Individual and Network Interventions With Injection Drug Users in 5 Ukraine Cities

Objectives. We evaluated the effects of an individual intervention versus a network intervention on HIV-related injection and sexual risk behaviors among street-recruited opiate injection drug users in 5 Ukraine cities.Methods. Between 2004 and 2006, 722 opiate injection drug users were recruited to participate in interventions that were either individually based or based on a social network model in which peer educators intervened with their network members. Audio computer-assisted self-interview techniques were used to interview participants at baseline and follow-up.Results. Multiple logistic analyses controlling for baseline injection and sexual risks revealed that both peer educators and network members in the network intervention reduced injection-related risk behaviors significantly more than did those in the individually based intervention and that peer educators increased condom use significantly more than did those in the individual intervention. Individual intervention participants, however, showed significantly greater improvements than did network members with respect to reductions in sexual risk behaviors.Conclusions. Social network interventions may be more effective than individually based interventions in changing injection risk behaviors among both peer educators and network members. The effectiveness of network interventions in changing sexual risk behaviors is less clear, probably owing to network composition and inhibitions regarding discussing sexual risk behaviors.Ukraine has experienced a dramatic and rapid rise in HIV infections, fueled initially by injection drug users. Yet, as recently as 1995 the World Health Organization characterized Ukraine as a low-prevalence country.¹ Within 2 years, however, all 25 regional capitals had reported cases of HIV.² Annual diagnoses have more than doubled each year since 2001, reaching 16 094 in 2006.³In 2007 it was estimated that 1.63% of the adult population (440 000 residents of Ukraine) was living with HIV/AIDS, an increase from 1.46% in 2005.⁴ Of note is that 75% of new infections are among those in the most active reproductive age group (20–34 years), contributing to a decline in Ukraine''s population from 47 million in 2004 to less than 46 million in 2006.⁵ The World Bank and the International HIV/AIDS Alliance in Ukraine have estimated that up to 820 400 citizens will be infected by 2014 ⁶ and that more than 140 will die each day, the majority under age 35 years and half female.⁷Over the past decade, the epidemic has begun to spread through heterosexual transmission.⁸ In Donetsk and Odessa, 55% to 60% of new infections in 2005 were attributed to sexual transmission.⁹ As in many countries, the epidemic is unevenly distributed across Ukraine. The HIV prevalence in the southern and eastern oblasts, including Odessa, Donetsk, Simferopol, and Nikolayev, is approximately 3 times that of the remaining areas of Ukraine.³A number of factors were probably responsible for the HIV epidemic among injection drug users in Ukraine. Following the collapse of the Soviet Union in December 1991, there was widespread social and economic disintegration throughout Eastern Europe, but particularly in Ukraine.^10–12 The illicit economy, including drug trafficking and money laundering, was estimated to have tripled in the first 5 years after the Soviet withdrawal, accounting for more than 40% of the gross national product from 1994 to 1995.¹³ With the withdrawal of the Soviet Union, police controls became ineffective, drugs more readily available, and corruption rampant.^14–17 Locally produced opiates and stimulants proliferated,^11,18 as did the number of substance users.The number of registered drug users increased between 1990 and 1996 from 30 000 to 63 000, and new cases of drug dependence grew from an estimated 4544 in 1991 to 11 443 in 2001.¹⁹ After this sharp rise in the number of drug users, new cases of HIV began to appear as well, coinciding with cuts in most government services, including health care and education.^20,21 As late as 2005, Ukraine had no public health information service, no HIV prevention policy or substance abuse treatment services, no sex education in schools, and no dissemination strategy to address the HIV/AIDS epidemic.²²The injecting practices of Ukraine drug users also probably played a critical role in the epidemic.^23–25 In Ukraine, liquid poppy straw, liquid poppy straw mixed with Demerol (an opiate–sedative mix), and pseudoephedrine (a stimulant) are the most commonly injected drugs by street users.¹¹ Liquid poppy straw is typically purchased from dealers or in the form of preloaded syringes from open-air markets.²⁶ Drug dealers, most of whom are also users, extract the solution from a common container with the user''s needle or syringe or use their own needle or syringe and frontload or backload (i.e., remove the needle or plunger and squirt the solution into the front or back of the user''s syringe).²⁷ In a single day, numerous needles could be used to withdraw the drug solution. By the late 1990s, it had been reported that HIV serostatus was associated with the use of liquid opiates.²⁸Pseudoephedrine (known as boltushka, vint, and jeff) is typically obtained in over-the-counter cold medicines and also involves the use of shared drug-mixing containers.^16,29,30 It is a common practice for a group of Ukraine injection drug users to inject ephedrine-based solutions together, which involves the sharing of both the drug solution and needles or syringes.^16,31We compared 2 intervention projects we conducted with injection drug users in Ukraine. The first was an individually focused intervention implemented between 2004 and 2006 in Kiev, Odessa, and Donetsk. The second was a network intervention conducted in 2005 and 2006 in Nikolayev and Simferopol, 2 cities in the Crimea. HIV prevalence at baseline ranged from 20% (Donetsk) to 65% (Nikolayev). In each location, notable for their high concentrations of injection drug users, interventions were delivered by nongovernmental agencies (NGOs) selected as a result of their experience in working with injection drug users and their expressed interest in HIV prevention.The 2 interventions (both guided via instruction manuals) were implemented in their respective cities to reduce injection and sexual risk behaviors. The sampling plan was similar across all sites, as were the study methodology, participant eligibility criteria, and measures used, including audio computer-assisted self-interview (ACASI) techniques. Also, intervention training was conducted by the same staff, including the principal investigator, data manager, and intervention trainers.     

西昌市社区吸毒人群艾滋病行为干预

目的 目前国内艾滋病高危人群的行为干预均在探索阶段。该研究旨在探索社区吸毒人群预防艾滋病的行为干预模式。方法 干预方法主要是以同伴为基础的社区健康教育、建立医学咨询服务点、避孕套及注射器市场营销。结果 1998－1999年四川省性病艾滋病防治协会在凉山州西昌市3个村开展了社区吸毒人群艾滋病干预项目。社区人群及吸毒人员干预后艾滋病知识均有明显提高（P＜0．01）。吸毒人员均放弃了共用注射器行为,但避孕套的推广使用不理想。结论 以同伴为基础的社区健康教育和避孕套及注射器营销在预防控制艾滋病方面是有效的手段,但避孕套的推广工作有待进一步改进。     

吸毒人群HIV感染现患调查

目的　了解吸毒人群 HIV感染及相关行为。　方法　收集衡阳、长沙和娄底三地在戒毒所 112 0名吸毒者的尿液和行为资料 ,检测尿液中 HIV抗体。　结果　HIV阳性总检出率为 2 .8% ,经静脉注射毒品达到 88.0 % ,有共用注射史者达到 6 6 .3%。衡阳吸毒检出率最高 ,达到 7.3%。　结论　HIV在吸毒人群中流行形势应引起重视。     

Low-Frequency Heroin Injection among Out-of-Treatment, Street-Recruited Injection Drug Users

In this paper, we explore the understudied phenomenon of “low-frequency” heroin injection in a sample of street-recruited heroin injectors not in drug treatment. We conducted a cross-sectional study of 2,410 active injection drug users (IDUs) recruited in San Francisco, California from 2000 to 2005. We compare the sociodemographic characteristics and injection risk behaviors of low-frequency heroin injectors (low-FHI; one to 10 self-reported heroin injections in the past 30 days) to high-frequency heroin injectors (high-FHI; 30 or more self-reported heroin injections in the past 30 days). Fifteen percent of the sample met criteria for low-FHI. African American race, men who have sex with men (MSM) behavior, and injection and noninjection methamphetamine use were independently associated with low-FHI. Compared to high-FHI, low-FHI were less likely to report syringe sharing and nonfatal heroin overdose. A small but significant proportion of heroin injectors inject heroin 10 or less times per month. Additional research is needed to qualitatively examine low-frequency heroin injection and its relationship to drug use trajectories.     

The Relationship between Drug User Stigma and Depression among Inner-City Drug Users in Baltimore, MD

There is growing awareness of the role of stigma and discrimination in HIV prevention, testing, and medical care. Yet, few studies have examined the stigma associated with using illicit drugs. In the present study, we examined the relationship between social network characteristics, drug user stigma, and depression. Study participants were comprised of 340 individuals who reported cocaine, crack, and/or heroin use in the prior 6 months and were involved in an HIV prevention study. They were recruited through street outreach, referrals, and word of mouth in inner-city Baltimore, MD, USA. The stigma scale was comprised of eight items, such as “how much do you feel ashamed of using drugs?” Depression was assessed with the Center for Epidemiological Studies Depression Scale, using cutoffs of 16 and 20 or greater. In the bivariate analyses, gender, homelessness in the past 6 months, drug user stigma, larger size of drug network, and current use of heroin, cocaine, and crack were all significantly associated with high levels of depression, whereas in the multivariate analyses, only drug user stigma remained significantly associated with depression. The results of this study suggest that drug treatment providers and other professionals who provide services to drug users should consider developing trainings to address drug user stigma. These programs should focus on the attitudes and behaviors of health and service providers toward drug users, among drug users themselves, and among family members and others who provide social support to drug users.     

福建省近年来吸毒人群吸毒行为特征的调查分析

［目的］了解福建省吸毒人群的吸毒行为特征，为艾滋病防制措施的制定提供依据。［方法］1998-2000年，对福州市某强制戒毒所中的1637名戒毒人员进行问卷调查。［结果］吸毒者中注射吸毒的比例已从1998年的29.2%上升到2000年的61.0%，注射吸毒者中有21.1%曾与他人共用过注射针具。［结论］福建省注射吸毒者中存在HIV流行传播的危险性，迫切需要进行预防艾滋病的健康教育和行为干预活动。     

南宁市社区吸毒人员HBV、HCV、HIV和梅毒感染情况调查

[目的]了解南宁市社区注射吸毒人员乙型肝炎病毒（HBV）、丙型肝炎病毒（HCV）、艾滋病病毒（HIV）及梅毒（TP）感染情况,完善吸毒人群艾滋病防治策略。[方法]2006年和2007年对注射吸毒人员340名进行问卷调查,同时检测HBsAg、抗-HCV、抗-HIV和梅毒抗体。[结果]2006年调查189人,HBsAg阳性率为7.9%,抗-HCV为91.0%,抗-HIV为19.0%和TP为4.8%,36名HIV感染者均合并感染HCV;2007年调查151人,HBsAg阳性率为10.6%,抗-HCV为91.4%,抗-HIV为19.9%,TP为3.3%,30名HIV感染者均合并感染HCV。[结论]注射吸毒人员HCV、HIV、TP感染率较高,应继续加强宣教与干预措施。     

Neighborhood Perceptions and Health-Related Outcomes Among Latinos with Diabetes from a Rural Agricultural Community

Little is known about how neighborhood perceptions are related to diabetes outcomes among Latinos living in rural agricultural communities. Our objective was to examine the association between perceived neighborhood problems and diabetes outcomes. This is a cross-sectional survey study with medical record reviews of a random sample of 250 adult Latinos with type 2 diabetes. The predictor was a rating of patient ratings of neighborhood problems (crime, trash and litter, lighting at night, and access to exercise facilities, transportation, and supermarkets). The primary outcomes were the control of three intermediate outcomes [LDL-cholesterol (LDL-c) < 100 mg/dl, AlC < 9.0 %, and blood pressure (BP) < 140/80 mmHg], and body mass index (BMI) < 30 kg/m². Secondary outcomes were participation in self-care activities (physical activity, healthy eating, medication adherence, foot checks, and glucose checks). We used regression analysis and adjusted for age, gender, education, income, years with diabetes, insulin use, depressive symptoms, and co-morbidities. Forty-eight percent of patients perceived at least one neighborhood problem and out of the six problem areas, crime was most commonly perceived as a problem. Perception of neighborhood problems was independently associated with not having a BP < 140/80 [Adjusted odds ratio (AOR) = 0.45; 95 % CI 0.22, 0.92], and BMI < 30 (AOR = 0.43; 95 % CI 0.24, 0.77), after controlling for covariates. Receipt of recommended processes of care was not associated with perception of neighborhood. Perception of neighborhood problems among low-income rural Latinos with diabetes was independently associated with a higher BMI and BP.     

南宁市社区注射吸毒者HIV感染及性行为分析

目的了解注射吸毒人群艾滋病病毒（HIV）感染状况及性行为特征,为在注射吸毒人群中开展包括性行为干预在内的综合干预措施提供依据。方法采用“滚雪球”式方法在南宁市社区中寻找吸毒者,面对面无关联匿名问卷调查和血标本的采集。结果共调查200名吸毒者,HIV阳性57人,阳性率28．5％;性伴对象包括配偶、临时性伴（非商业性伴）、商业性伴及同性等,最近1次性行为安全套使用率仅38．5％;HIV阳性感染者的安全套使用率更低,仅33．3％。结论静脉注射吸毒人群HIV感染率高,性伴种类多,安全套使用率低。     

Experiencing Violence as a Predictor of Drug Use Relapse among Former Drug Users in Baltimore,Maryland

The purpose of this study was to examine experiencing violence as a predictor of subsequent drug relapse among a sample of former crack, cocaine, and heroin users in Baltimore, MD, USA. The sample consists of 228 former drug users in Baltimore who were recruited through street outreach. Mixed-effects models were used to examine experiencing violence as a predictor of drug relapse at follow-up after adjusting for clustering of responses among participants living in the same census block. Using longitudinal data, we found that experiencing violence in the past year predicted drug relapse at 2-year follow-up among former drug users. Results indicate experiencing violence is a determinant of drug use relapse and highlight the importance of addressing the fundamental issues of violence experienced in inner-city communities. Addressing the extent of recent violence among drug treatment participants, providing coping skills, and reducing community violence are strategies that may address the link between violence and drug relapse.     

四川省西昌市吸毒人群HCV感染及其危险因素研究

目的　了解四川省西昌市吸毒人群吸毒方式及性行为特征与HCV感染的关系。方法　于2 0 0 4 - 0 5 / 0 7,调查四川省西昌市吸毒人群的社会人口学、吸毒方式及性行为特征与HCV感染的关系。采集血样进行HCV和梅毒抗体检测。结果　在调查的吸毒人群6 19人中,HCV感染率为5 5 .9% (346 / 6 19) ,其中静脉吸毒者的HCV感染率为71 9% (2 35 / 32 7)。在单因素和多因素分析中,曾经静脉注射吸毒(OR =2 .6 3;95 %CI为1 .79～3 .89,P <0 .0 0 1)和曾经共用针头或注射器具吸毒(OR =2 .98,95 %CI为1 .78～5 . 0 0 ,P <0 . 0 0 1)与HCV感染有统计学意义。结论　吸毒人群HCV感染与其高危吸毒行为有关。     

Sexual Behaviors among Club Drug Users: Prevalence and Reliability

HIV prevention efforts require a focus on reducing high risk sexual behavior. Because these are self-reported, assessments that reduce memory bias and improve elicitation of data are needed. As part of a multi-site psychometric study of club drug use, abuse, and dependence, data were collected with a test-retest design that measured the reliability of the Washington University Risk Behavior Assessment for Club Drugs (WU-RBA-CD). Reliability was assessed separately by sex via kappa coefficients and intraclass correlation coefficients (ICC); z tests compared coefficients by sex. A total of 603 participants were interviewed by independent assessors with 5 days in between interviews. Reliability for all 51 items of the sexual activity section of the WU-RBA-CD ranged from .23 to 1.00; 71% (n = 36) of items resulted in moderate to high reliability (.55–1.00). Number of lifetime sex partners was consistently reported for same-sex partners for both men and women and opposite-sex partners. Items with high reliability included reporting ever being under the influence of ecstasy (.87) or GHB (.87) while having sex. Items with lower reliability included those that queried the determinants of condom use (.45–.82) and about behaviors and attitudes experienced while using drugs (.23–.87). Very few sex differences were revealed in the reliability of reported sexual activities. Overall, the WU-RBA-CD performed with fairly high reliability rates. Assessing situations of when, how, and why individuals use condoms may offer the clearest evaluation of determinants of sexual behaviors, yet those items are not as reliable.     

兰州市吸毒者艾滋病知识,态度和行为调查

为了解兰州市吸毒者的性行为学特征及他们艾滋病相关行为、知识和态度情况,对在兰州市某戒毒所内戒毒的４７７ 名吸毒者进行匿名问卷调查。发现９０－９ ％ 的吸毒者曾有过性行为,４２－０ ％ 的已婚者曾有过婚外性行为,２－９ ％ 的吸毒者曾有过同性性行为。８７－１ ％ 的吸毒者口吸毒品,２－２ ％ 静脉注射,１０－８ ％ 口吸混合静脉注射;２９－５ ％ 的吸毒者与固定的人在一起吸毒,２７－３ ％ 的吸毒者与不固定的人一起吸毒;２１－０ ％ 的静脉吸毒者曾借过或用过他人的注射器吸毒。只有６－３ ％ 的吸毒者认为自已有可能感染艾滋病。只有４１－７ ％ 的吸毒者认为自己出戒毒所后不会再吸毒了。调查结果提示,兰州市吸毒者艾滋病知识、行为和态度情况不容乐观,应该引起有关部门的重视,及时做好艾滋病的预防工作     

静脉吸毒人员艾滋病知识知晓率影响因素的非条件Logistic回归分析

[目的]探讨静脉吸毒人员艾滋病知识知晓率的影响因素,以便制定该人群预防艾滋病病毒(HIV)传播的措施.[方法]2002～2003年,在广东省选取2个社区,1个为干预区,采用针具交换干预措施;另1个为对照区,不采取任何干预措施,进行10个月的干预,于干预前后采用方便抽样,利用结构问卷对抽取的注射吸毒者分别进行面对面的断面调查,进行艾滋病防治知识知晓率及其影响因素的非条件Logistic回归分析.[结果]干预前后分别调查静脉吸毒人员428、429名,干预组艾滋病知识知晓率分别为29.36%和58.67%(P＜0.01).多因素非条件Logistic回归分析结果,进入回归模型的因素按照贡献率依次为干预地区(OR=0.337),看过宣传资料(OR=2.815)、初中文化(OR=2.207)、高中及以上文化(OR=2.799)、40岁以上年龄(OR=0.510).[结论]静脉吸毒人员初中以上文化程度、接受过针具交换项目宣传者艾滋病知识知晓率高,40岁以上及干预地区的吸毒人员艾滋病知识知晓率较低.     

Prevalence and Characteristics of Femoral Injection among Seattle-Area Injection Drug Users

Injection drug use (IDU) into central veins, most common among long-term IDUs with no other options, can lead to severe infectious, vascular, and traumatic medical consequences. To follow-up on anecdotal reports of femoral vein injection and related medical problems in Seattle, we analyzed data from the annual survey of a community-based syringe exchange program. A total of 276 (81%) of 343 program attendees completed the survey in August 2010. Among 248 IDUs, 66% were male, 78% white, and 86% primarily injected opiates. One hundred respondents (40%) had injected into the femoral vein, 55% of whom were actively doing so, and 58% of whom reported medical complications that they attributed to the practice. Most (66%) used the femoral vein due to difficulty accessing other veins, although 61% reported other veins they could access and 67% reporting using other sites since initiating femoral injection. While injecting into muscle was more frequent among older IDUs with longer injection careers, the prevalence of femoral injection was highest among respondents in their late twenties with 2.5–6 years of injecting drugs. Multivariate analysis demonstrated an increased risk of initiating femoral injection each calendar year after 2007. Injecting into the femoral vein was also associated with white versus other race (odds ratio [OR] 2.7, 95% CI 1.3–5.4) and injection of primarily opiates versus other drugs (OR 6.3, 95% CI 1.2–32.9) and not associated with age, length of IDU career, or a history of injecting into muscle. These findings suggest a secular trend of increasing femoral injection among Seattle-area IDUs with a high rate of related medical problems. Interventions, such as education regarding the hazards of central venous injection and guidance on safe injection into peripheral veins, are needed to minimize the health consequences of femoral injection.     

Unsafe Injection and Sexual Risk Behavior among Injecting Drug Users in Georgia

Injection drug users (IDUs) are at risk for acquiring human immunodeficiency virus (HIV) through parenteral and sexual transmission. In this paper, we describe the prevalence and correlates of unsafe drug injecting and sexual behaviors among IDUs recruited across five cities in Georgia in 2009. IDUs were administered a questionnaire collecting information on demographics, drug use, sexual behaviors, and HIV testing behaviors. Correlates of risky injecting and sexual behaviors were determined using logistic regression. Of 1,127 IDUs, the majority (98.7%) were men, and the median duration of injecting drugs was 7 years. Unsafe injecting behavior at last injection was reported by 51.9% of IDUs, while 16.8% reported both unsafe injecting behavior and not using condoms with last occasional and/or commercial partner. In the multivariate analysis, independent correlates of unsafe injecting behavior at last injection were types of drugs injected [p = 0.0096; (for ephedrine, adjusted odds ratio (aOR) = 7.38; 95% CI, 1.50–36.26)] and not using condoms at last commercial sex (aOR = 2.29, 1.22–4.32). The following variables were significantly associated with unsafe injecting behavior at last injection and not using condoms at last sex with commercial and/or occasional partners in the multivariate analysis: marital status [p = 0.0002; (for divorced, widowed, and separated aOR = 2.62, 1.62–4.25; for single aOR = 1.61, 1.08–2.39)], being a member of a regular injecting group (aOR = 0.62, 0.44–0.88), types of drugs injected in the past month [p = 0.0024; (for buprenorphine aOR = 0.34, 0.18–0.63)], city of residence (p = 0.0083), and not receiving information on HIV (aOR = 1.82, 1.07–3.09). Though only ephedrine was injected by a smaller number of IDUs (9.1%), the vast majority of these (81.4%) reported unsafe injecting practices at last injection. High prevalence of unsafe injecting behaviors and diverse and at-risk sexual partnerships highlight the need to implement complex and targeted HIV interventions among IDUs in Georgia.     

云南省吸毒人群中HIV及HCV感染流行状况的研究

笔者对云南省吸毒人群５０７人的ＨＩＶ及ＨＣＶ感染状况进行了研究，指出静脉吸毒是ＨＩＶ及ＨＣＶ的主要传播途径。静脉吸毒者中ＨＩＶ及ＨＣＶ有极高的感染率，分别为６６．５％及９４．９％，明显高于非静脉吸毒组。血清ＨＩＶ抗体阳性组中ＨＣＶ抗体阳性率为９７．５％，ＨＣＶ抗体阳性组中ＨＩＶ抗体阳性率为５７％，证明该人群中ＨＩＶ及ＨＣＶ的抗体阳性率有着密切的相关性。上述结果说明改变吸毒行为对预防此两种病毒的传播具有重要意义。     

某口岸地区141例吸毒者HIV抗体和梅毒监测报告

为了解某口岸地区吸毒者艾滋病和梅毒的感染、传播和流行状况,采用血清学检测方法,对141例吸毒者进行HIV抗体和梅毒检测,结果,141例吸毒者HIV抗体检测为阴性,梅毒检出阳性16例(11.4％,16/141),其中女性检查35人,梅毒阳性13例(37.1％,13/35),男性检查106人,梅毒检出3例(2.8％,3/106),其差异有显著性意义(x~2=30.79,P<0.01),13例女性梅毒阳性者中未婚女青年占11例(84.6％),分析了梅毒检出与年龄、文化程度、职业、吸毒时间、吸毒方式以及婚外性生活史等之间的关系。     

Patterns of Drug Use and HIV-Related Risk Behaviors among Incarcerated People in a Prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.