports, imposed financial burdens on some of the participants and predisposed them to practice shared MA injection. This study finding contrasts with a study in the USA which showed that lower rates of sharing needle and syringe were observed in IDUs who injected alone²¹ and contrasts with a study which showed that injection in the context of social and familial networks were associated with higher needle and syringe sharing.²² The roles of separation from family, homelessness and unemployment among those participants who reported shared MA injection deserve extensive research and should be considered in tailoring drug use treatment and harm reduction programmes that target this group in Iran.

Participants who were living with their sex partners were more engaged in practicing shared MA injection. Our participants were likely to use shared MA injection as a way of expressing love, support, care and showing intimacy and trust in their drug-using sex partners, or they were likely to need help in the injecting process. Studies show that sharing of needles and syringes commonly occurs within intimate relationships.²³ A study on Vietnamese female IDUs in Melbourne, Australia, showed that the initiation and continued injection of heroin was heavily influenced by men, especially primary sex partners.²⁴ Sharing drug injection is sometimes viewed as showing solidarity among IDUs, and is more common within intimate social networks, and between sex partners.²⁵ Several studies have shown that being “injection dependent” is a risk factor for spreading blood-borne viral infections.^26,27 Shared MA injectors and their primary sex partners should be informed about the risk of being infected with blood-borne infectious diseases by practicing shared MA injection.

Longer duration of MA injection (≥3 years) was an important correlate of shared MA injection among some of our respondents. It was likely that longer years of MA injection contributed to making a transition from MA injection to sharing needles and syringes among some participants. Long duration of drug use could have health implications. For example; a study showed that spreading viral hepatitis in IDUs was associated with sharing injection equipment and longer duration of drug use.⁸ Longer duration of MA injection is likely to be a marker for greater addiction severity (e.g. shared MA injection), but this issue still deserves further studies. MA injectors with a longer duration of MA injection could be a vulnerable group to blood-borne infectious diseases. They may need special attention during tailoring drug use treatment and harm reduction programmes.

Injection with pre-filled syringes in the past 12 months prior to intake was an important correlate of shared MA injection among some of our participants. This is a new study finding that we found no similar study to compare with. MA use was likely to increase high-risk behaviours among some of our participants or was likely to encourage them to practice injection with pre-filled syringes as a HIV-related behaviour. Injection with pre-filled syringes, especially used syringes, could contribute to spreading of blood-borne infectious diseases. Special drug education and harm reduction programmes are needed to specifically target injection with pre-filled syringes among those Iranian MA injectors who practice shared MA injection. At the same time, renewed efforts to increase availability of clean syringe/needles are urgently needed to decrease the rate of using pre-filled syringes.

Homosexual sex without condom use was another correlate of shared MA injection among some of our respondents. Compared to other substances, MA use is more often linked to increased casual partners and decreased condom use,²⁸ unprotected sex and increased risk for being infected with sexually transmitted infections (STIs).²⁹ A study on 139 heterosexual patients who were MA abusers showed that they had reused syringes and shared needles.³⁰ A study on 1056 IDUs in Tijuana, Mexico, showed that among male participants, MA use was more associated with having sex with other men.³¹ This issue has important clinical and health implications because of its relationship with HIV/HCV and STIs. A study showed that risky sex among heterosexual and MSM users of MA contributed to higher rates of hepatitis and HIV infection rates.³² Educational programmes should be developed to prevent unsafe sex among Iranian MA injectors.

The paucity of NA group attendance in the past 12 months and the paucity of attendance in individual psychotherapeutic sessions in the past 12 months were two important correlates of increased shared MA injection. These are new study findings that we found no study to compare with. These study findings may emphasize the necessity of group therapeutic sessions and individual psychotherapeutic interventions in reducing the rate of shared MA injection. Such interventions should be specifically considered for this group of drug users at community-based treatment centres and DICs in Iran.

One critical finding in our study was the association between shared MA injection and HCV infection. The high prevalence of hepatitis C infection among MA injectors practicing shared MA injection could be the primary vector for hepatitis C transmission.¹⁹ A study in Iran showed that sharing behaviour during the previous 6 months prior to study recruitment was associated with an increased rate of HCV infection.⁹ Shared MA injection was likely to predispose some of our respondents to be infected with HCV or was likely to result in exacerbating HCV infection. The spread of HCV infection among some of the participants who need antiretroviral therapies in medical settings, which should be implemented during tailoring risk-reduction interventions in Iran. Increased opportunities for HCV testing and increased needle exchange programmes are suggested.

Interventions targeting needle-sharing attitudes deployed within the clinical care setting may be well-positioned to reduce sharing practices. Evidence shows that when knowledge of blood-borne infectious diseases improves, and supplies of readily available sterile injecting equipment increase, syringe sharing decreases.³³ It is suggested that needle and syringe programmes become more expanded in social and clinical settings for Iranian MA injectors. Concerted effort should be made to increase the use of effective procedures for disinfecting shared equipment. MA injectors should rely on disinfection to prevent infection with HIV and HCV only when they cannot stop injecting or do not have access to new, sterile injecting equipment. Alternative disinfectants may be used or needed. At the same time, renewed efforts to increase availability of clean syringes and needles are needed to decrease transmitting viral infections. A combination of drug dependence treatment programmes including pharmacotherapies, psychosocial interventions, sterile needle and syringe access programmes, outreach and education programmes are required to cease shared MA injection among Iranian MA injectors. It should be noted that the current study has several limitations. First, the study population was recruited from those treatment seekers who were enrolled for treatment at community-based treatment centres and DICs in an area of Tehran. Therefore, findings may not be generalizable to MA injectors in other drug use treatment settings such as detoxification residential centres. Second, participants’ serologic testing status was assessed by their self reports and might underestimate the actual prevalence of blood-borne infections. However, there is evidence that one’s belief about one’s serologic testing status is conceptually more closely related to injection behaviours than biologically confirmed serologic testing status.³⁴ Finally, the cross-sectional design of the study limits our ability to infer causality. The observed multivariable associations between some studied factors with shared MA injection may reflect overall greater drug use severity among those who were shared MA injectors rather than a causal pathway toward increased risky behaviours. Regardless, the association highlights the need of our MA injectors for some harm reduction interventions. To sum up, the current study confirms the importance of certain factors previously associated with shared MA injection. Further research is required to assess the nature of this association.

Author contributions

ZAM designed the study and supervised the statistical analysis. ZA and LA conducted the study and reviewed the manuscript. AN drafted the manuscript and helped in study design. MZ helped in conducting the study and reviewing the literature and manuscript. All authors read and approved the final manuscript.

Footnotes

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Colfax

Shoptaw

. The methamphetamine epidemic: implications for HIV prevention and treatment. Curr HIV/AIDS Rep 2005; 2: 194–199.

Alam Mehrjerdi

. Crystal in Iran: methamphetamine or heroin Kerack. Daru 2013; 21: 1–3.

UNODC (United Nations Office on Drugs and Crime). World Drug Report. Vienna, Austria: UNODC, www.unodc.org/documents/…/WDR2012/WDR_2012_web_small.pdf (2012, accessed 11 July 2012).

Alam Mehrjerdi

Noroozi

. An emerging trend of methamphetamine injection in Iran: a critical risk for blood-borne infection diseases. Hepat Mon 2013; 13: e8154–e8154.

UNAIDS (Joint United Nations Program on HIV/AIDS). 2006 Report on the Global AIDS Epidemic: AUNAIDS 10th Anniversary Special Edition. Geneva, Switzerland: UNAIDS, www.popline.org/node/179746 (2006, 11 July 2012).

Halkitis

Parsons

Stirratt

. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. J Homosex 2001; 4: 17–35.

Shoptaw

Reback

. Methamphetamine use and infectious disease-related behaviors in men who have sex with men: implications for interventions. Addiction 2007; 102: 130–135.

Alavi

Behdad

. Seroprevalence study of hepatitis C and hepatitis B virus among hospitalized intravenous drug users in Ahvaz, Iran (2002–2006). Hepat Mon 2010; 10: 101–104.

Amin-Esmaeili

Rahimi-Movaghar

Razaghi

. Factors correlated with hepatitis C and B virus infections among injecting drug users in Tehran, IR Iran. Hepat Mon 2012; 12: 23–31.

10.

Zamani

Ono-Kihara

Ichikawa

. Potential for sexual transmission of HIV infection from male injecting-drug users who have sex with men in Tehran, Iran. Sex Transm Dis 2010; 37: 715–718.

11.

Ramezani

Mohraz

Gchkar

. Epidemiologic situation of human immunodeficiency virus (HIV/AIDS patients) at a private clinic in Tehran, Iran. Arch Iran Med 2006; 9: 315–318.

12.

Zamani

Kihara

Gouya

. High prevalence of HIV infection associated with incarceration among community-based injecting drug users in Tehran, Iran. J Acquir Immune Defic Syndr 2006; 42: 342–346.

13.

Day

Nassirimanesh

Shakeshaft

. Patterns of drug use among a sample of drug users and injecting drug users attending a general practice in Iran. Harm Reduct J 2006; 3: 2–2.

14.

Zamani

Radfar

Nematollahi

. Prevalence of HIV/HCV/HBV infections and drug-related risk behaviors amongst IDUs recruited through peer-driven sampling in Iran. Int J Drug Policy 2010; 21: 493–500.

15.

Rafiey

Narenjiha

Shirinbayan

. Needle and syringe among Iranian drug injectors. Harm Reduct J 2009; 6: 21–21.

16.

Razzaghi

Rahimi Movaghar

. Rapid assessment and response: Multi-center project on injection drug use, Tehran: WHO, 2003.

17.

McLellan

Kushner

Metzger

. The fifth edition of the Addiction Severity Index. J Subst Abuse Treat 1992; 9: 199–213.

18.

Hassannejad

Kassaian

Ataei

. High risky behaviors among intravenous drug users in Isfahan, Iran: a study for hepatitis C harm reduction programs. Int J Prev Med 2012(Suppl 1): S73–S78.

19.

Centers for Disease Control and Prevention. HIV-associated behaviors among injecting-drug users-23 cities, United States, May 2005-February 2006. MMWR Morb Mortal Wkly Rep 2009; 58: 329–332.

20.

Rusch

Lozada

Pollini

. Poly drug use among IDUs in Tijuana, Mexico: correlates of methamphetamine use and route of administration by gender. J Urban Health 2009; 86: 760–777.

21.

Hagan

Campbell

Thiede

. Injecting alone among young adult IDUs in five US cities: evidence of low rates of injection risk behavior. Drug Alcohol Depend 2007; 91: S48–S55.

22.

Shaw

Shah

Jolly

. Determinants of injection drug user (IDU) syringe sharing: the relationship between availability of syringes and risk network member characteristics in Winnipeg, Canada. Addiction 2007; 102: 1626–1635.

23.

MacRae

Aalto

. Gendered power dynamics and HIV risk in drug-using sexual relationships. AIDS Care 2000; 12: 505–15.

24.

Higgs

Owada

Hellard

. Gender, culture and harm: an exploratory study of female heroin users of Vietnamese ethnicity. Cult Health Sex 2008; 10: 681–695.

25.

Des Jarlais

Perlis

Stimson

. WHO Phase II Drug Injection Collaborative Study Group: using standardized methods for research on HIV and injecting drug use in developing/transitional countries: case study from the WHO Drug Injection Study Phase II. BMC Public Health 2006; 6: 54–54.

26.

Spittal

Craib

Wood

. Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. CMAJ 2002; 166: 894–899.

27.

Wood

Spittal

Kerr

. Requiring help injecting as a risk factor for HIV infection in the Vancouver epidemic: Implications for HIV prevention. Can J Public Health 2003; 94: 355–359.

28.

Semple

Grant

Patterson

. Female methamphetamine users: social characteristics and sexual risk behavior. Women Health 2004; 40: 35–50.

29.

Schwarcz

Scheer

McFarland

. Prevalence of HIV infection and predictors of high-transmission sexual risk behaviors among men who have sex with men. Am J Public Health 2007; 97: 1067–1075.

30.

Semple

Patterson

Grant

. The context of sexual risk behavior among heterosexual methamphetamine users. Addict Behav 2004; 29: 807–810.

31.

Rusch

Lozada

Polloni

. Polydrug use among IDUs in Tijuana, Mexico: correlates of methamphetamine use and route of administration by gender. J Urban Health 2009; 86: 760–775.

32.

Greenwell

Brecht

. Self-reported health status among treated methamphetamine users. Am J Drug Alcohol Abuse 2003; 29: 75–104.

33.

McCoy

Inciardi

. Sex, drugs, and the continuing spread of AIDS, Los Angeles, CA: Roxbury Publishing Co, 1995.

34.

Todd Korthuis

Feaster

Gomez

. Injection behaviors among injection drug users in treatment: the role of hepatitis C awareness. Addict Behav 2012; 37: 552–555.