Mohsen Malekinejad

Using respondent-driven sampling methodology for HIV biological and behavioral surveillance in international settings: a systematic review.

To determine operational and analytical characteristics of respondent-driven sampling (RDS) in international settings and to explore factors that may affect recruitment of most-at-risk populations using RDS, we reviewed HIV biological and behavioral surveillance studies that used this method outside of the United States. We identified 123 eligible studies, 59 from Europe, 40 from Asia and the Pacific, 14 from Latin America, seven from Africa and three from Oceania. Studies collectively recruited 32,298 participants between 2003 and 2007; 53% of studies were conducted among injecting drug users, which generally had faster recruitment compared with studies among sex workers. All but 13 studies reached ≥90% of their intended sample size, and six studies failed to reach equilibrium for key variables. This review has shown that RDS is an effective technique, when designed and implemented appropriately, to sample most-at-risk populations for HIV biological and behavioral surveys.

Implementation Challenges to Using Respondent-Driven Sampling Methodology for HIV Biological and Behavioral Surveillance: Field Experiences in International Settings

Using respondent-driven sampling (RDS), we gathered data from 128 HIV surveillance studies conducted outside the United States through October 1, 2007. We examined predictors of poor study outcomes, reviewed operational, design and analytical challenges associated with conducting RDS in international settings and offer recommendations to improve HIV surveillance. We explored factors for poor study outcomes using differences in mean sample size ratios (recruited/calculated sample size) as the outcome variable. Ninety-two percent of studies reported both calculated and recruited sample sizes. Studies of injecting drug users had a higher sample size ratio compared with other risk groups. Study challenges included appropriately defining eligibility criteria, structuring social network size questions, selecting design effects and conducting statistical analysis. As RDS is increasingly used for HIV surveillance, it is important to learn from past practical, theoretical and analytical challenges to maximize the utility of this method.

Comparing Respondent-Driven Sampling and Targeted Sampling Methods of Recruiting Injection Drug Users in San Francisco

The objective of this article is to compare demographic characteristics, risk behaviors, and service utilization among injection drug users (IDUs) recruited from two separate studies in San Francisco in 2005, one which used targeted sampling (TS) and the other which used respondent-driven sampling (RDS). IDUs were recruited using TS (n = 651) and RDS (n = 534) and participated in quantitative interviews that included demographic characteristics, risk behaviors, and service utilization. Prevalence estimates and 95% confidence intervals (CIs) were calculated to assess whether there were differences in these variables by sampling method. There was overlap in 95% CIs for all demographic variables except African American race (TS: 45%, 53%; RDS: 29%, 44%). Maps showed that the proportion of IDUs distributed across zip codes were similar for the TS and RDS sample, with the exception of a single zip code that was more represented in the TS sample. This zip code includes an isolated, predominantly African American neighborhood where only the TS study had a field site. Risk behavior estimates were similar for both TS and RDS samples, although self-reported hepatitis C infection was lower in the RDS sample. In terms of service utilization, more IDUs in the RDS sample reported no recent use of drug treatment and syringe exchange program services. Our study suggests that perhaps a hybrid sampling plan is best suited for recruiting IDUs in San Francisco, whereby the more intensive ethnographic and secondary analysis components of TS would aid in the planning of seed placement and field locations for RDS.

Transition to injection amongst opioid users in Iran: Implications for harm reduction

Driven by opioid use, HIV prevalence is high (15-27%) amongst injection drug users (IDU) in Iran. Harm reduction programmes are associated with a reduction in high risk injecting behaviours; however, Iran has a large number of non-injecting opioid users not immediately targeted by harm reduction programmes. The vast majority of heroin injectors tend to have a history of several years of smoking opium or heroin before transitioning to injection, and a small fraction may even start their drug career by injection of opioids, behaviours that can undermine the effectiveness of the harm reduction programmes. In this study, we have reviewed evidence on the HIV epidemic, extent and pattern of opioid use, and correlates of the transition to injection in Iran. We have concluded that harm reduction policies should also emphasize prevention of the transition to injection amongst high-risk non-injecting opioid users as an additional strategy against the spread of HIV infection in Iran.

High hepatitis C virus prevalence among drug users in Iran: systematic review and meta-analysis of epidemiological evidence (2001–2012)

OBJECTIVE Drug users, particularly drug injectors, are at elevated risk of blood-borne diseases. This study systematically reviewed the prevalence of hepatitis C virus (HCV) mono-infection and its co-infections with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in drug users in Iran. METHODS Searches were conducted in international, regional, and Iranian databases. Documents were screened, data extracted, and pooled point prevalence and 95% confidence intervals (CI) were calculated. RESULTS Overall, 13,821 subjects (87.4% male) with an average age of 32.4 years (95% CI 31-33 years) from 24 original studies were included in the analysis. The pooled HCV prevalence (95% CI) among drug users with and without an injection history was 45% (37-54%) and 8% (4-13%), respectively. The pooled HCV prevalences (95% CI) among individuals with vs. without a history of imprisonment and needle sharing were 58% (39-77%) vs. 44% (20-68%) and 56% (41-71%) vs. 49% (26-71%), respectively. The prevalence of HCV/HIV co-infection among injectors was 11% (95% CI 5-16%). CONCLUSIONS HCV prevalence is high in drug users in Iran, especially among those with a history of injection drug use, needle sharing, and imprisonment. Drug user-focused HCV prevention and treatment programs are urgently needed.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran. METHODS We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection. RESULTS A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market). CONCLUSION Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Effectiveness of Policies on Reducing Exposure to Ionizing Radiation From Medical Imaging: A Systematic Review

PURPOSE The use of medical imaging has expanded greatly in the past three decades, raising concern about potential unwanted carcinogenic harms associated with exposure to ionizing radiation among patients. This study summarizes evidence of efficacy of interventions that have prompted policies, and structural-level interventions aimed at reducing radiation dose and risk of cancer, especially among women. METHODS Using standard terms, we conducted searches in MEDLINE, Scopus, and Web of Science, and de-duplicated retrieved citations. We hand-searched the reference section of eligible studies and contacted radiology experts to identify studies missed from electronic searches. Two reviewers screened retrieved citations based on predefined eligibility criteria, to identify relevant studies, extract key information from each, rate the quality of evidence, and summarize data in tabular and graphical format. RESULTS From a total of 1,543 unique citations identified from all sources, 16 were included for data extraction. Half of the studies focused on reduction of ionizing exposure from CT, and half on x-ray or fluoroscopy. Identified interventions were broadly categorized as: policy or structural intervention (two; 13%); multipronged (four; 25%); dose-feedback system (five; 31%); provision of training (four; 25%); and quality-control audit (one; 6%). In general, multipronged programs had a higher range for dose reduction (22%-74%), followed by policy/structural interventions (37%-50%). CONCLUSIONS Existing evidence on the effectiveness of policies aimed at reducing patient radiation dose is disperse and low in quality. Compared with other approaches, multipronged efforts may offer more patient protection.

Relative risk reduction is useful metric to standardize effect size for public heath interventions for translational research

OBJECTIVES Heterogeneity of effect measures in intervention studies undermines the use of evidence to inform policy. Our objective was to develop a comprehensive algorithm to convert all types of effect measures to one standard metric, relative risk reduction (RRR). STUDY DESIGN AND SETTING This work was conducted to facilitate synthesis of published intervention effects for our epidemic modeling of the health impact of human immunodeficiency virus [HIV testing and counseling (HTC)]. We designed and implemented an algorithm to transform varied effect measures to RRR, representing the proportionate reduction in undesirable outcomes. RESULTS Our extraction of 55 HTC studies identified 473 effect measures representing unique combinations of intervention-outcome-population characteristics, using five outcome metrics: pre-post proportion (70.6%), odds ratio (14.0%), mean difference (10.2%), risk ratio (4.4%), and RRR (0.9%). Outcomes were expressed as both desirable (29.5%, eg, consistent condom use) and undesirable (70.5%, eg, inconsistent condom use). Using four examples, we demonstrate our algorithm for converting varied effect measures to RRR and provide the conceptual basis for advantages of RRR over other metrics. CONCLUSION Our review of the literature suggests that RRR, an easily understood and useful metric to convey risk reduction associated with an intervention, is underused by original and review studies.

Effectiveness of School-Based Teen Pregnancy Prevention Programs in the USA: a Systematic Review and Meta-Analysis

School-based programs have been a mainstay of youth pregnancy prevention efforts in the USA. We conducted a systematic review and meta-analysis to assess their effectiveness. Eligible studies evaluated the effect on pregnancy rates of programs delivered in elementary, middle, or high schools in the USA and Canada, published between January 1985 and September 2016. The primary outcome was pregnancy; secondary outcomes were delay in sexual initiation, condom use, and oral contraception use. Randomized controlled trials (RCTs) and non-RCTs with comparator groups were eligible. We developed a comprehensive search strategy, applied to major bibliographic databases, article bibliographies, gray literature, and contact with authors. We calculated risk ratios (RR) with 95% confidence intervals (CI) for each outcome and pooled data in random effects meta-analysis. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess evidence quality. Ten RCTs and 11 non-RCTs conducted from 1984 to 2016 yielded 30 unique pooled comparisons for pregnancy, of which 24 were not statistically significant. Six showed statistically significant changes in pregnancy rates: two with increased risk (RR 1.30, 95% CI 1.02–1.65; and RR 1.39, 95% CI 1.10–1.75) and four with decreased risk ranging from RR 0.56, 95% CI 0.41–0.77, to RR 0.75, 95% CI 0.58–0.96. All studies were at high risk of bias, and the quality of evidence was low or very low. Identified evidence indicated no consistent difference in rates of pregnancies between intervention recipients and controls.

Factors Influencing Transition to Shisheh (Methamphetamine) among Young People Who Use Drugs in Tehran: A Qualitative Study

ABSTRACT Background: Iran has experienced an emerging epidemic of methamphetamine use during recent years which has added to existing non-injecting and injecting opioid use in the country. This study explored factors influencing the initiation into or transition to methamphetamine use among young people who use drugs (PWUD). Methods: We conducted 42 semi-structured, in-depth interviews with young PWUD (n = 35) and health care workers (HCWs) (n = 7) between July and October 2011 in Tehran, Iran. The PWUD were purposefully recruited from different tiers of drug services and lived in geographically diverse areas of Tehran. The HCWs were substance use experts and/or service providers of treatment and harm reduction facilities. All interviews were recorded, transcribed, and coded using OpenCode 3.6 software. Results: The predominant factors for initiation into or transition to methamphetamine use were individual domain factors. The peer domain factors were the second most frequently stated perceived factor category for transition to methamphetamine use. Other perceived factors affecting transition to stimulant use included both family and community domains. Conclusion: Drug prevention programs should consider targeting certain settings, including workplaces and sports clubs, for preventative interventions. Existing opioid treatment and harm reduction services should be adjusted in response to the methamphetamine use epidemic.