Abstract
Background
HIV testing is critical for HIV prevention and treatment among PWID and their social networks. This study aimed to examine the trend of HIV testing among PWID in Iran. We also assessed the factors associated with HIV testing in 2020.
Methods
This study used data from three consecutive nationwide bio-behavioral surveillance surveys (BBSS) of PWID conducted between 2010 and 2020. The primary outcome variable was a history of HIV testing and having received the results within the past 12 months. Cochran-Armitage trend test was used to assess the trend of HIV testing over the years. Bivariable and multivariable logistic regression models were used to investigate factors associated with HIV testing in 2020.
Results
A total of 6887 HIV-negative PWID (2206 in 2010, 2092 in 2014, and 2589 in 2020) were included in the analysis. The uptake of HIV testing increased significantly from 25.1% (95% CI 23.9%, 27.6%) in 2010 to 30.0% (95% CI 28.0%, 32.0%) in 2014, and 39.3% (95% CI 37.4%, 41.2%) in 2020 (p < 0.001). In 2020, people with unstable employment (adjusted odds ratio [AOR] = 2.35, 95% CI 1.70, 3.25) had higher odds of HIV testing than those with stable employment. Also, the age at first drug use ≥ 18 years (AOR = 1.42, 95% CI 1.13, 1.80), and sufficient HIV knowledge (AOR = 1.71, 95% CI 1.37, 2.14) were significantly associated with higher odds of HIV testing.
Conclusions
Despite the increasing trend, HIV testing among PWID in Iran remains considerably low. Policies and strategies, such as HIV self-testing, expansion of harm reduction services to include HIV testing, and encouraging HIV testing among PWID, are required to increase HIV testing uptake in this population. Targeted interventions focusing on raising knowledge about the importance of HIV testing may contribute to further increased testing uptake among PWID.
Keywords: HIV testing, Substance use, People who inject drugs, HIV diagnosis, Iran
Background
HIV testing and diagnosis are critical components of the prevention and control of HIV [1]. Early diagnosis through regular testing can lead to increased access to appropriate care, improved quality of life, and reduced HIV transmission [2]. Undiagnosed HIV infection accounts for approximately 30% of transmissions [3]. Currently, 87.1% of people living with HIV (PLHIV) are aware of their HIV status worldwide [4]. However, in the Eastern Mediterranean Region (EMR), particularly in Iran, there are considerable challenges in achieving high rates of HIV diagnosis. In Iran, the primary gap in the HIV cascade of care is low diagnostic coverage, with only 51% of PLHIV aware of their HIV status as of 2022 [5].
According to the Centers for Disease Control and Prevention (CDC), individuals with high-risk behaviors should be tested for HIV at least once a year [6]. People who inject drugs (PWID) represent one of the high-risk groups for contracting HIV. PWID are typically infected through the use of shared needles and syringes [7], as well as other contaminated injection equipment. Additionally, other risky behaviors, such as unsafe sex further elevate transmission risk [8–10]. Globally, PWID are estimated to be 24 times more likely than the general population to acquire HIV [11].
In Iran, HIV prevalence among PWID was approximately 3.1% in 2023 [5]. Despite recommendation for annual HIV testing and the high-risk nature of this population, data on HIV testing among PWID remain limited. A study in 2010 revealed that only 24.9% of male PWID had tested for HIV in the preceding 12 months and received their test results [12]. Since 2010, several interventions have been implemented to improve HIV testing among PWID. For example, HIV rapid tests have been introduced as a routine component of harm reduction services, and voluntary counseling and testing (VCT) centers and drop-in centers (DICs) have been expanded [13]. Despite these efforts, studies show that the prevalence of HIV testing among PWID remain low [14, 15]. Notably, these studies were limited to Tehran, the capital of Iran, and were conducted in 2010 and 2014, thus they may not represent the entire population or diverse contexts within the country. The present study aimed to examine the trend of HIV testing among PWID using three consecutive nationwide bio-behavioral surveillance surveys. We also assessed the factors associated with HIV testing among participants in the most recent survey in 2020.
Methods
Study design and participants
This study used data from three consecutive national bio-behavioral surveillance surveys (BBSS) of Iranian PWID, conducted between 2010 and 2020. The surveys have been previously described [16–18]. In brief, the surveys were conducted in major cities across the country, representing various geographical regions. A convenience sampling strategy was used to recruit 2546 PWID in 2010, and 2399 PWID in 2014. A respondent-driven sampling (RDS) technique was used to recruit 2684 PWID for the 2020 survey (July 2019 to March 2020). In all surveys, the eligibility criteria were (i) being 18 years old and older at the time of the survey, (ii) having self-reported drug injection in the past 12 months, (iii) residing in the surveyed cities, and (iv) providing a valid referral coupon consistent with the study methodology (2020 survey only). In all three surveys, participants received a monetary incentive for the interview and HIV test, as well as additional rewards for each successful peer referral in the 2020 survey.
Data collection
After providing informed verbal consent, participants completed a face-to-face interview in a private room in a DIC. Data were collected on socio-demographic characteristics, drug use, injection-related behaviors, sexual practices, knowledge about HIV, incarceration history, HIV testing history, drug use treatment, harm-reduction programs, and care-seeking behaviors.
Outcome variable: HIV testing
The outcome variable in this study was HIV testing in the past 12 months. Interviewers asked participants, “Have you tested for HIV in the past 12 months?” If participants answered affirmatively, they were subsequently asked, “Did you receive the test results?” These two questions were combined to create the HIV testing outcome variable. Participants who answered yes to both questions were categorized as “yes,” while those who did not answer yes to both questions were categorized as “no.”
Covariates
Covariates included the following: age at interview (< 30 vs. ≥ 30 years), sex (male vs. female), marital status (single vs. married vs. other [separated/divorced/widowed]), education levels (less than high school vs. high school or above), lifetime history of incarceration (yes vs. no), employment status (stable vs. unstable), age at first injection drug use (< 18 vs. ≥ 18 years), age at first drug use (< 18 vs. ≥ 18 years), HIV knowledge that included eight questions about HIV modes of transmission and prevention (insufficient vs. sufficient [correct response to all eight knowledge questions]), needle/syringe sharing (yes vs. no), condomless sex (yes vs. no) and use of unsafe preparation instrument (yes vs. no).
Statistical analysis
Analysis was restricted to HIV-negative participants. Descriptive statistics, including frequencies and percentages, were reported for HIV testing prevalence, sociodemographic characteristics, risk behaviors, and harm reduction service utilization across all three surveys. The Cochran-Armitage trend test was used to assess the trend of HIV testing over the years. Bivariable and multivariable logistic regression models were constructed to estimate the odds of having received an HIV test within the past 12 months among various subgroups of PWID. Variables in the bivariable logistic regression model with a p-value less than 0.2 were entered into the multivariable logistic regression model [19]. The final model was selected using the backward elimination procedure. The results included crude and adjusted odds ratios (AORs) as well as 95% confidence intervals (CIs). Data were analyzed using Stata version 14.1 (StataCorp, College Station, Texas). Statistical significance was defined as p-values less than 0.05.
Results
Demographic characteristics
Of the 2206 HIV-negative PWID in the 2010 survey, most were male (97.3%), 64.7% were 30 years or older, 47.2% were single, and 29.6% had sufficient knowledge about HIV. Among these participants, 75.9% had a history of incarceration, and 2.9% reported needle/syringe sharing. Among sexually active participants, 50.9% and 84.1% reported condomless sex with opposite and same-sex partners, respectively.
Among the 2092 HIV-negative PWID in the 2014 survey, 97.9% were male, 77.9% were 30 years or older, 45.6% were single, and 16.9% had sufficient knowledge about HIV. Also, 75.9% had a history of incarceration, and 7.3% reported needle/syringe sharing. Among sexually active participants , 61.3% and 83.6% reported condomless sex with opposite and same-sex partners, respectively.
Among the 2589 HIV-negative PWID in the 2020 survey, 96.6% were male, 88.5% were 30 years or older, 36.7% were single, and 47.2% had sufficient knowledge about HIV. Furthermore, 6.3% reported a history of needle/syringe sharing. Among sexually active participants, the percentage of condomless sex with opposite and same partners was 52.4% and 85.8%, respectively. (Table 1).
Table 1.
Characteristics of HIV-negative people who inject drugs (PWID) during 2010, 2014 and 2020
| Levels of covariates | 2010 N (%) |
2014 N (%) |
2020 N (%) |
|---|---|---|---|
| HIV-Negative PWID | 2206 (86.6) | 2092 (90.6) | 2589 (96.4) |
| Age | |||
| < 30 | 777 (35.3) | 461 (22.1) | 291 (11.5) |
| ≥ 30 | 1423 (64.7) | 1629 (77.9) | 2246 (88.5) |
| Sex | |||
| Male | 2146 (97.3) | 2048 (97.9) | 2471 (96.6) |
| Female | 60 (2.7) | 44 (2.1) | 87 (3.4) |
| Marital status | |||
| Single | 1041 (47.2) | 953 (45.6) | 908 (36.7) |
| Married | 672 (30.4) | 579 (27.7) | 813 (32.9) |
| Other (separated/divorced/widowed) | 493 (22.4) | 558 (26.7) | 752 (30.4) |
| Education level | |||
| Less than high school | 1531 (69.5) | 1427 (68.2) | 1762 (69.2) |
| High school or above | 671 (30.5) | 663 (31.8) | 783 (30.8) |
| Employment status | |||
| Stable | 155 (7.7) | 326 (15.7) | 385 (18.1) |
| Unstable | 1881 (92.3) | 1751 (84.3) | 1735 (81.9) |
| Lifetime history of incarceration | |||
| No | 529 (24.1) | 505 (24.1) | 877 (34.7) |
| Yes | 1670 (75.9) | 1584 (75.9) | 1651 (65.3) |
| Age at first injection drug use | |||
| < 18 years | 121 (5.6) | 166 (8.1) | 85 (3.4) |
| ≥ 18 years | 2016 (94.4) | 1896 (91.9) | 2394 (96.6) |
| Age at first drug use | |||
| < 18 years | 995 (45.7) | 952 (45.9) | 841 (35.4) |
| ≥ 18 years | 1183 (54.3) | 1126 (54.1) | 1533 (64.6) |
| HIV-related knowledge | |||
| Insufficient | 1323 (70.4) | 1302 (83.1) | 932 (52.8) |
| Sufficient | 554 (29.6) | 265 (16.9) | 833 (47.2) |
| Needle/syringe sharinga | |||
| No | 2099 (97.1) | 1768 (92.7) | 2154 (93.7) |
| Yes | 61 (2.9) | 140 (7.3) | 146 (6.3) |
| Having condomless sex with opposite sexb | |||
| No | 344 (49.1) | 383 (38.7) | 363 (47.6) |
| Yes | 356 (50.9) | 607 (61.3) | 401 (52.4) |
| Having condomless sex with same sexc | |||
| No | 14 (15.9) | 15 (16.4) | 6 (14.2) |
| Yes | 74 (84.1) | 76 (83.6) | 36 (85.8) |
| Using unsafe preparation instrumentd | |||
| No | NA | 1370 (71.3) | 1951 (87.3) |
| Yes | NA | 551 (28.7) | 282 (12.7) |
aUsing a syringe or needle that has been used for injection by another individual within the past 12 months
bHaving sexual relations without a condom with a non-primary partner of the opposite sex in the past 12 months, including paid and unpaid partners
cHaving sexual relations without a condom with same-sex in the past 12 months
dUsing drug injection preparation instruments that another person has already used
HIV testing
The uptake of HIV testing and receipt of results in the past 12 months increased from 25.1% (95% CI 23.9%, 27.6%) in 2010 to 30.0% (95% CI 28.0%, 32.0%) in 2014, and 39.3% (95% CI 37.4%, 41.2%) in 2020 (p-value< 0.001) (Fig. 1). In addition, the majority of covariates showed significant trends, such as HIV testing in men ( p-value< 0.001), HIV knowledge ( p-value< 0.001), and incarceration history ( p-value< 0.001) (Table 2).
Fig. 1.
Trend of overall HIV testing in the past 12 months and based on sex (male vs. female) among HIV-negative people who injected drugs in 2010, 2014, and 2020 in Iran. P-value for overall trend <0.001
Table 2.
Trend of HIV testing among HIV-negative people who inject drugs (PWID) during 2010, 2014, and 2020 in Iran
| Levels of covariates | 2010 N (%) | 2014 N (%) | 2020 N (%) | p-value |
|---|---|---|---|---|
| HIV-Negative PWID | 560 (25.1) | 616 (30.0) | 979 (39.3) | < 0.001 |
| Age | ||||
| < 30 | 163 (21.1) | 129 (28.2) | 98 (34.3) | 0.018 |
| ≥ 30 | 397 (28.2) | 486 (30.5) | 874 (39.9) | < 0.001 |
| Sex | ||||
| Male | 538 (24.9) | 589 (29.3) | 939 (39.1) | < 0.001 |
| Female | 22 (36.0) | 27 (62.7) | 40 (45.9) | 0.656 |
| Marital status | ||||
| Single | 257 (24.9) | 275 (29.1) | 356 (40.5) | < 0.001 |
| Married | 156 (23.7) | 190 (33.7) | 291 (36.7) | 0.007 |
| Other (separated/divorced/widowed) | 147 (30.1) | 150 (27.5) | 295 (39.9) | 0.018 |
| Highest level of education completed | ||||
| Secondary school or below | 397 (26.3) | 423 (30.1) | 685 (39.8) | < 0.001 |
| High school or above | 163 (24.4) | 192 (29.7) | 287 (37.7) | 0.003 |
| Employment status | ||||
| Stable | 38 (24.5) | 72 (22.5) | 95 (25.6) | 0.804 |
| Unstable | 487 (26.1) | 539 (31.3) | 714 (42.1) | < 0.001 |
| Lifetime history of incarceration | ||||
| No | 102 (19.3) | 135 (27.3) | 297 (34.3) | 0.003 |
| Yes | 458 (27.8) | 481 (30.9) | 675 (42.1) | < 0.001 |
| Age at first injection drug use | ||||
| < 18 years | 29 (24.3) | 49 (30.2) | 48 (58.5) | 0.001 |
| ≥ 18 years | 521 (26.0) | 558 (29.9) | 907 (38.8) | < 0.001 |
| Age at first drug use | ||||
| < 18 years | 269 (27.3) | 253 (26.9) | 295 (36.1) | 0.021 |
| ≥ 18 years | 290 (24.7) | 362 (32.9) | 594 (39.6) | < 0.001 |
| HIV-related knowledge | ||||
| Insufficient | 332 (25.3) | 404 (31.6) | 329 (36.2) | 0.002 |
| Sufficient | 158 (28.7) | 108 (41.3) | 407 (49.3) | < 0.001 |
| Needle/syringe sharing | ||||
| No | 538 (25.8) | 540 (31.0) | 844 (40.1) | < 0.001 |
| Yes | 17 (28.3) | 18 (13.4) | 57 (39.3) | 0.180 |
| Having condomless sex with opposite sex | ||||
| No | 85 (24.8) | 155 (41.2) | 153 (43.2) | 0.010 |
| Yes | 74 (20.9) | 118 (20.1) | 161 (40.9) | < 0.001 |
| Having condomless sex with same sex | ||||
| No | 3 (21.4) | 3 (21.4) | 1 (20.0) | 0.981 |
| Yes | 25 (33.7) | 14 (18.9) | 17 (47.2) | 0.443 |
| Using unsafe preparation instrument | ||||
| No | NA | 405 (29.9) | 768 (40.3) | NA |
| Yes | NA | 155 (29.0) | 117 (42.5) | NA |
Bivariable regression
In the 2020 survey, bivariable regression analysis showed that people with unstable employment (crude odds ratio [COR] = 2.11, 95% CI 1.64, 2.72) had a higher odds of HIV testing than stable employed people. Also, incarceration history (COR = 1.39, 95% CI 1.17, 1.65), age of first injection drug use (COR = 0.44, 95% CI 0.28, 0.70), and HIV knowledge (COR = 1.71, 95% CI 1.41, 2.07) were significantly associated with HIV testing (Table 3).
Table 3.
Associated factors of HIV testing among Iranian HIV-negative people who inject drugs in 2020 using bivariable and multivariable logistic regression
| Levels of covariates | HIV testing in past 12 months | |
|---|---|---|
| Crude OR (95%CI) | Adjusted OR (95%CI) | |
| Age | ||
| < 30 | 1 | |
| ≥ 30 | 1.27 (0.98, 1.64) | |
| Sex | ||
| Male | 1 | |
| Female | 1.32 (0.86, 2.03) | |
| Marital status | ||
| Single | 1 | |
| Married | 1.17 (0.96, 1.43) | |
| Other (separated/divorced/widowed) | 1.14 (0.93, 1.41) | |
| Highest level of education completed | ||
| Secondary school or below | 1 | |
| High school or above | 0.91 (0.76, 1.08) | |
| Employment status | ||
| Stable | 1 | 1 |
| Unstable | 2.11 (1.64, 2.72) | 2.35 (1.70, 3.25) |
| Lifetime history of incarceration | ||
| No | 1 | |
| Yes | 1.39 (1.17, 1.65) | |
| Age at first injection drug use | ||
| < 18 years | 1 | |
| ≥ 18 years | 0.44 (0.28, 0.70) | |
| Age at first drug use | ||
| < 18 years | 1 | 1 |
| ≥ 18 years | 1.16 (0.97, 1.38) | 1.42 (1.13, 1.80) |
| HIV-related knowledge | ||
| Insufficient | 1 | 1 |
| Sufficient | 1.71 (1.41, 2.07) | 1.71 (1.37, 2.14) |
| Needle/syringe sharing | ||
| No | 1 | |
| Yes | 1.05 (0.75, 1.48) | |
| Having condomless sex with opposite sex | ||
| No | 1 | |
| Yes | 0.91 (0.68, 1.22) | |
| Having condomless sex with same sex | ||
| No | 1 | |
| Yes | 1.34 (0.19, 9.01) | |
| Using unsafe preparation instrument | ||
| No | 1 | |
| Yes | 1.09 (0.84, 1.41) | |
Statistically significant values are shown in bold
Multivariable logistic regression
The multivariable logistic regression model in the 2020 survey showed that people with unstable employment (adjusted odds ratio [AOR] = 2.35, 95% CI 1.70, 3.25) compared to PWID with stably employment had higher odds of HIV testing. Also, PWID who started drug use at 18 or later (AOR = 1.42, 95% CI 1.13, 1.80), and PWID with sufficient HIV knowledge (AOR = 1.71, 95% CI 1.37, 2.14) had higher odds for HIV testing (Table 3).
Discussion
In this study, we examined the status of recent HIV testing among PWID from 2010 to 2020. HIV testing showed an increasing trend over this period. The 12-month prevalence of HIV testing and receiving results increased from around 25% in 2010 to around 40% in 2020. Additionally, we found that those who had unstable employment, had their first drug use at 18 or later, and had sufficient knowledge about HIV were more likely to receive an HIV test in the past 12 months in 2020.
Based on our results, in 2010, approximately one-fourth of PWID had experienced HIV testing and received their test results within the past 12 months. This proportion increased to about one-third in 2014 and two-fifths in 2020. Other HIV-related indicators support this finding. For example, the cascade of HIV in Iran showed that the proportion of PLHIV in Iran who were aware of their status increased from 30% in 2014 [20] to 51% in 2023 [5]. This increase in HIV testing in Iran represents significant progress in Iran’s HIV response during the study period. From 2010 to 2014, building on foundational harm reduction programs initiated in 2002, this period saw accelerated expansion of HIV testing infrastructure. The case-based HIV surveillance system implemented in 2009 began generating actionable data, while the national PWID surveys commenced in 2009, provided policymakers with evidence-based insights to refine strategies. VCT centers expanded beyond the inaugural center established in 2000, with particular growth in urban areas with high PWID populations [21]. From 2014 to 2020, more systematic scaling-up occurred as the PWID mapping study enabled strategic placement of DICs and methadone clinics in areas of highest need, directly improving testing accessibility [22]. HIV rapid testing also became increasingly integrated as a core component across all harm reduction service delivery points. This policy-driven approach could partly explain the modest improvement from 25.1 to 30.0% during 2010–2014 as foundational systems strengthened, followed by substantial gains to 39.3% during 2014–2020 as targeted interventions reached scale. These results further underscore that sustained, evidence-informed policy implementation can lead to meaningful improvements in HIV testing uptake among populations at high risk of HIV.
Despite the progressive trend in HIV testing from 2010 to 2020, only two-fifths of PWID had experienced HIV testing in the past 12 months in the 2020 survey, which remains below international benchmarks. The findings of this study were consistent with previous research in Iran, which found that HIV testing among PWID is relatively low compared to international standards [14, 15]. According to an analysis of PWID in Iran's capital, two-thirds of them had tested for HIV at least once in their lifetime [23]. In addition, the results of the PWID bio-behavioral survey in 2010 revealed that approximately half of PWID had tested for HIV in their lifetime, with approximately one-third in the previous year [12]. International comparisons demonstrate this gap; studies from other countries showed that HIV testing was 53% in the US in 2012 [24], and 47% in the Seattle Area in 2015 [25], both higher than Iran’s 39.3% in 2020. One of the reasons for low HIV testing in Iran may be inadequate HIV-related knowledge among PWID [26]. Therefore, strategies for increasing HIV knowledge among both the general population and PWID, such as media and school-based education, can improve HIV testing as a result of increased HIV risk perception [27]. Other important reasons for low HIV testing are stigma and discrimination [28]. More efforts should be made to encourage service providers and society to stop discriminating against PWID [29]. An essential component of reducing stigma is ongoing stigma reduction counseling and integrating psycho-behavioral interventions into services [30]. Multiple channels for implementing multifaceted interventions, such as information-based approaches, coping skills acquisition, counseling, and contact with affected groups, can effectively reduce stigma and discrimination [31]. Another way to increase HIV testing is HIV self-testing. A study showed that 73.6% of PWID in Iran reported high/very high willingness to use HIV self-testing programs [32]. HIV self-testing offers privacy, ease of use, convenience, and facilitates multiple testing opportunities, that can increase HIV testing uptake [33]. Countries with a similar sociocultural context to Iran also have low rates of HIV testing among PWID. In Pakistan, for instance, HIV testing coverage among PWID is low because not enough people know about it, and there is a lot of stigma and discrimination [34]. Conversely, research from countries with more robust health systems and reduced HIV prevalence indicates that the implementation of routine HIV testing for all adults aged 15–64, annual HIV testing for high-risk individuals, and one-time testing for all other adults are cost-effective approaches that significantly enhance testing uptake, resulting in earlier diagnosis and prompt referral to care. These international comparisons show how structural factors and policy approaches affect HIV testing results [35].
Our results showed that PWID who had unstable employment had higher odds of getting tested for HIV. This counterintuitive finding contrasts with broader literature patterns. In contrast to our result, another study in Iran in 2010 showed that the employment status of PWID was not related to recent HIV testing [12]. A scoping review investigated the relationship between employment status and HIV continuum of care and concluded that employed people were more likely to engage in HIV testing [36]. However, similar patterns to ours have been documented in other contexts where targeted interventions focus on marginalized populations. For example, studies from Toronto and construction worker populations demonstrated that employment-related barriers, including time constraints and employer concerns, can paradoxically reduce testing among stably employed individuals. This apparent contradiction can be explained by targeted interventions in Iran, such as harm reduction services and HIV testing campaigns that specifically focus on high-risk populations, including people with unstable jobs and unemployed people. As evident from the time trend analysis, recent HIV testing among PWID with stable jobs remained constant over time, while among people with unstable jobs, recent HIV testing increased significantly from 26.1% in 2010 to 42.1% in 2020. The higher odds of HIV testing among unstably employed PWID could be due to increased access to targeted health services [37] and greater availability during VCT operating hours, which typically coincide with standard working schedules [38, 39]. We also acknowledge that this finding may represent a chance association influenced by unmeasured confounders, such as participation in targeted interventions, healthcare-seeking behavior patterns, or employment misclassification given the informal nature of much work among PWID populations. Future longitudinal studies are needed to examine these context-specific mechanisms more definitively.
We also found that people who had their first drug use at 18 or later were more likely to receive an HIV test. This might happen because people’s perceived risk increases with age [40]. On the other hand, people who start drug use at an early age usually have low socioeconomic status and a lack of social support [41, 42]. A study in China showed that low socioeconomic status decreases the odds of HIV testing uptake [43]. People who start using drugs before the age of 18 also have more risky behavior [44] and are more likely to leave school early [45]. Leaving school early reduces the likelihood of getting tested for HIV because it reduces access to health education and information about HIV risks and testing, and also reduces social connections.
In this study, sufficient knowledge was associated with higher odds of HIV testing. This finding is in line with another study in Iran [23]. According to the evidence, higher knowledge about HIV makes people more willing to get tested for HIV. Other explanations for higher educational status and acceptance of HIV testing include more information in academic settings and more messages received as a result of more extensive social networks. People with a lower level of education have less knowledge about health [46, 47], and a low level of health knowledge is linked to a low level of HIV-related knowledge [48, 49].
Limitations
We acknowledge the limitations of this study. First, because our data were based on self-reports from participants, they may be subject to recall bias. Second, since the sampling method was different in each of the three rounds of the study, the prevalence of HIV testing in the first two rounds can be overestimated because we sampled the participants from facilities where PWID received the harm-reduction services. The difference in sampling method was also the reason why the data were not aggregated to check the associated factors. Third, our study was cross-sectional, so causal inferences cannot be drawn due to reverse causation and other limitations of cross-sectional assessments. Fourth, we used the Cochran-Armitage trend test for assessing trend of HIV testing over time, which has some limitations, such as the assumption of linearity, the assumption of equal variance, sensitivity to sample size, inability to account for confounding variables, inability to handle missing data, and the assumption of independent observations should be considered.
Conclusions
Our research reveals a persistent inadequacy in HIV testing among PWID in Iran, despite a noted increase over time. While progress has been made, HIV testing rates remain below optimal levels and require continued policy attention. Addressing this issue requires the implementation of targeted policies and strategies aimed at enhancing HIV testing uptake among PWID. One promising approach is the adoption of HIV self-testing, a method that encourages individuals to test for HIV in the privacy of their own homes. This approach holds significant potential for increasing testing rates among PWID, offering convenience and privacy, and potentially reducing barriers to accessing traditional testing services. Moreover, integrating HIV self-testing into existing healthcare systems alongside comprehensive support services could improve its effectiveness in reaching and engaging PWID in HIV testing initiatives.
Acknowledgements
For this paper, we would like to acknowledge the scientific input received from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH123256. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health. The 2010 survey was funded by the United Nations Development Program (UNDP), the primary recipient of funds from the Global Fund for AIDS, Tuberculosis, and Malaria Projects Iran (Grant Number: IRN-202-G01-H-00). The 2014 and 2020 studies were funded by WHO and the Global Fund for HIV/AIDS, respectively. We also thank the Student Research Committee, Kerman University of Medical Sciences.
Abbreviations
- BBSS
Bio-behavioral surveillance surveys
- PLHIV
People living with HIV
- AOR
Adjusted odds ratio
- EMR
Eastern Mediterranean Region
- PWID
People who inject drugs
- CDC
Centers for Disease Control and Prevention
- VCT
Voluntary counseling and testing
- DICs
Drop-in centers
- CIs
Confidence intervals
- COR
Crude odds ratio
Author contributions
MK, AM, AAH, and HSH design and conduct of the survey. MKH, FT and SM did data collection. PJA analyzed data, and wrote the main manuscript text. MK, AAH, MKH, AM, FT, SM, MSH and NGH reviewed and edited this work. HM and HSH contributed equally to the methodology design, reviewing, and editing, and should be regarded as co-senior authors. All authors contributed to the revision of the manuscript and approved the final version of the manuscript.
Funding
The 2010 survey was funded by the United Nations Development Program (UNDP), the primary recipient of funds from the Global Fund for AIDS, Tuberculosis, and Malaria Projects Iran (Grant Number: IRN-202-G01-H-00). The 2014 and 2020 studies were funded by WHO and the Global Fund for HIV/AIDS, respectively.
Data availability
The data obtained from the survey cannot be publicly shared due to the sensitive nature of the information and the need to uphold the privacy and security of the participants.
Declarations
Ethics approval and consent to participate
The Kerman University of Medical Sciences ethics committee reviewed and approved the survey protocols (Ethics Codes: IR.KMU.REC.597 (2010 survey), IR.KMU.REC.93.205 (2014 survey), and IR.KMU.REC.1397.573 (2020 survey)). Verbal informed consent was obtained from all participants.
Consent for publication
All participants expressed consent for publication.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher's Note
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Contributor Information
Hossein Mirzaei, Email: hosseinmirzaei64@yahoo.com.
Hamid Sharifi, Email: sharifihami@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data obtained from the survey cannot be publicly shared due to the sensitive nature of the information and the need to uphold the privacy and security of the participants.