Research Article: Blood-Borne Hepatitis in Opiate Users in Iran: A Poor Outlook and Urgent Need to Change Nationwide Screening Policy

Date Published: December 2, 2013

Publisher: Public Library of Science

Author(s): Behnam Honarvar, Neda Odoomi, Mohsen Moghadami, Parvin Afsar Kazerooni, Alireza Hassanabadi, Parvin Zare Dolatabadi, Ehsan Farzanfar, Kamran Bagheri Lankarani, Jason Blackard.


Iran has the highest rate of opiate use worldwide. However, most opiate users are not screened for hepatitis virus infections. This study aimed to provide accurate, detailed data on the size of the opiate user population at risk of developing these infections.

This seroprevalence study was conducted in the city of Shiraz, southern Iran. All participants were screened for HBV, HCV and HIV infection. The data were analyzed with SPSS.

Among 569 participants, 233 (40.9%) were injection drug users (IDU), 369 (64.8%) were heterosexual, 84 (14.7%) were bisexual and 15 (2.6%) were homosexual. One hundred nine (19.1%) were HCV antibody-positive, 18 (3.1%) were HBS antigen-positive, 72 (12.6%) were HBc antibody-positive and 23 (4%) were HIV-positive. Among IDU compared to non-IDU, positivity rates for HBS antigen (5.5 vs 1.4%), HBc antibody (22.7 vs 5.6%), HCV antibody (40.3 vs 4.4%) and HIV (7.7 vs 1.4%) were higher (P < 0.05). Most patients with HBV (80.7%) and HCV infection (83.4%) were HIV-negative. In the cumulative analysis, only history of imprisonment was a statistically significant determinant of infection by HCV or HBV in opiate users. The current policy of screening only HIV-positive drug users for HBV and HCV in Iran misses most cases of HBV and HCV infection. We therefore recommend urgent revision of the nationwide protocol by the Ministry of Health in Iran to implement routine screening of all opiate users and especially IDU for these viruses, regardless of their HIV status.

Partial Text

Iran has one of the highest rates of opiate use in the world, and the use of opium and heroin increased in 2010 compared to earlier figures [1]. Among the population of Iran between the ages of 15 and 64 years, 2.7% (1.1% to 5.9%) are estimated to use opiates [2]; 40% of these users consume opium, and the rest mainly consume heroin [3]. The main and most worrisome impact of opiate use is on health. Long-term opium use, even at relatively low doses, is associated with an estimated 86% increase in the risk of death [4]. The mortality rate per million among drug users aged 15 to 64 years in Iran was estimated as 69.1, with the majority of deaths related to opiate use [5], compared to 5.4-48.6 per million in Asia and 22 to 55.9 per million worldwide [1].

This seroprevalence and questionnaire-based cross-sectional study was conducted from November 2012 to February 2013. All high-risk persons including persons with a history of drug use or high-risk sexual behaviors who were referred to the BCC affiliated with Shiraz University of Medical Sciences in Shiraz (Fars province, southern Iran) were interviewed face to face privately by a trained clinical psychologist. Participation was voluntary and confidentiality was ensured for all participants. The anonymous, coded questionnaire used to structure the interview consisted of an introductory explanation about the aims of the study, introduction of the researchers, a consent form, and questions regarding demographic data, history of drug use, pattern of sexual activity and other risk factors such as imprisonment, tattooing and cupping. The content and face validity of the piloted questionnaire were evaluated by expert opinion, and its reliability was calculated as 0.71 according to the formula for Cronbach’s alpha by SPSS.

A total of 569 participants (484 men, 85.06%) took part in this study. Their mean age was 30.04 ± 7.79 years; 315 (55.36%) were single, and 426 (74.86%) were high-school educated. One hundred forty-eight (26.01%) were unemployed and 544 (95.6%) lived in the city (Table 1). Injection drug users and non-IDU differed in all demographic characteristics except place of residence (Table 1). Among all participants, 146 (25.65%) were referred to the BCC because of risky sexual behaviors only, compared to 56 (9.84%) who were opiate users only and 323 (56.76%) who were both opiate users and had high-risk sexual behaviors. Two hundred thirty-three (40.94%) used opiates only via injection or both injection and other routes, whereas 145 (25.48%) used these drugs only via non-injection routes.

Our findings speak strongly for the need to screen opiate users, including non-IDU and especially IDU regardless of whether they are positive for HIV infection or not, for HBV and HCV infection. Illicit drug use takes a heavy toll worldwide. According to the World Drug Report by the United Nations Office on Drug and Crime (UNODC), 230 million people, or 1 in 20 adults, are estimated to have used an illicit drug at least once in 2010. This includes 12 to 21 million opiate users or 0.3% to 0.5% of the world population aged 15-64 years, and 15.9 (11.0-21.2) million IDU [3]. Around 60% of all problem drug users worldwide inject drugs, and IDU account for about 7.5% [3] to 8.4% [8] of all drug users worldwide. The number of drug users has been predicted to increase by a quarter before 2050, and developing countries will suffer more than developed countries in this regard [1]. More than half of the world’s opiate users are in Asia [3]. In the Middle East region of Asia 1,890,000 to 3,820,000 people were opiate users in 2008 [7]. According to experts, the opiate use rate in Iran has increased in recent years [3,9] . Iran accounted for 42% (452 tons) of the estimated global opium consumption in 2008, making this country the largest opium consumer worldwide, and the consumption of 17 tons heroin in that same year accounted for 5% of global heroin use [6,10]. The annual prevalence of opiate use (including heroin and opium) in Iran in 2010 was about 2.7% (1.1%-5.9%) of the 53.2 million population between 15 and 64 years of age, and 40% of the estimated opiate users in this country consume opium, while the rest mainly consume heroin [1-3]. In Iran, the rate of drug-related deaths was 69.1 per 1 million people aged 15-64 years [5] compared to 22 to 55.9 deaths per one million inhabitants in this age range worldwide [1].