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Original research
Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study
  1. Ali Mirzazadeh1,2,
  2. Mostafa Shokoohi2,3,
  3. Mohammad Karamouzian2,4,
  4. Haleh Ashki5,
  5. Razieh Khajehkazemi6,
  6. Apameh Salari2,
  7. Negin Abedinzadeh7,
  8. Seyed Alireza Nadji8,
  9. Hamid Sharifi2,
  10. Parvin Afsar Kazerooni9,
  11. Minoo Mohraz7,
  12. Ali-Akbar Haghdoost10
  1. 1 Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, USA
  2. 2 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
  3. 3 Division of Social and Behavioural Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  4. 4 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
  5. 5 Open Medicine Institute, Mountain View, California
  6. 6 Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
  7. 7 Iranian Research Centre for HIV/AIDS, Tehran University of Medical Sciences, Tehran, Iran
  8. 8 Virology Research Center, National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
  9. 9 HIV/AIDS Control Office, Center for Communicable Disease, Ministry of Health, Tehran, Iran
  10. 10 Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
  1. Correspondence to Dr Ali Mirzazadeh, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA; ali.mirzazadeh{at}


Objective The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran.

Methods We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher’s exact test to compare the HIV prevalence between the two survey rounds.

Results HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus.

Conclusions HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.

  • HIV
  • sexually transmitted infections
  • drug injection
  • female sex workers
  • Iran

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  • Handling editor Jackie A Cassell

  • Twitter @MKaramouzian

  • Contributors Project design and proposal writing: AM, MS, MK, RK, HS and A-AH. Standard operating protocol development: AM, MS and RK. Supervision of the project: AM and MS. Paper drafting: AM, MS, MK, HA and AS. Statistical analysis: MS and RK. Interpretation of results, critical review of paper and approval of final version: all authors.

  • Funding Both FSW IBBS projects were supported by United Nations Development Programme, The Global Fund to Fight AIDS, Tuberculosis and Malaria. We also wish to acknowledge the support from the University of California, San Francisco's International Traineeships in AIDS Prevention Studies (ITAPS), US NIMH, R25 MH064712. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. MS was supported by an Ontario Trillium Scholarship (OTS).

  • Competing interests PAK is affiliated with Ministry of Health, CDC, Tehran, Iran.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was reviewed and approved by the Research Ethics Board at the Kerman University of Medical Sciences (ethic code for the 2010 survey: 90/122 and for the 2015 survey: K/93/209).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The Ministry of Health and Medical Education owns the data. Sex work is highly stigmatised and currently illegal in Iran. To protect the study population, all individuallevel data on their size and risk behaviours are being considered sensitive data. It is required that all researchers who wanted to work on this data submit their data request access to (the HIV/STI Surveillance Research Center).