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Abstract
Objectives The existence of street and working children in Iran is undeniable. The precarious conditions of these children (including disrupted family, poverty, high prevalence of crime among relatives, family members and peers) cause social harm and high-risk behaviours, including drug addiction, selling sex or having sex with adolescents or peers. Here we explore the HIV, hepatitis B and hepatitis C status of street and working children in Tehran.
Methods One thousand street and labour children, aged 10–18 years, were recruited by using the time-location sampling method, and semistructured questionnaires were used to find demographic information and information on HIV/AIDS-related high-risk sexual behaviours. Blood samples were collected from children, with use of the dried blood sampling method.
Results 4.5% of children were HIV infected, 1.7% were infected with hepatitis B virus and 2.6% were infected with hepatitis C virus (HCV). Having parents who used drug, infected with HCV and having experience in trading sex significantly increased the likelihood of getting HIV among the street children of Tehran.
Conclusion HIV prevalence among street children is much higher than general population (<0.1%), and in fact ,the rate of positivity comes close to that among female sex workers in Iran. These findings must be an alarm for HIV policymakers to consider immediate and special interventions for this at-risk group.
- HIV
- HEPATITIS C
- HEPATITIS B
- CHILDREN
- SEROPREVALENCE
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Introduction
Quantifying the exact number of street children is impossible, but estimates showed that this number might be tens of millions or even higher around the world.1 In Iran, different and unconfirmed reports regarding number of these children indicate a range from 20 000 to 2 million children who live and work in streets in Iran. Based on the Iran State Welfare Organization report in 2003, 31 000 street children are registered and settled in shelters and children centres, 80% are working children; 24 700 come from other cities to Tehran and have been gathered from bus terminals and around the city. According to the latest Iran Multiple Indicator Demographic and Health Survey, 11.4% of children aged 5–14years are involved in child labour.2
Child labour is a violation against children. Labour along with other violations such as sexual exploitation, violence, physical abuse and neglect could be reasons for high-risk sexual behaviours (such as trading sex) and drug use, which put children in a vulnerable position with regard to communicable diseases such as HIV and other infections.3 ,4
Few studies have addressed seroprevalence of HIV and other viral infections among this population in Iran. Furthermore, knowledge about the overall condition of the HIV epidemic in Iran is limited, but all indications point to an increase in the prevalence of HIV and high-risk behaviours in the near future. As a result, assessing the prevalence of HIV-related high-risk behaviours and HIV infection is imperative. This study is aimed at answering questions and filling gaps regarding status of these children, and their vulnerability to HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV).
Method
For this first biobehavioural surveillance survey by time-location sampling from December 2012 to April 2013, we used a map of Tehran with complete details and determined 70 time locations of street children on the map, based on interviews with experts and related organisations (municipality, welfare organisation, police, non-governmental organisations). Following that, 50 time locations were chosen randomly and eligible children were recruited at those venues. We define street children as working children aged under 18 years who live in the street, or with their relatives or families, and work on the street to augment the family income.
After getting consent of participants, we conducted unnamed interviews based on a questionnaire coded so as to protect participants' anonymity and confidentiality. The questionnaire was designed based on questionnaires developed by Family Health International5 and also HIV national core indicators. After filling out the questionnaire, three drops of blood were taken from a fingertip of the participant; these samples were coded, fixed and sent to the laboratory of the Iranian Research Centre for HIV/AIDS (IRCHA). In case they wanted to know their blood test results, the address of the laboratory and a personal code was given to each participant.
The dried blood spots specimen was tested for HIV seropositivity by Microelisa (Biomerieux, France) and hepatitis C and hepatitis B by Microelisa (Dia.Prodiagnostic, Italy).
Statistical analysis
To compare the characteristics of HIV-positive participants and with that of other participants, we used Pearson's χ2 test. The variables that were significantly associated with HIV infection in univariate analysis at 0.05 level were included in a multiple logistic regression model to explore the risk factors associated with HIV infection.
Results
Of the 1000 street and working children, 4.5% were infected with HIV; 1.7% were infected with HBV, and HCV infections were detected in 2.6%. HIV/HCV coinfections occurred in 0.5% of children, and 8.1% of participants had been infected with at least one of the three assessed viruses.
Participants' ages ranged from 10 to 18 years with mean age (±SD) of 15.62 (±2.5) years, and regarding formal education, 57.4% had dropped out school and 17.2% had never attended any formal educational programme.
In total, 291 participants had engaged in sexual contact with the mean age (±SD) of first sexual encounter being 14.62 (±2.5) years; for 38.5% of these (291 participants), their first sexual experience was with an individual of same sex (all were male who had sex with another male). Almost all (89.3%) of the 291 participants had had sexual relationships during the 12 months prior to this study, 39.2% of the same group reported having more than two sexual partners during this time and 28.5% reported using a condom in their last sex act.
In multiple regression analysis, after controlling for all the significant factors in univariate analysis, having parents who used drugs (OR 2.60, CI 1.3 to 4.9), being infected with HCV (OR 5.51, CI 1.8 to 16.2) and having experience of trading sex (OR 2.15, CI 1.0 to 4.7) were found to be significantly associated with being infected with HIV (table 1).
Characteristics of study participants and association with HIV infection
Discussion
This study found that among 1000 working and street children in Tehran, 4.5% and 2.6% were infected with HIV and HCV, respectively. These results are considerably higher than those of Vahdani et al.6 In regard to HBV infection, our finding is noticeably lower than previous studies.6 ,7
More than half of our children had dropped out of formal education due to poverty, and some had never attended any formal educational programme. This is much in line with the findings of other studies, which have estimated that 30% of Tehran street children are illiterate7 and have had less than 8 years of formal education.8
About 30% of our participants had had sexual contact at the time of recruitment to the study, with first sex act occurring at a mean age of 14.6 years; almost two-fifths of these relationships were with individuals of the same sex (men with men). By comparison, in Brazil, almost 60% of street children have had experience of sex in their lifetime.3 This difference could be the result of stronger cultural and familial frameworks in Iran that create barriers to having sexual contacts before marriage. On the other hand, the unprotected homosexual contacts and multiple partnerships evidenced in this study may have increased risk of HIV among working and street children by comparison with working and street children in other countries. This may explain why nearly all of our children with sex experience had also had sex during 1 year prior to the study—a finding comparable to that of Marshall et al 9 for Vancouver, where 78% of young people on the street were found to be sexually active. So while there may be greater restrictions and barriers in Iranian than in Canadian society (eg, more religious limitations and moral policing), there are also similarities that should give cause for alarm. More comparable to what we find in this study are the findings of a study in Lahore, where 40% of street children were found to have had sex in the 3 months before the study.10 This greater similarity could be the result of religious background, but it could also be due to the fact that more than half of the participants lived with their families. Nevertheless, almost half of the working and street children in our study had experienced commercial sex. Trading sex, along with other jobs, can often be the only way for homeless children to gain a living.
Some studies have stressed the engagement of most of these children in criminal behaviours—particularly drug abuse—and that they have been victims of sexual abuse or have committed rape while living on the streets.8 ,11 It must be borne in mind, however, that 32.5% of these children have been abused physically, mentally or sexually during their lifetime, and nearly half recalled at least one occasion of sexual abuse in their lifetime. In reality, this percentage could be even higher as Baratvand et al 11 found among homeless children in Ahvaz, Iran, but is under-reported due to fear or shame.
Through comparative analysis, we have demonstrated that prevalence of HCV is almost six times higher among our HIV-positive group, relative to other participants. This may simply point to the exposure of these children to infectious diseases that share a route of transmission. On the other hand, the high risk among the HIV-positive group of having drug user parents (RR 2.6) suggests the possibility of infection through mother to child transmission—a possibility that would be consistent with the recent increase in the number of HIV-positive women, who are mostly infected by drug-addicted husbands or sex partners, and the rise in the number of HIV-infected children under 5 years old in Iran.12 Then there is the higher risk among the HIV-positive group of having had commercial sex (RR 2.15). This is a contributory factor that is both denied by organisations and usually covered up by the family or child for legal and family reasons.
Like other HIV/AIDS biobehavioural surveillance surveys, this study has examined the association of HIV positivity with factors found to be significant in HIV epidemics at the national and international scale. Because our sampling was mostly conducted in the street and during the children's work time, our questionnaire-based findings may be inaccurate—especially where these relate to sexual history. There is likely to have been some measure of non-reporting or false reporting.
Given the concentrated nature of this HIV epidemic and its approximation in scale to the HIV epidemic among Tehran's female sex workers,13 street children should, like female sex workers, be taken into account in Iran's HIV prevention strategy. Our findings also point to the need for working and street children to be targeted by prevention programmes, especially those children with addicted parents, as well as by support programmes designed to prevent engagement with commercial sex (which increases threefold their risk of getting HIV infection).
Footnotes
Handling editor Jackie A Cassell
Contributors SM, MF and AS collaborated in the writing of the manuscript. MF, MM, AS and MS and MM were involved in the design and conducting of the survey. NM and SM performed the statistical analyses. SB has done serological analysis. MM and AS supervised the survey and revised the manuscript before submission.
Funding This study has been funded and supported by Tehran University of Medical Sciences (TUMS).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Tehran University of Medical Sciences ethical committee and the IRCHA approved the protocol for this study. The ethics committee approval number is 88-02-55-8988.
Provenance and peer review Not commissioned; externally peer reviewed.