Hot Spot Mapping and Size Estimation of Illicit Drug Users in Iran: A Pilot Study Mahmoud Khodadost IUMS: Iran University of Medical Sciences Nima Ghalehkhani Kerman University of Medical Sciences Ahmad Hajebi IUMS: Iran University of Medical Sciences Mohammad Mahdi Gouya MOHME: Iran Ministry of Health and Medical Education Parvin Afsar Kazerooni Shiraz University of Medical Sciences Ebrahim Ghodusi MOHME: Iran Ministry of Health and Medical Education Hamid R Fathi Mashhad University of Medical Sciences Toktam Khojasteh Bojnordi MOHME: Iran Ministry of Health and Medical Education Fatemeh Sarvi Hamadan University of Medical Sciences Jamshid Vashani IUMS: Iran University of Medical Sciences Fatima Zare Banad Kokie Yazd University of Medical Science: Shahid Sadoughi University of Medical Sciences and Health Services Mahmoud Reza Hashemvarzi Mazandaran University of Medical Sciences Reza Davasazirani Ahvaz Jundishapur University of Medical Sciences: Ahvaz Jondishapour University of Medical Sciences Hamid Shari Kerman University of Medical Sciences Seyed Abbas Motevalian ( [email protected] ) Iran University of Medical Sciences https://orcid.org/0000-0003-4241-4300 Page 1/22 Research Keywords: People who inject drugs, People who use drugs, Mapping, Size estimation, Iran, Illicit drug use Posted Date: January 11th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-141437/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 2/22 Abstract Background: Mapping and size estimation of people who use (PWUD) or inject drugs (PWID) are important issues for control of drug use. The aim of this pilot study is to mapping and estimate the number of PWUD and PWID in Iran. Methods: We used the hotspot mapping and size estimation method to estimate the number of illicit drug users in four cities of Iran from December 2017 to January 2019. We identied hotspots by local knowledge of key informants. For size estimation in each hotspot, three estimates were made during hotspot visit: a) KAP-KI (Key Affected Population Key Informant) estimate (drug users met in the hotspot), b) Non-KAP KI estimate (e.g. taxi drivers, shopkeepers nearby the hotspot); c) estimation made by eld observers. Locations of hotspots were recorded by the eld team and ArcGIS software was used for mapping. Results: A total number of 335 hot spots were identied in four cities of them, 70 (20.9%) were in Ahvaz, 90 (26.9%) in Sari, 67 (20%) in Yazd and 108(32.2%) in district 2 of Tehran metropolitan. We identied nine high-density areas for PWUDs of them three were in Ahvaz, one in the south of Sari, two in district 2 of Tehran and three in Yazd. The total numbers of 1524 key informants were interviewed by the eld team in 335 identied hot spots. Based on the median estimated number of PWUD, Ahvaz had the highest estimated number of PWUD (1242, range, 606-1285), followed by Sari (788, range, 373-1044), district 2 of Tehran (684, range, 642-728) and Yazd (123, range, 76-316). The median estimated number of PWID indicated that Ahvaz had the highest estimated number of PWID (843, range, 703-887), followed by Sari (346, range, 307-666), Yazd (228, range, 221-471) and Tehran (18, range, 18-34). Conclusions: Findings highlight the importance of geographical targeting of illicit drug users to provide harm reduction programs with a broader reach in Iran. Introduction Illicit drug use is a major health problem worldwide and annually hundreds of millions of people consume at least one of a variety of illicit drugs. Based on world drug report in 2019, there was estimated 585,000 deaths and 42 million years of life lost due to drug use. Globally, the number of deaths and disability- adjusted life years (DALYs) in the past three decades have approximately doubled(1). Mental health problems and attempted and completed suicides that occur due to illicit drug use exacerbated this situation (2). The sexual high risk behaviors in this population including multiple sexual relationship and sexual networks with people who inject drugs (PWID) can lead to vulnerability for sexually transmitted infections (STIs) (3, 4). HIV prevalence among PWUD was reported 10 times greater and in PWID was 22 times higher than the general population (2, 5–7). Viral hepatitis C and B (HCV, HBV) are another infectious diseases with greater prevalence among PWUD (8, 9). The injecting drug use is a major cause of HIV transmission in Iran. Based on the report of Iran's Ministry of Health and Medical Education (MOHME), there is estimated about 200, 000 to 230, 000 PWID in Iran Page 3/22 and more than 65% of HIV identied cases was related to injection drug use (10, 11). Accurate size estimation of illicit drug users can help in management of intervention and preventive plans, allocation of the resources and monitoring the interventions(12). Various techniques are available to estimate the size and dynamics of at risk populations, including multiplier, capture recapture and network scale-up method (13–16). With these size estimation techniques, the reliable estimates can be obtained, but they cannot describe the geographical location of these populations and related hotspots. The objectives of mapping and size estimation method is to determine the illicit drug use hotspots, the high risk activities that occur in hotspots, peoples who are involved and to estimate the number PWUD and PWID and in totally we can access to detailed information of these locations (17, 18). The aim of this study was to determine the geographic distribution of illicit drug use hotspots and estimating the size of PWUD and PWID by using mapping and population size estimation method in four cities if Iran as a pilot study. Material And Methods In this study, we used the key informant-driven mapping and enumeration approach(12) to describe the geographic distribution of illicit drug hotspots and estimating the number of PWUD and PWID and prevalence of related high risk behaviors in hotspots. This study conducted during December 2017 to January 2019. Field team members started data collection activities in four cities of Iran (Ahvaz, Sari, Yazd and district 2 of Tehran metropolitan). Ahvaz is located in the southwest of Iran and the capital of Khuzestan province with a population size of about 1,300,000 populations; Sari located in the southern coast of the Caspian Sea in the north of Iran and is the capital of Mazandaran province with a population size of about 504,000 populations; Yazd is located in the middle of the Iranian plateau and is the capital of Yazd province with a population size of about 656,000 populations and district 2 of Tehran metropolitan is located in the west of Tehran and is neighboring both Azadi Square and the green gardens of Farahzad and Evin (with high prevalence of illicit drug use) with a population size of 700,000 populations. A comprehensive practical protocol was developed based on the key informant-driven mapping and enumeration approach (12), which includes: a) primary assessments and determine the eld team members, primary and secondary key informants b) data collection methodology and data collection tools c) data synthesis, analysis and reporting the results. The study protocol was approved by the Research Ethics Committee of Iran University of Medical Sciences. Field team, primary and secondary key informants The eld team consists of four people: 1) team manager, 2) interviewer, 3) person who is responsible for the counting of PWID and PWUD in hotspots. He also helps the team to recognize the right persons in the hotspots. 4) a driver who is also responsible for the executive process and security of the team. Field team members were selected among the service providers for PWID, e.g. members of mobile centers and Page 4/22 outreach team, or from persons who were current and former drug users. For every 50 hotspots, one eld team was assigned. Primary and secondary key informants were interviewed during the data collection process. Primary key informants were interviewed during focus group discussion and in-depth interviews at the rst step of study. The two types of secondary key informants were interviewed at the eld level including: a) Key affected population key informant (KAP KI); b) Non-key affected population key informant (Non-KAP KI). The details of key informant persons were explained in the Table 1. Table 1 Types of key informants enrolled in the study Group name Organizational status Role in data collection Primary Persons who provided services • They are knowledgeable about hot key to or interacted regularly with spots or drug users and provided the informant drug users, police ocers, primary information about the nongovernmental organization hotspots and their locations during (at the staff (NGO), outreach team focus group discussion and in-depth rst step staff, drop-in centers (DIC), interviews at the rst step of the of study) welfare organization staff, study. municipality and the staff of AIDS and addiction oce. • They help to provide the master list of all known hot spots during focus group discussion and in-depth interviews. Secondary a) Key The PWID or PWUD peoples They were interviewed at the eld Key affected who resident in hot spots. level and provide information about informant population hotspots e.g. hot spot and its features key including estimates of the number of (at the informant people in which the hot spot is eld visit (KAP KI) presenting, if available, information stage) on the high risk activities that people do in the hot spot and introducing b) Non-key Peoples who do not use new hot spots. affected substances but have population information about hotspots e.g. key taxi drivers, shopkeepers, park informant security ocer and so on.