Until thirty years ago, Iran had a long history of Opium production. Iran has a major drug market, as well as a transit route of Opioids from the neighboring country, Afghanistan, to other regions, including Europe. Opioids, including Opium and Heroin, followed by Cannabis and stimulants are the main drugs used in the country (Daneshmandan, et al., 2011; Rahimi-Movaghar, et al., 2012). Iran is one of the countries with the highest proportion of Opioid users in the world (UNODC, 2011). In recent years, a sudden rise in stimulant use has occurred and has been associated with new mental health problems, such as stimulant psychosis (Hemmati, et al., 2011). In the last decade, injecting drug use has been a vast health problem. Currently, the estimations on the size of PWIDs range from 200,000 (Iran MoH, 2012) to 260,000 (Rahimi-Movaghar, Amin-Esmaeili, et al., 2011). Heroin is the most common drug of injection (Narenjiha, et al., 2009; Rahimi-Movaghar, et al., 2008). In Iran, treatment centers for drug users have been well developed. There are thousands of treatment centers for DUs all over the country, including outpatient, inpatient and residential centers providing a range of services, such as various types of detoxification, maintenance treatment, psychosocial interventions, self-help groups and mandatory treatment. However, quality of services and mechanisms of health sector supervision have remained the main challenges.

Iran has a low HIV prevalence in the general population. However, PWIDs are the main at risk group, followed by non-IDUs and FSWs. About 70% of all identified HIV positive cases are attributed to injecting drug use. Since 2005, numerous studies with thousands of samples have assessed HIV prevalence among PWIDs in various parts of the country. (Ghanbarzadeh, et al., 2006; Haghdoost, Osouli, et al., 2012; Haghdoost, Sadjadi, et al., 2012; Ilami, et al., 2012; Iran MoH, 2010a; Jahani, et al., 2009; Malekinejad, 2008; Mathers, et al., 2011; Mirahmadizadeh, et al., 2009; Rahimi-Movaghar, et al., 2010; Zamani, 2008; Zamani, Radfar, et al., 2010). Overall, the estimation is in a range of 10% to 20%. A systematic review on HIV prevalence among PWIDs in Iran (Rahimi-Movaghar, Amin-Esmaeili, et al., 2011) showed that the prevalence has increased significantly in recent years, from 8.7% before 2005 to 18.4% from 2005 to 2007. Another systematic review has shown that HIV prevalence among non-IDUs has increased to 5.4% in Tehran after 2005 to the year 2007 (Amin-Esmaeili, Rahimi-Movaghar, Haghdoost, et al., 2012). HIV prevalence has also been reported to be high in the primary sex partners of PWIDs (Haghdoost, Sadjadi, et al., 2012). In addition, since 2007, studies on HCV prevalence among PWIDs have also reported a range of 34% to 80%(Haghdoost, Sadjadi, et al., 2012; Kheirandish, et al., 2009; Rahimi-Movaghar, et al., 2010; Sarkari, et al., 2011; Zamani, Radfar, et al., 2010).

In Iran, massive developments have occurred in response to drug use. Drug treatment services were developed 15 years ago. Harm reduction interventions started in the last 10 years and expanded in a short period of time. Both the National Strategic Plan (2010-2014) and National Drug Control Program acknowledge harm reduction as a main HIV response strategy. In mid-2011, hundreds of sites were providing needles and syringes, as well as condoms. In a one year period, millions of syringes were distributed (Iran MoH, 2012). Thousands of Methadone clinics, mainly in the private sector, are providing MMT. Iran reports that in a one year period, about 500,000 drug users received MMT. Moreover, tens of thousands of prisoners are receiving MMT (Iran MoH, 2012). In 2010, integrated bio-behavioral survey (IBBS) in 10 provinces showed that more than 40% of PWIDs had received MMT during the previous year (Haghdoost, Osouli, et al., 2012). Buprenorphine as well as Tincture of Opium are provided in some of the treatment centers. VCT and ART are widely available all through the country, including in prisons (Iran MoH, 2012). A large number of NGOs, PLHIV, self-help groups and the private sector are engaged in providing harm reduction services.

The provision of the extensive number of services available has resulted in a fall with a slight slope in the number of the identified cases since 2005. Nevertheless, the greatest number of new cases of HIV infection remains among PWIDs and their sex partners (Iran MoH, 2012). The coverage and the number of syringes distributed are low. The emergence of the use of amphetamine-type stimulants has also brought a new challenge and needs for the development of new interventions to control and reduce their harms. Budget constraint is a major barrier for expanding services. The capacity of NGOs still needs to be expanded considerably. In the last decade, international contributions for expansion and improvement of current services have been considerable and discontinuance of the assistances will place all the developments at risk.

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