Risk factors associated with injection initiation among

Archives Des Sciences

Vol 65, No. 8;Aug 2012

Risk factors associated with injection initiation among youth drug users admitted to the three Drug Treatment Centers in Tehran, Iran Neda Mehrdad Assistant professor Center for Nursing Care Research, Tehran University of medical Sciences (TUMS), Tehran- Iran Email:[email protected] Soghra Nikpour(Corresponding author) Assistant professor Center for Nursing Care Research, School of Nursing and Midwifery, Tehran University of Medical Sciences and Health Services, Tehran, Iran Address :Center for Nursing Care Research of TUMS, Tehran University of medical Sciences (TUMS), Rashid Yasami St.Valiasr ave.Tehran ,Po.BOX:12324.5627, Iran postcode:12285 Mobile: +989125245184

Email:[email protected]

Eftekharalsadat Hajikazemi Assistant professor Center for Nursing Care Research, Tehran University of medical Sciences (TUMS), Tehran- Iran

Email: [email protected] Hamid Haghani

MsE in social stastistics,member of scientific board of faculty of management and information, Tehran University of Medical Sciences and Health Services,Tehran,Iran. [email protected]

The research is financed by World health Organization. No. 2006-7/11 (Sponsoring information)

Abstract

Circumstances surrounding injection initiation have not been well addressed in many

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developing country contexts. A cross-sectional survey was conducted among drug users. The population consisted of Drug users were admitted for inpatient treatment. Three Drug Treatment Centers in Tehran were selected by randomization. Participants were selected consecutively in every Drug Treatment Center. A total of 1000 drug users were included into this analysis. A structured questionnaire was used. A multiple logistic regression was employed to identify the independent effects from potential risk factors of transition into injection. Variables that were included in the initial and final multiple logistic models were based on statistical significance (p < 0.05) scientific importance.After controlling other covariates, being 25 years of age or older, single, higher education, urban residence, being unemployed, having a history of incarceration and lack of awareness about transmission ways of AIDS were significantly associated with higher likelihood of injection initiation. Smoking (99.4%) was very common. Multiple sex partners and an experience of sex abuse and engaged in prostitution were associated with an increased risk of injection initiation. Comparing to those whose first drug was heroin and Crack, individuals using opium as their initiation drug, Family injection drug use, friends, partners or schoolmates injection drug use had greater risk of injection initiation (p < 0.05). Age of drug initiation didn’t have a significant impact on the likelihood of starting injection. Understanding these factors will benefit the design of approaches to successfully prevent or delay transition into injection. Key words: Risk factors, injection initiation, drug users, cross-sectional survey, Drug Treatment Centers

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Introduction A range of studies have examined the factors associated with transition from noninjection into injection drug use; however most of them are conducted in the developed world (Swift et al 1999, Neaigus etal2001, Fuller etal2002, Bravo etal2003, Roy etal2003). Sexual abuse alone has put drug users at a higher likelihood of injection initiation (Roy et al. 2003, Ompad et al. 2005). A study has recorded the independent effect of drug use characteristics on onset of injection, such as types of recently used drugs (Roy et al. 2003); intensiveness and/or length of drug use (Narimani &sadeghieh .2008); and current treatment status(Swift et al1999). At the social-culture level, low socio-economic status has consistently been found to be one of the most important factors in initiating injection in the developed world (Neaigus et al2001, Bravo et al2003). An exploration of the circumstances around the critical time of initiating injection practices in developing countries as related to medical outcomes has not been well addressed (Yingkai et al 2006). Result One study in Iran showed Evidence of injecting drug use and drug-related harm was found in 5 of 6 study districts. Several profiles of injecting drug users were identified: depending on their socioeconomic status and degree of stability, injecting drug users employed different injecting behaviors and syringe hygiene practices. The prevalence of sharing injection instruments ranged from 30–100%. Varied magnitudes of risk were evident among the identified IDUs typologies in terms of syringe disinfection methods, level of HIV awareness, and personal hygiene exhibited. At the time of research, there were no active HIV prevention programs in existence in Tehran (Razzaghi et al 2006). In the Middle East, as it is worldwide, injecting drug use is a main route for transmitting HIV. The rise of injecting drug use, however, is still a relatively new phenomenon in Iran, where for century’s opium smoking was the predominant form of drug use (Reid& Costigan. 2002, Nissaramanesh et al2005). Thus, it could be roughly concluded that the injecting drug user (Injecting Drug Users) population in Iran is over 200,000. Other sources place the number of drug users in Iran at 3.3 million and the number of Injecting drug users at over 300,000(MAP Network. 2001, Iran News Daily. 2001). Regardless of the actual number of Injecting drug users, worrying trends suggest

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that, compared to non-injecting drug use, the prevalence of injecting drug use has increased more rapidly during the past decade and will continue to rise in Iran (Reid& Costigan. 2001, Rahimi Movaghar et al2002, INCB. 2005). Indeed, many regard drugs as the most lethal threat to Iran today (Tait. 2005). HIV/AIDS is closely associated with injecting drug use in Iran. The prevalence of HIV among the Injecting drug users in one study was 15.2 %( Zamani et al 2005). Early-onset injection drug users take more health risks than other injection drug users by sharing needles, syringes and other injection equipment (Razzaghi et al 2006). As a result, they are at greater risk than any other drugusing group of contracting blood-borne viruses (BBVs)—hepatitis B and C in developed countries, and HIV in many parts of the world—and of experiencing long-term health problems (Roy et al2003). In order to plan preventive health programmes, it is important to recognize the factors that lead to early onset injection (Fuller et al2001). There are a lot of studies about drug abuse in Iran (Rahbar et al 2004, Ahmadi et al2004, Bolhari. 2003, Solati et al2004, Ghoreishi Zadeh & Torabi.2002, Nohesara et al2004, Amani et al2005) but there has been little research area about factors related to onset of injection among drug users. However, with the exception of Fuller et al. (2001), who compared adolescent with adult injectors, there has been little, research in this area (Fuller et al2001). The present study attempted to fill this gap. The aim of the study was to identify Risk factors associated with injection initiation among youth drug users admitted to the three Drug Treatment Centers in Tehran, Iran. Methodology: This study is a part of cross sectional study. The population consisted of Drug Users were admitted for inpatient treatment. The inclusion criteria in the current study were : being 12 years or older; being admitted for opiate or met amphetamine dependence; agreeing to receive pre and post-test HIV counseling and venipuncture for antibody testing for HIV infection; providing informed consent for those 18 and older and parental consent and2 assent for individuals below the z s2 age of 18. The project sample size determined by n= 2 formula, was1000 drug users d and all of them completed the questionnaire. Three Drug Treatment Centers in Tehran were selected by randomization. Participants were selected consecutively in every Drug Treatment Center.

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After explaining study requirements and obtaining informed consent, an interviewer conducted a 30–40 minute risk factor questionnaire in a private setting. It was ascertained information on demographics, tobacco and alcohol use, non-parenteral modes of HIV transmission, and a comprehensive drug use and sexual behavior history. Age at first use, priority of reasons for first use. Injection history was also obtained, including characteristics of first injection, syringe sharing history, and syringe disinfection practices. Drug treatment and family and friends' drug use were also examined. With a view to obtaining a broad spectrum of injecting drug users (IDU), ranging from those who injected drugs occasionally (e.g. at dance parties) to those who injected several times a day. Following HIV pre-test counseling; a serum specimen was collected; one week later patients were given their HIV test results during HIV post-test counseling. The data were collected during 2007. There were no missing data because they were collected by interview. Researchers collected data by interview for 6 days a week for 4 months in 2007. Questionnaire was developed based on information from pilot studies (in-depth interviews and focus groups) and a systematic literature review. A formal pre-test was conducted in a similar setting. Three Interviewers received formal training and were fluent in Persian language. The study has been approved by the institutional review boards of the Tehran University of medical Sciences. Permission to carry out the research was obtained from the university internal review board. A gift was given to all of samples research by Researchers. After data gathering, the statistical package for the social sciences (SPSS for windows) version 14 was used for data entry and analysis. Independent variables included demographic factors, sexual behaviors and drug use characteristics, specifically age, gender, education, employment, residence, number of sex partners, sex abuse history, and types of drugs ever used, and age of drug initiation. The dependent variable was initiation of injection. Universite analysis was conducted to describe the study sample's demographics, sex and drug use behaviors. The Chi-square test and Student’s t-test were used for categorical and continuous variables. Variables that were significant at p < .05 in the bivariate analysis were included in the multivariate model. Logistic regression was employed to assess risk factors.

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Variables that were included in the initial and final multiple logistic models were based on statistical significance (p < 0.05) and/or scientific importance. Odds ratio and 95% confidence were calculated. Results Descriptive results are located in Table 1. The Mean age of participants was 27.63±5.67years. Nearly 87.2% of participants were male. In this analysis, the marital statue of single (77.5%) included those who were single, separated, divorced or widowed. 87%samples lived in urban areas. About one-third had high school education. 50.2% of the participants were employed. Smoking (99.4%) was very common and drinking alcohol (8.7%). 55.3%of participants ever gave a history of incarceration. In the current study AIDS 15.4%. More than 50 % of participants had moderate awareness about Transmission ways of AIDS. Half of the participants had five or more lifetime sex partners with 1-10. 301 participants (36.8%) engaged in prostitution for money or drug. In this study the average age overall of initiation to drug use was 18.93±3.21. Opium was the drug most commonly first used (51.6%), followed by Crack (23%) and Heroin (20.9%). The Mean age of first injected drugs was 25.05±5.20years. In total, 818 participants (81.8%) ever injected drugs. Results from The Chi-square test& Student’s t-test showed statistically significant variables between non Injection drug used and injection drug used. These variables contain of age, place of living, occupational status, monthly income, marital status, education level, Ever smoking, Ever drinking, Ever been in jail/prison, HIV positive, awareness about transmission ways of AIDS, Type of initiation drug, Age of drug initiation, Family injection drug use, friends, partners or schoolmates injection drug use, Age of School-leaving, No of sex partners, Type of Sexual contact, HIV-infected sexual partner(s),Ever selling sex, Ever sex abuse(p