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Abstract Background Hepatitis B virus (HBV) infection is a silent epidemic among people who inject drugs (PWID). HBV testing and vaccination are important for PWID to reduce the risk of infection, prevent chronic complications and contribute to public health efforts in addressing HBV transmission. Our objective was to assess the self-reported lifetime uptake of HBV testing and vaccination among PWID in Iran and their associated factors. Method This cross-sectional study was conducted among 2,684 PWID in 11 large cities from July 2019 to March 2020 using a respondent-driven sampling method. Participants were interviewed face-to-face and asked about their lifetime experience of HBV testing and vaccination uptake as the outcome. Logistic regression models were built to identify related factors for reporting HBV testing and vaccination uptake. Results The prevalence of HBV testing and vaccination uptake among PWID was 14.2% (95% confidence intervals [CI]: 12.8–15.6) and 16.4% (95% CI: 14.9–18.1), respectively. Shared needles, syringes, or equipment in the past 12 months decreased the odds of reporting lifetime HBV testing uptake (Adjusted odds ratio [AOR]:0.46, 95% CI: 0.29–0.72). However, having an academic education (AOR: 1.89, 95% CI: 1.09–3.30) and lifetime experience of homelessness (AOR: 1.58, 95% CI: 1.21–2.06) increased the odds of reporting lifetime HBV vaccination uptake. Conclusion Our study highlighted the low prevalence of HBV testing and vaccination uptake among PWID in Iran. It is essential to understand and address the obstacles preventing PWID from getting tested and vaccinated for HBV. Addressing these barriers could significantly reduce the burden of HBV among this socio-economically marginalized population.

BACKGROUND: Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran. METHODS: This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome. RESULTS: The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation. CONCLUSION: Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

IntroductionPatients with Tuberculosis (TB) still have barriers in accessing high quality care and treatment services. In this qualitative study, we investigated barriers in accessing TB health services including confirmatory diagnosis, treatment adherence and recurrence of pulmonary TB using patients, physicians, and policy makers point of view.Materials and methodsIn this qualitative research from November to March 2021, 3 policy makers from the Ministry of Health, 12 provincial TB experts and physicians from the TB control program and 33 patients diagnosed with TB from 4 provinces were enrolled for a semi-structured in-depth interview. All interviews were audio recorded and then transcribed. Framework analysis was done by MAXQDA 2018 software to identify key themes.ResultsSeveral barriers reported for TB care and treatment: Poor knowledge of patents about TB symptoms, failure to screen for TB among at-risk patients by physicians, similar symptoms between TB and other lung diseases, low sensitivity of TB diagnostic tests, incomplete case finding and contact-tracing, stigma related to TB, and patients poor adherence due to long TB treatment. In addition, COVID-19 pandemic disrupted TB services and decreased detection, care and treatment services for TB patients.ConclusionOur findings highlight the need for interventions to increase public and healthcare providers awareness about TB symptoms, using more sensitive diagnostic tests, and interventions to reduce stigma, and improve case finding and contact tracing effort. Improving patients' adherence required better monitoring and shorter effective treatment regimes.

Background: Female sex workers (FSWs) are at higher risk of HIV due to high-risk sexual and drug use related behaviors. This study characterized sexualized substance use among FSWs in Iran. Methods: In 2015, 1,337 FSWs were recruited from centers for vulnerable women and through outreach efforts in 13 major cities in Iran. Data were collected via face-to-face interviews from consenting FSWs on a range of socio-demographic and behavioral characteristics. The primary outcome of interest was sexualized substance use, defined as reporting alcohol or drug use before or during sex in the past month. Bivariable and multivariable modified Poisson regression models were used to assess the correlates of sexualized substance use. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were reported. Results: The prevalence of sexualized substance use was 31.3% (95% CI: 28.7, 34.0). Inconsistent condom use during sex with clients in the past month (aPR = 1.31; 95% CI: 1.01, 1.71), regular (i.e., at least weekly in the past month) alcohol use (aPR = 2.87; 95% CI: 2.17, 3.80), regular opioid use (aPR = 2.09; 95% CI: 1.45, 3.02), regular stimulant use (aPR = 2.68; 95% CI: 2.12, 3.39), and self-reported HIV negative status (aPR= 1.88; 95% CI: 1.14, 3.10) were significantly and positively associated with sexualized substance use. Conclusions: Sexualized substance use was associated with riskier sexual behavior and self-reported HIV sero-negativity. Harm reduction messaging to FSWs needs to go beyond focusing on sexual health promotion and further highlight the risks associated with sexualized substance use.

BackgroundPeople who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.MethodsThis study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.ResultsA total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.ConclusionOur integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population.

Abstract Background Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran. Methods This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome. Results The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation. Conclusion Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

Background: Tuberculosis is one of the oldest known diseases in humans, and early detection of tuberculosis is one of the main measures to decrease the spread of tuberculosis. In many parts of the world, including Iran, the diagnosis of tuberculosis is based on the detection of acid-fast bacillus in sputum smear microscopy and PCR. this study aimed to synthesize evidence on the diagnostic accuracy of sputum smear and PCR compared to sputum culture for the diagnosis of PT in Iranian patients. Methods: This systematic review and meta-analysis was conducted based on PRISMA guideline for systematic review and meta-analysis. Eligible studies were cross-sectional original diagnostic studies published in English and Persian in Iran which examined the sensitivity or specificity(study outcome) of sputum smear microscopy or PCR( as the test) relative to sputum culture (as the gold standard/comparator) among Iranian patients suspected of having tuberculosis( study population). Studies whose data were not complete or extractable were excluded. Results: A total of 3518 subjects were evaluated from 15 eligible studies. The pooled sensitivity of sputum smear and PCR was 75.12 (95% CI: 66.68-83.56) and 88.02 (95% CI: 82.87-93.27), respectively. The specificity for sputum smear and PCR was 93.94 (95% CI: 91.26-96.63) and 91.82 (95% CI: 87.29-96.35) respectively. The sensitivity of both sputum smears was higher in studies published after 2010, and had higher quality. The specificity of sputum smear was a bit lower in studies published after2010 but higher in studies with higher quality. The specificity of PCR was higher in studies published after 2010 but higher in studies with higher quality. Conclusion:The increased sensitivity of sputum smear and PCR during recent years suggests the improvement of preparation and laboratory methods in recent years. However, the imperfect sensitivity of these tests highlights the need for a more accurate diagnostic method for the detection of pulmonary tuberculosis in Iran.

BackgroundIncarcerated people are at an increased risk of contracting HIV and transmitting it to the community post-release. In Iran, HIV epidemics inside prisons were first detected in the early 1990s. We assessed the HIV prevalence and its correlates, as well as the continuum of care among incarcerated people in Iran from 2010 to 2017.MethodsWe used data collected in three national bio-behavioral surveillance surveys among incarcerated individuals in 2010 (n = 4,536), 2013 (n = 5,490), and 2017 (n = 5,785) through a multistage cluster sampling approach. HIV was tested by the ELISA method in 2010 and 2013 surveys and rapid tests in 2017. Data on demographic characteristics, risky behaviors, HIV testing, and treatment were collected via face-to-face interviews. HIV prevalence estimates along with 95% confidence intervals (CI) were reported. Using data from the 2017 round, multivariable logistic regression models were built to assess the correlates of HIV sero-positivity and conduct HIV cascade of care analysis.ResultsThe HIV prevalence was 2.1% (95% CI: 1.2%, 3.6%) in 2010, 1.7% (95% CI: 1.3%, 2.1%) in 2013, and 0.8% (95% CI: 0.6%, 1.1%) in 2017 (trend P value

BackgroundUnderstanding the reasons for loss to follow-up (LTFU) in cohort studies, especially among marginalized groups such as people who inject drugs (PWID), is needed to strengthen the rigor of efficacy trials for prevention and treatment interventions. We assessed the proportion and reasons for loss to follow-up in a recent cohort of PWID enrolled in the southeast of Iran.MethodsUsing respondent-driven sampling, we recruited 98 PWID age 18 years or older who reported injecting drugs in the past 6 months, and were negative for HIV and HCV at initial screening. Participants were followed at 6 week intervals, alternating a short six-week visit and long 12-week or quarterly visit to measure incidence of HIV and HCV. Methods to enhance retention included incentives for completing each visit, tracking people who missed the scheduled visits through their peer referral networks, engaged outreach teams to explore hotspots and residences, and photos. LTFU was defined as participants who missed their quarterly visits for two or more weeks.ResultsMean (SD) age of participants was 39.7 years (SD 9.6). Of 98 enrolled, 50 participants (51.0%) were LTFU by missed their scheduled quarterly visits for 2 weeks or more. For those whose reasons for LTFU could be defined (46.0%, 23 of 50), main reasons were: forgetting the date of visit (43.5%, 10 of 23), being incarcerated (39.1%, 9 of 23), and moving out of the city (17.4%, 4 of 23).ConclusionThis study highlighted the difficulty in retaining PWID in longitudinal studies. Despite having several retention strategies in place, over half of PWID were LTFU. The LTFU might be reduced by setting up more effective reminder systems, working closely with security systems, and online means to reach those who move outside the study area.

Background: The novel coronavirus disease (COVID-19), as a global concern, has affected different economic and social aspects, as well as health costs in various communities. Finding effective and available treatment is an urgent need. A recent study has demonstrated that the ketogenic diet (KD) activates innate immunity and has a protective property against virus infection. Accordingly, we conducted this study to find the effect of oral medium-chain triglyceride (MCT) on COVID-19 and its clinical manifestations. Methods: This was a randomized clinical trial on 195 patients clinically suspected of COVID-19 referred to infectious disease clinics of Kerman. Patients were randomly assigned into two groups. The Control group received standard supportive treatment, the recommendation for carbohydrate avoiding and diet modification. Patients in the intervention group received all mentioned recommendations beside MCT oil. Patients` clinical symptoms, including body temperature, respiratory rate, body pain, and dyspnea, were recorded in a checklist and analyzed. Results: The mean age of patients was 37.78 ± 12.42 years in the intervention group and 40.81 ± 13.23 years in controls (P = 0.231). The patients in the intervention group had lower duration of weakness (P = 0.004), body pain (P = 0.004), dyspnea (P = 0.004), gastrointestinal manifestations (P

BackgroundOpioid agonist therapy (OAT) uptake has been associated with multiple positive health outcomes among people who inject drugs (PWID). This study evaluated the pattern of OAT uptake among PWID in two consecutive national bio-behavioral surveillance surveys (2010 and 2014) in Iran.MethodsData were obtained from two national bio-behavioral surveillance surveys (N2010 = 1783 and N2014 = 2166) implemented using convenience sampling at the harm reduction facilities and street venues in 10 geographically diverse urban centers across Iran. Multivariable logistic regression models were built to determine the correlates of OAT uptake for the 2014 survey, and adjusted odds ratios (AORs) along with 95% confidence intervals (CI) were reported.ResultsThe prevalence of OAT uptake decreased from 49.2% in 2010 to 45.8% in 2014 (P value = 0.033). OAT uptake varied across the studied cities ranging from 0.0 to 69.3% in the 2010 survey and 3.2 to 75.5% in the 2014 survey. Ever being married (AOR = 1.40; 95% CI 1.12, 1.75), having a history of incarceration (AOR = 1.56; 95% CI 1.16, 2.09), and human immunodeficiency virus (HIV) sero-positivity (AOR = 1.63; 95% CI 1.08, 2.50) were associated with OAT uptake. Conversely, PWID who reported using only non-opioid drugs (AOR = 0.43; 95% CI 0.26, 0.71) and those who reported concurrent use of opioid and non-opioid drugs (AOR = 0.66; 95% CI 0.51, 0.86) were less likely to uptake OAT.ConclusionsAlthough OAT uptake among PWID in Iran is above the 40% threshold defined by the World Health Organization, there remain significant disparities across urban settings in Iran. Importantly, the OAT services appear to be serving high-risk PWID including those living with HIV and those with a history of incarceration. Evaluating service integration including mental health, HIV and hepatitis C virus care, and other harm reduction services may support the optimization of health outcomes associated with OAT across Iran.

BackgroundThe lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.MethodsUsing targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.ResultsIn total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.ConclusionsStrategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

Abstract Background Incarcerated people are at a disproportionate risk of contracting HIV. We estimated the prevalence and correlates of HIV testing among incarcerated people with a history of HIV-related high-risk behaviours in Iran. Methods Data for this analysis were obtained from three consecutive nationwide bio-behavioural surveillance surveys of a random sample of incarcerated people in 2009 (n = 5953), 2013 (n = 5490), and 2017 (n = 5785). History of testing for HIV in the last 12 months was the primary outcome variable. HIV testing was examined among those with a history of HIV-related high-risk behaviours (i.e., having multiple sex partnerships, injection drug use practices, or a history of having a tattoo). The outcome variable was divided into three categories: Never tested for HIV, ever tested for HIV inside the prison in the last 12 months, and ever tested for HIV outside the prison in the last 12 months. We used multivariable multinomial logistic regression models to examine factors associated with HIV testing. Results Overall, 8,553 participants with a history of HIV-related high-risk behaviors with valid responses to the HIV testing question were included in the analysis. Although HIV testing inside prison has increased (23% [2009], 21.5% [2013], and 50.3% [2017]: P-value

We used two national surveys (2010: N = 1597; 2013: N = 1057) of people who inject drugs (PWID) in past-month to assess the prevalence and population size of PWID with either safe or unsafe injection and sex behaviors, overall and by HIV status. In 2013, only 27.0% (vs. 32.3% in 2010) had safe injection and sex, 24.6% (vs. 23.3% in 2010) had unsafe injection and sex, 26.4% (vs. 26.5% in 2010) had only unsafe injection, and 22.0% (vs. 18.0% in 2010) had unsafe sex only. Among HIV-positive PWID in 2013, only 22.1% (~ 2200 persons) had safe injection and sex, 14.2% (~ 1400 persons) had unsafe injection and sex, 53.1% (~ 5200 persons) had unsafe injection, and 10.6% had unsafe sex (~ 1100 persons). Among HIV-negative PWID in 2013, only 27.5% (~ 22,200 persons) had safe injection and sex, 25.9% (~ 20,900 PWID) had unsafe injection and sex, 23.2% (~ 18,700 persons) had unsafe injection, and 23.3% (~ 18,800 persons) had unsafe sex. HIV-positive and -negative PWID in Iran continue to be at risk of HIV acquisition or transmission which calls for targeted preventions services.

Abstract Background Incarcerated people are at an increased risk of contracting HIV and transmitting it to the community post-release. In Iran, HIV epidemics inside prisons were first detected in the early 1990s. We assessed the HIV prevalence and its correlates, as well as the continuum of care among incarcerated people in Iran from 2010 to 2017. Methods We used data collected in three national bio-behavioral surveillance surveys among incarcerated individuals in 2010 (n = 4,536), 2013 (n = 5,490), and 2017 (n = 5,785) through a multistage cluster sampling approach. HIV was tested by the ELISA method in 2010 and 2013 surveys and rapid tests in 2017. Data on demographic characteristics, risky behaviors, HIV testing, and treatment were collected via face-to-face interviews. HIV prevalence estimates along with 95% confidence intervals (CI) were reported. Using data from the 2017 round, multivariable logistic regression models were built to assess the correlates of HIV sero-positivity and conduct HIV cascade of care analysis. Results The HIV prevalence was 2.1% (95% CI: 1.2%, 3.6%) in 2010, 1.7% (95% CI: 1.3%, 2.1%) in 2013, and 0.8% (95% CI: 0.6%, 1.1%) in 2017 (trend P value

Introduction: Patients with Tuberculosis (TB) still have barriers in accessing high quality care and treatment services. In this qualitative study, we investigated barriers in accessing TB health services including confirmatory diagnosis, treatment adherence and recurrence of pulmonary TB using patients, physicians, and policy makers point of view. Materials and methods: In this qualitative research from November to March 2021, 3 policy makers from the Ministry of Health, 12 provincial TB experts and physicians from the TB control program and 33 patients diagnosed with TB from 4 provinces were enrolled for a semi-structured in-depth interview. All interviews were audio recorded and then transcribed. Framework analysis was done by MAXQDA 2018 software to identify key themes. Results: Several barriers reported for TB care and treatment: Poor knowledge of patents about TB symptoms, failure to screen for TB among at-risk patients by physicians, similar symptoms between TB and other lung diseases, low sensitivity of TB diagnostic tests, incomplete case finding and contact-tracing, stigma related to TB, and patients poor adherence due to long TB treatment. In addition, COVID-19 pandemic disrupted TB services and decreased detection, care and treatment services for TB patients. Conclusion: Our findings highlight the need for interventions to increase public and healthcare providers awareness about TB symptoms, using more sensitive diagnostic tests, and interventions to reduce stigma, and improve case finding and contact tracing effort. Improving patients’ adherence required better monitoring and shorter effective treatment regimes.

Background: Early diagnosis of congenital heart disease (CHD) has a significant impact on the prognosis of the patient. This study aimed to determine the sensitivity and specificity of cardiomegaly according to Chest X-ray (CXR) indices in comparison with echocardiography in the diagnosis of CHD in infants.Methods: In this cross-sectional study, the clinical status of 166 infants aged 2 to 24 months who referred to the Pediatric Ward of Afzalipour Hospital in Kerman and needed CXR for any reason, was evaluated from November 2019 to November 2020. CXR and echocardiography were performed for all infants by a pediatric cardiologist and the probability of CHD was confirmed or ruled out. Therefore, the sensitivity and explicitness of CXR were determined. Data were analyzed using SPSS version 20.Results: The most common anomalies observed in infants were Patent ductus arteriosus (PDA), atrial septal defect (ASD), ventricular septal defect (VSD) and pulmonary stenosis (PS), respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CXR, for determining cardiomegaly in these infants were 65.7%, 51.1%, 26.4%, and 84.8%, respectively.Conclusion: The results of this study showed that the sensitivity and specificity of CXR for determining cardiomegaly were 65.7% and 51.1%, respectively. Therefore, when echocardiography is not available, the chances of finding congenital heart abnormalities with the help of CXR will be quite high.

Background and Objectives: This study was conducted to compare the personality type and alexithymia between opiates dependents, concurrent opiates and methamphetamine users and control groups presenting to drug abuse treatment centers in Kerman in 2020. Methods: In this cross-sectional analytical study, three groups with a sample size of 130 participants were recruited through convenience sampling from six drug abuse treatment centers (two governmental and four private centers) in Kerman, 2020. The first group comprised opiates-only users. The second group included concurrent opiates and methamphetamine users. The third group included never-drug users. The data were collected using three questionnaires including a demographic questionnaire, the Friedman and Rosenman personality types questionnaire and Toronto Alexithymia Scale. Comparison of variables between the three groups was done using multivariable multinomial logistic regression. Results: The research outcomes indicated a higher chance of type A personality in the opiates with methamphetamine dependents (adjusted odds ratio (AOR):1.97; 95% confidence interval (95% CI): 3.64, 1.06) compared to the control group. The chance of severe alexithymia was higher among opiates dependents (AOR: 1.86; 95% CI: 3.27, 1.06) and concurrent opiates and methamphetamine users (AOR: 2.7; 95% CI: 4.83, 1.51) compared to the control group. The concurrent opiates and methamphetamine users were more likely to be male (AOR: 3.1; 95% CI: 6.25, 1.53), single (AOR: 2.6; 95% CI: 4.72, 1.43) and unemployed (AOR: 4.01; 95% CI: 9.09, 1.77) compared to the control group. Compared to the control group, the opiates dependents (AOR: 4.14; 95% CI: 7.71, 2.22) and the opiates with methamphetamine dependents (AOR: 1.95; 95% CI: 3.69, 1.03) were more likely to have education levels lower than secondary school diploma. Conclusion: Considering the relationship between the personality type and alexithymia with opiates and methamphetamine use, early screening, continuous care, and necessary trainings are required to prevent drug dependency in high-risk people, especially at younger ages.

Background and purpose: Virtual social networks (VSNs) are among the most popular communication paths that have become an integral part of most people's lives, including students. This study aimed to investigate the prevalence of VSNs addiction and their related factors, and identify the patterns of addictive-related factors among the students in Kerman, Iran in 2019. Materials and Methods: This cross-sectional study was conducted on 400 students from Kerman University of Medical Sciences. The study instrument was a standardized questionnaire. Descriptive analysis, logistic regression models, and latent class analysis were used to analyze the data. The data were analyzed using SPSS26, Stata12 and WinLTA (v. 3.1) software. Results: 50% of the participants were male, staying in dormitory. The number of individuals in the levels of education in the four groups was equal. Around 0.5% of the students were addicted and 36.5% were at the risk of addiction to VSNs. The most commonly used VSNs was the Telegram (76.8%), and most students (28.8%) spent between 2-3 hours a day on VSNs. In the multivariate model, using 1-2 hours (AOR = 3.33, 95% CI: 1.07 - 10.19), 2-3 hours (AOR = 7.33, 95% CI: 2.50 - 21.52) and more than 3 hours a day (AOR = 18.54, 95% CI: 6.05 - 56.8) of VSNs were associated with an increased odds of being at the risk of VSNs addiction. The Latent Class Analysis showed that high-risk addictive factors including using Telegram for entertainment, providing accommodation in the dormitory, and having a graduate degree significantly influenced the classification. Conclusion: More than one-third of Kerman college students were found to be at the risk of VSNs addiction. Providing appropriate interventions including alternative activities as well as raising knowledge especially for undergraduate students is urgently needed.

Objectives: Bladder-Sparing Approach was presented in patients who are not willing or not suitable for Radical Cystectomy (RC). There have been inconsistencies in the literature regarding the comparison of survival rates of these two methods. Our objective is to evaluate the survival rate of patients with muscle-invasive bladder cancer (MIBC) undergoing different treatment methods. Design: Retrospective cross-sectional study. Setting: A secondary care, multicenter study in Kerman, Iran 2008 to 2016. Participants: All 200 patients who were diagnosed with Muscle Invasive Bladder Cancer and were admitted to our hospitals. Patients with inaccessible medical files and patients with pathologies other than TCC were excluded. Main outcome measures: Radical cystectomy and different methods of bladder preservation were compared based on their survival rate. Interventions: Radical cystectomy or bladder preservation Results: Overall survival of the patients was 2 years [95% CI: 1.37–2.63]. The overall 5-year survival rate of patients with MIBC was 32%. Having a 6.4 years overall survival, the RC group showed the highest survival compared with others (p = 0.01); the overall survival of patients undergoing TMT, TURT, chemotherapy, or radiotherapy monotherapy was 3.15 years [95% CI: 2.242–4.061], 4.06 [95% CI: 3.207–4.931], 2.58 [95% CI: 1.767–3.399], and 3.14 [95% CI: 1.614–4.672] years, respectively. Patients younger than 65 undergoing RC had an overall survival of 7 years, compared with 2 years for the TMT group. (p = 0.0001). Conclusions: The Bladder-Preservation method, as a replacement for RC, showed a lower overall survival rate in our study. A prospective randomized clinical trial may declare the best treatment. [ABSTRACT FROM AUTHOR]

Background: Patients with beta-thalassemia (BT) are susceptible to psychological disorders such as depression. The present study was conducted to estimate the pooled prevalence of depression among patients with BT in Iran. Methods: Domestic and international databases were searched for relevant articles published from 1991 until June 2019. We searched international databases such as Scopus, ISI, and Embase; Iranian databases such as SID, Magiran, and IranDoc; and Google Scholar and PubMed search engines. The MeSH keywords used were “depression”, “mental health”, “depressive disorder”, “thalassemia”, “beta-thalassemia major”, “prevalence”, “epidemiology”, and “Iran”. Relevant cross-sectional or cohort studies were included in the analysis. Cochran’s Q test and the I2 index were used to assess heterogeneity. The pooled prevalence and its 95% confidence interval (CI) were calculated using “metaprop” commands in Stata 14. In cases, where the I2 statistic was greater than 50%, the random-effects model was used. Results: Eighteen eligible studies were included. The pooled prevalence of depression was 42% (95% CI: 33% to 52%), whereas the pooled prevalence of mild, moderate, severe, and extremely severe depression was 16% (95% CI: 11% to 22%), 13% (95% CI: 9% to 18%), 13% (95% CI: 9% to 17%), and 3% (95% CI: 0% to 8%), respectively. The pooled prevalence of depression in moderate- and high-quality studies was 45% (95% CI: 29% to 61%), and 39% (95% CI: 27% to 51%), respectively. Conclusion: The high prevalence of depression highlights the urgent need for the establishment of interventions for the prevention, early detection, and treatment of depression among Iranian patients with BT.

We examined the association of dyadic-level factors with syringe sharing among people who inject drugs (PWID) in Kerman, Iran. In a cross-sectional study, we collected data on 329 drug-injecting dyads by individual face-to-face interviews. An injecting dyad was defined as 2 PWID who knew each other and injected drugs together during the last 6 months. If they reported at least 1 occasion of syringe sharing, the dyad was considered high-risk. Dyadic-level factors associated with syringe sharing were assessed using cross-classified multilevel logistic regression. The rate of syringe sharing was significantly higher for dyads who were more intimate (adjusted odds ratio [AOR] 4.5, CI 95%, 2.3-8.6), who had instrumental support (AOR 2.1, 95% CI 1.1-4.5), and who pooled money for drugs (AOR 4.1, 95% CI 2.0-8.3). The rate was lower in same-sex dyads (AOR 0.4, 95% CI 0.2-0.9) and in dyads who shared health information (AOR 0.5, 95% CI 0.2-0.9). Findings highlight close-peer influences on syringe-sharing behavior.

Among 1337 Iranian adult female sex workers in 2015, we assessed the diagnostic value of 4 self-reported sexually transmitted infection (STIs) symptoms for detecting laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, human papillomavirus (HPV), and syphilis. While 37.7% reported vaginal discharge (VD), 25.9% reported pain or burning (P/B), 3.0% reported genital ulcers (GU), and 1.4% reported genital warts (GW), the prevalence of laboratory-confirmed syphilis, gonorrhea, chlamydia, trichomoniasis, and HPV was 0.4, 1.3, 6.0, 11.9, and 41.9%, respectively. The sensitivity of VD was 40.3% for detecting tricomoniasis, 37.5% for chlamydia, and 37.5% for gonorrhea. The sensitivity of P/B ranged from 12.5% for gonorrhea to 25.2% for trichomoniasis. The sensitivity of GU and GW was very low for 5 STIs. The sensitivity of all symptoms combined was also lower than 50%. Among asymptomatic participants, 41.2% tested positive for HPV, 11.8% for trichomoniasis, and less than 6.6% for other STIs. Symptom-based case management and surveillance of STIs can lead to misclassification of a large proportion of cases.

Objective: Clients with borderline personality disorder (BPD) often engage in high-risk sexual behaviors. Online sexual platforms convey abusive and harmful themes, especially for this group of sexually impulsive patients. We hypothesized a correlation between their online sexual activities and the severity of BPD symptoms. Method: Fifty clients with BPD who were referred to Iran psychiatric hospital and Tehran Psychiatric Institute in 2020 participated in this research. The Borderline Evaluation of Severity over Time (BEST) questionnaire was used to assess the severity of BPD symptoms, and the Internet Sex Screening Test (ISST) was used to evaluate online sexual behaviors. A psychiatric interview considered substance abuse and other confounding factors. Results: The mean ISST and BEST scores were 7.82 ± 5.74 and 41.7 ± 12.5, respectively. There was a positive and significant correlation between the severity of BPD symptoms and online sexual activities (P < 0.001, r = 0.480). There was also a significant relationship between online sexual activities and a history of substance abuse (P = 0.003, F = 25.06). Conclusion: Online sexual activity can harm clients with BPD who are more vulnerable to high-risk sexual behaviors. More severe borderline personality traits were associated with more online sexual activity, which underlines the importance of providing education about and managing such activities in clients with BPD.

Background: The global attention to the capacities of traditional medicine for alleviating the clinical manifestations of COVID-19 has been growing. The present trial aimed to evaluate the efficacy and safety of a Persian herbal medicine formula among patients with COVID-19. Methods: The present trial was conducted in Afzalipour hospital, Kerman, Iran, from June to September 2020. Hospitalized COVID-19 patients were randomly divided into intervention (Persian herbal medicine formula + routine treatment) or control (only routine treatment) groups. The intervention group received both capsule number 1 and 2 every 8 hours for 7 days. Capsule number 1 contained extract of the Glycyrrhiza glabra, Punica granatum, and Rheum palmatum, and the second capsule was filled by Nigella sativa powder. Participants were followed up to 7 days. The primary outcome was the number of hospitalization days, while cough, fever, and respiratory rate, days on oxygen (O2) therapy, and mortality rate were considered as the secondary outcomes. Results: Eighty-two patients were enrolled to the study, while 79 cases completed the trial and their data were analyzed (mean age: 59.1 ± 17.1 years). Based on the results, the Persian medicine formula decreased the mean hospitalization days, so that the mean difference of length of hospitalization as primary outcome was 2.95 ± 0.43 days. A significant clinical improvement was observed regarding dyspnea, need for O2) therapy, and respiratory rate in the intervention group. No adverse effects were reported. Conclusion: The present study supported the use of the Persian medicine formula as an adjuvant therapy for hospitalized COVID-19 patients. Study registration: Iranian Registry of Clinical Trials (www.irct.ir): IRCT20200330046899N1.

Objective: This study's objectives were to describe the 15-year trend from 2005 to 2019 and examine the tuberculosis cascade in the Kurdistan province from 21 march 2018–20 march 2019. Methods: This retrospective study was in 2744 patients with tuberculosis from 2005 to 2019 who were registered in Kurdistan disease registration centers. For the initial evaluation of demographic data, we utilized SPSS software version 20 and excel. Additionally, to design a care cascade, we utilized draw.io software for registered patients from 21 march 2018 to 20 march 2019 . As a result, 2489 new cases of tuberculosis remained in our study. Results: The results showed that the mean of age of people with tuberculosis was 58 years and sex distribution were 1441 (57.9) female and 1048 (42.1) male. Additionally, a cascade model showed that in Kurdistan Province, an estimated 112 new cases of smear-positive pulmonary tuberculosis, of which 90% (101 people) were sent to medical facilities and underwent diagnostic testing, with 80% of these patients (81 people). Infection was identified in 81 individuals, all of whom had their diagnoses recorded in the medical database. 82% (67 patients) of the patients who were enrolled in the treatment system received access to treatment, and 65 patients, or 97 percent, experienced no recurrence for at least a year after treatment. Correct diagnosis and therapy represented the biggest gap. Conclusion: Cascade can enhance surveillance program and focus activities to better cases, diagnose, connect to care, and help TB patients survive without recurrence.

ObjectiveThis study aimed to evaluate the effect of laparoscopic cystectomy on ovarian reserve in patients with ovarian cysts.Material and methodsThis prospective study was performed on 113 women with ovarian cysts in a tertiary referral teaching hospital. All patients underwent laparoscopic cystectomy. Serum levels of antimüllerian hormone (AMH) were measured pre-and, 3 months postoperatively. The primary outcome of the study was to assess the effect of laparoscopic cystectomy on ovarian reserve based on alterations in serum AMH levels. The secondary outcome of the present study was to evaluate the impact of the number of cauterizations, size and type of cysts, bilaterality (bilateral or unilateral), age, and body mass index (BMI) on the ovarian reserve after laparoscopic excision.ResultsLaparoscopic cystectomy reduced the serum AMH levels preoperatively (1.32 ± 4.48 ng/ml) to postoperatively (3.2 ± 1.93 ng/ml) and the difference (- 1.28 ng/ml) was statistically different (0.001 >P). There was a negative significant relationship between the number of cauterizations used and postoperative serum AMH levels (p ≤ 0.001). There was a significant relationship between the location (p ≤ 0.01), type of cyst (p ≤ 0.001) and the serum AMH levels reduction.ConclusionThe number of cauterizations used during surgery, the type of cyst, and bilaterality can affect AMH levels that need to be addressed.

Abstract Background Understanding the reasons for loss to follow-up (LTFU) in cohort studies, especially among marginalized groups such as people who inject drugs (PWID), is needed to strengthen the rigor of efficacy trials for prevention and treatment interventions. We assessed the proportion and reasons for loss to follow-up in a recent cohort of PWID enrolled in the southeast of Iran. Methods Using respondent-driven sampling, we recruited 98 PWID age 18 years or older who reported injecting drugs in the past 6 months, and were negative for HIV and HCV at initial screening. Participants were followed at 6 week intervals, alternating a short six-week visit and long 12-week or quarterly visit to measure incidence of HIV and HCV. Methods to enhance retention included incentives for completing each visit, tracking people who missed the scheduled visits through their peer referral networks, engaged outreach teams to explore hotspots and residences, and photos. LTFU was defined as participants who missed their quarterly visits for two or more weeks. Results Mean (SD) age of participants was 39.7 years (SD 9.6). Of 98 enrolled, 50 participants (51.0%) were LTFU by missed their scheduled quarterly visits for 2 weeks or more. For those whose reasons for LTFU could be defined (46.0%, 23 of 50), main reasons were: forgetting the date of visit (43.5%, 10 of 23), being incarcerated (39.1%, 9 of 23), and moving out of the city (17.4%, 4 of 23). Conclusion This study highlighted the difficulty in retaining PWID in longitudinal studies. Despite having several retention strategies in place, over half of PWID were LTFU. The LTFU might be reduced by setting up more effective reminder systems, working closely with security systems, and online means to reach those who move outside the study area.

Background: We aimed to identify the level of known risk factors of diabetes associated with doubled likelihood of diabetes type 2. Methods: In this cross-sectional study, an analysis was performed on the data of 9930 individuals aged 15 yr and older participating from 2014 to 2018 in the second phase of the Kerman coronary artery disease risk factors study (KERCADRS), Kerman, Iran. Data were collected using a standard questionnaire. Multivariable logistic regression was performed to identify factors associated with doubled chance of diabetes. Results: The mean age of participants was 46.1±15.5 yr from which 59.5% were women. Overall, 1105 (11.1%) individuals had type 2 diabetes. An increase of 13.86 yr in age, an increase of 17.32 kg/m2 unit in the amount of body mass index, an increase of 0.17 in the waist-to-hip ratio, a 77 mmHg increase in systolic blood pressure and 6.07 unit increase in triglyceride to HDL ratio doubled the chances of developing type 2 diabetes. Conclusion: Slight changes in the waist-to-hip circumference ratio (0.17), aging (14 yr), and increase in TG/HDL ratio (6.07 unit) were the most important risk factors, while intense physical activity was the most important protective factor associated with doubling of the chances of developing diabetes. Since most of these risk factors are modifiable, increase in physical activity and providing facilities to improve lifestyle in the community seems necessary.

IntroductionCutaneous leishmaniasis (CL) is currently a health problem in several parts of Iran, particularly Kerman. This study was conducted to determine the incidence and trend of CL in Kerman during 2014-2020 and its forecast up to 2023. The effects of meteorological variables on incidence was also evaluated.Materials and methods4993 definite cases of CL recorded from January 2014 to December 2020 by the Vice-Chancellor for Health at Kerman University of Medical Sciences were entered. Meteorological variables were obtained from the national meteorological site. The time series SARIMA methods were used to evaluate the effects of meteorological variables on CL.ResultsMonthly rainfall at the lag 0 (β = -0.507, 95% confidence interval:-0.955,-0.058) and monthly sunny hours at the lag 0 (β = -0.214, 95% confidence interval:-0.308,-0.119) negatively associated with the incidence of CL. Based on the Akaike information criterion (AIC) the multivariable model (AIC = 613) was more suitable than univariable model (AIC = 690.66) to estimate the trend and forecast the incidence up to 36 months.ConclusionThe decreasing pattern of CL in Kerman province highlights the success of preventive, diagnostic and therapeutic interventions during the recent years. However, due to endemicity of disease, extension and continuation of such interventions especially before and during the time periods with higher incidence is essential.

Abstract Background The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators. Methods Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach. Results In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31–40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID. Conclusions Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

Abstract Background Opioid agonist therapy (OAT) uptake has been associated with multiple positive health outcomes among people who inject drugs (PWID). This study evaluated the pattern of OAT uptake among PWID in two consecutive national bio-behavioral surveillance surveys (2010 and 2014) in Iran. Methods Data were obtained from two national bio-behavioral surveillance surveys (N 2010 = 1783 and N 2014 = 2166) implemented using convenience sampling at the harm reduction facilities and street venues in 10 geographically diverse urban centers across Iran. Multivariable logistic regression models were built to determine the correlates of OAT uptake for the 2014 survey, and adjusted odds ratios (AORs) along with 95% confidence intervals (CI) were reported. Results The prevalence of OAT uptake decreased from 49.2% in 2010 to 45.8% in 2014 (P value = 0.033). OAT uptake varied across the studied cities ranging from 0.0 to 69.3% in the 2010 survey and 3.2 to 75.5% in the 2014 survey. Ever being married (AOR = 1.40; 95% CI 1.12, 1.75), having a history of incarceration (AOR = 1.56; 95% CI 1.16, 2.09), and human immunodeficiency virus (HIV) sero-positivity (AOR = 1.63; 95% CI 1.08, 2.50) were associated with OAT uptake. Conversely, PWID who reported using only non-opioid drugs (AOR = 0.43; 95% CI 0.26, 0.71) and those who reported concurrent use of opioid and non-opioid drugs (AOR = 0.66; 95% CI 0.51, 0.86) were less likely to uptake OAT. Conclusions Although OAT uptake among PWID in Iran is above the 40% threshold defined by the World Health Organization, there remain significant disparities across urban settings in Iran. Importantly, the OAT services appear to be serving high-risk PWID including those living with HIV and those with a history of incarceration. Evaluating service integration including mental health, HIV and hepatitis C virus care, and other harm reduction services may support the optimization of health outcomes associated with OAT across Iran.

Bladder cancer (BC) is the 10th most common cancer in the world. While there are FDA-approved urinary assays to detect BC, none have demonstrated sufficient sensitivity and specificity to be integrated into clinical practice. Telomerase Reverse Transcriptase (TERT) gene mutations have been identified as the most common BC mutations that could potentially be used as non-invasive urinary biomarkers to detect BC. This study aims to evaluate the validity of these tests to detect BC in the Kerman province of Iran, where BC is the most common cancer in men. Urine samples of 31 patients with primary (n = 11) or recurrent (n = 20) bladder tumor and 50 controls were prospectively collected. Total urinary DNA was screened for the TERT promoter mutations (uTERTpm) by Droplet Digital PCR (ddPCR) assays. The performance characteristics of uTERTpm and the influence by disease stage and grade were compared to urine cytology results. The uTERTpm was 100% sensitive and 88% specific to detect primary BC, while it was 50% sensitive and 88% specific in detecting recurrent BC. The overall sensitivity and specificity of uTERTpm to detect bladder cancer were 67.7% and 88.0%, respectively, which were consistent across different tumor stages and grades. The most frequent uTERTpm mutations among BC cases were C228T (18/31), C250T (4/31), and C158A (1/31) with mutant allelic frequency (MAF) ranging from 0.2% to 63.3%. Urine cytology demonstrated a similar sensitivity (67.7%), but lower specificity (62.0%) than uTERTpm in detecting BC. Combined uTERTpm and urine cytology increased the sensitivity to 83.8%, but decreased the specificity to 52.0%. Our study demonstrated promising diagnostic accuracy for the uTERTpm as a non-invasive urinary biomarker to detect, in particular, primary BC in this population.

Objective: Fertility patterns are a key to the estimation of future population size, but they are restricted by serious indecision. One-child families are one of these patterns that is caused by a set of factors and one of these factors is the fear of re-pregnancy. In this regard, this study aimed to use a mindfulness-based stress reduction (MBSR) program to reduce the fear of women who have been experiencing anxiety after their first pregnancy and delivery. Materials and methods: This interventional study was conducted on 67 one-child women, who at least 6 years have been passed since the birth of their child and according to the short form of the Pregnancy Related Anxiety Questionnaire (PRAQ-17), have been experienced anxiety. These women were randomly divided into control and intervention groups. For the intervention group, the MBSR program was conducted in 8 sessions, once every week, each session lasting 2.5 hours. At the end of the program, a second PRAQ-17 was completed by both groups. Results: The findings showed that the MBSR approach in the intervention group significantly decreased the anxiety score in total (p=0.001) and individually in all subcategories. Conclusion: The MBSR approach can reduce the anxiety of one-child women who have experienced anxiety after their pregnancy and childbirth. Thus, using this method in helping women with pregnancy-related anxiety is recommended to increase the birth rate.

Background: The study aimed to evaluate the interval between first drug use and regular injection and factors associated with transition from first injection into premature regular injection among people who inject drugs (PWIDs).Methods: In a multicenter cross-sectional study, we recruited 400 PWIDs using snowball sampling. Age of first drug use, age of initiation of regular injection, and demographic and behavioral data were collected using face to face interview. Premature transition to regular injection was defined as initiation of regular injection within the five years of first injection. Data were analyzed using bivariate and multivariate logistic regression survey analysis.Findings: The mean age of first drug use and age of initiation of regular injection was 29.87 ± 6.54 years, respectively. Having history of sexual abuse in childhood [adjusted odds ratio (AOR) = 3.1], history of imprisonment (AOR = 3.4), use of heroin as the first drug (AOR = 4.3), and doing the first injection at friends’ houses (AOR = 2.2) or in ruins (AOR = 2.2) significantly increased the chance of premature transition to regular injection, while being a female decreased the chance of premature transition to regular injection (AOR = 0.4). Compared to curiosity, being friend with a drug user (AOR = 0.4), having withdrawal symptoms (AOR = 0.2), and low cost of injection (AOR = 0.3) at the first occasion of drug injection reduced the chance of premature transition to regular injection.Conclusion: New interventions to prevent injection initiation among drug users are needed and should be integrated in harm reduction programs.