Abstract

Background

Self-perception of risk for HIV acquisition is crucial for promoting preventive behaviors among people in prisons. This cross-sectional study examined self-perception of HIV risk and associated factors among people in prisons in Iran.

Methods

In 2017, we conducted a cross-sectional study in Iran using multistage random sampling approach to recruit participants from 33 prisons in Iran. Eligible participants were adult people in prisons for at least one week. Data were collected via gender-matched face-to-face interviews using a standard HIV risk assessment questionnaire. Multivariable logistic regression models were built to identify correlates of high self-perceived HIV risk. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were reported.

Results

Among 5,422 HIV-negative participants (94.0% men; mean age 35.7 years), 6.8% (95% CI: 6.1鈥�7.5%) reported high self-perception of risk for HIV acquisition. Among these, 3.6%, 5.2%, and 8.4% reported zero, one, and more than one risky behavior, respectively. Higher odds of high self-perceived risk were associated with being <鈥�30 years old (AOR: 1.50; 95% CI: 1.13鈥�2.00), having never got married (AOR: 1.58; 95% CI: 1.12鈥�2.23), engaging in condomless sex (AOR: 1.56; 95% CI: 1.13鈥�2.16), same-sex practices among men (AOR: 1.90; 95% CI: 1.43鈥�2.51), and recent sexually transmitted infection symptoms (AOR: 2.18; 95% CI: 1.19鈥�3.57).

Conclusions

A notable gap exists between actual HIV risk behaviors and self-perceived risk among people in prisons in Iran. Targeted prison-based educational interventions are essential to improve risk awareness and promote HIV prevention behaviors among this marginalized population.

Background

HIV remains a significant global health challenge, with approximately 39.9听million people affected worldwide by the end of 2023 [1]. In Iran, the HIV epidemic has shown an increasing trend over the last two decades, with an estimated ~43,000 people living with HIV in 2023 [2]. In 2023, Iran ranked among the top ten countries globally for prison population size, with a significant proportion of people in prisons for drug-related offenses and an estimated pooled HIV prevalence of 2.7% among this population [3, 4]. Prisons often include individuals engaged in risky behaviors which increases the likelihood of HIV transmission [5]. The prison environment could also facilitate the transmission of infectious diseases to the broader community after individuals are released [6]. Therefore, the prison system in Iran could serve as a significant contributor to the country鈥檚 HIV epidemic, warranting focused attention on this population.

Global estimates suggest that people who inject drugs with a history of being in prison have an 81% higher risk of HIV acquisition compared to those without such a history [7]. Self-perception of HIV risk refers to an individual鈥檚 assessment of their likelihood of contracting HIV, an awareness that is crucial for motivating preventive behaviors and encouraging HIV testing. In the prison context, aligning self-perception with actual risk is important for mitigating high-risk behaviors and improving HIV prevention efforts. However, factors such as lack of knowledge, denial, or social stigma may lead to risk misperception, potentially resulting in continued high-risk behaviors and reluctance to seek HIV testing [8, 9]. The likelihood of contracting HIV is higher among people in prisons compared to the general public, influenced by various factors specific to prison environments. A mismatch between perceived and actual risk in this setting could lead to missed opportunities for HIV diagnosis, as individuals may decline testing based on an underestimation of their risk [10, 11]. For example, studies have shown that people in prisons with higher perceived HIV risk are approximately three times more likely to seek HIV testing and counseling [12, 13]. While the importance of risk perception in shaping preventive behaviors is established, there is a notable knowledge gap regarding HIV risk self-perception among people in prisons in Iran. To address this, we analyzed data from Iran鈥檚 last bio-behavioral surveillance study conducted in 2017, investigating self-perceived HIV risk and its associated factors among people in Iranian prisons. Findings could inform culturally relevant interventions tailored to this vulnerable population.

Methods

Study design and data collection

In this cross-sectional survey in 2017, we recruited 5,785 people in prisons from 33 prisons across the country, using a multistage cluster random sampling approach. In the first stage, prisons were selected as clusters based on geographic regions to ensure nationwide representation. In the second stage, participants were randomly selected within each cluster (i.e., prison). Consenting participants aged 18 years or above who had been in prisons for at least one week were eligible to participate in the survey. Gender-matched interviewers collected data via face-to-face interviews in a private room inside prisons using a standard HIV risk assessment questionnaire. This questionnaire was adapted for cultural relevance in the Iranian context and validated through expert review and pilot tested before the survey administration. The questionnaire included sections on socio-demographic data, history of being in prison, non-injection and injection drug use history, sexual practices, knowledge about HIV and other sexually transmitted infections (STI), history of HIV testing, healthcare-seeking behaviors, drug use treatment, and self-perception of risk for HIV acquisition. Further details about the methodologies of the study design, sampling, and procedures have been previously described [14]. Details of the questionnaire used in the study have been published elsewhere [15].

Dependent variable

Self-perception of risk for HIV acquisition was the primary outcome of interest. Participants were asked: 鈥淗ow likely are you to contract HIV, based on your HIV knowledge and lifestyle?鈥� with the following answers: 鈥渘o chance,鈥� 鈥渓ow chance,鈥� 鈥渕oderate chance,鈥� and 鈥渉igh chance.鈥� We categorized responses into two groups: 鈥渓ow鈥� self-perception (participants reporting 鈥渘o chance鈥� or 鈥渓ow chance鈥�) and 鈥渉igh鈥� self-perception (those reporting 鈥渕oderate鈥� or 鈥渉igh鈥� chances). People with a sero-positive HIV test result were excluded from the analysis.

Covariates

Independent variables included in the analysis were: Age (<鈥�30 vs. 鈮�30 years), gender (men vs. women), educational level (illiterate or primary school vs. high school or above), marital status (never married vs. divorced or widowed or temporary marriage vs. currently married), history of the previous imprisonment (yes vs. no), age at first sexual intercourse (<鈥�18 vs. 鈮�18 years), history of sex with a non-primary partner in past 12 months (yes vs. no), condom use in the last sex (yes vs. no), condom accessibility inside prison (yes vs. no), STI symptoms within the last 12 months (yes vs. no), knowledge of STI symptoms (sufficient vs. insufficient) [15], lifetime history of same-sex practice among men (yes vs. no), HIV knowledge (sufficient vs. insufficient) [14], lifetime history of drug use (yes vs. no), lifetime history of drug injection (yes vs. no), history of shared injection in the last injection (yes vs. no), lifetime history of tattooing (yes vs. no), lifetime history of receiving opioid agonist therapy (yes vs. no). The categorization of age into two groups (<鈥�30 vs. 鈮�30 years) was based on its significance as a threshold for distinguishing younger individuals from middle-aged populations and aligns with previous research on HIV risk factors [15, 16].

Statistical analysis

We used descriptive statistics to compare the characteristics of participants stratified by self-perceived risk of HIV. Variables with a p-value鈥�<鈥�0.2 in the bivariable analysis were entered into a multivariable regression model [17]. The final model was fitted using a backward elimination approach [17]. Crude odds ratios (COR) and adjusted odds ratios (AOR), along with 95% confidence intervals (CIs), were reported. P-values鈥�<鈥�0.05 were considered statistically significant.

To further analyze self-perceived HIV risk, we examined its prevalence in relation to high-risk behaviors. We focused on three relevant key risk factors: use of unsterile equipment in their most recent tattoo, history of shared injection in the last injection event, and engagement in unsafe sex during the most recent sexual encounter. Based on these behaviors, we identified three categories of participants: those with no high-risk behaviors, those with one high-risk behavior, and those with more than one high-risk behavior. All analyses were conducted in Stata version 17 (Stata Corp LP; College Station, Texas, USA).

Results

Participant characteristics and self-perception of risk for HIV acquisition

Of 5,785 people in prisons screened, 5,422 (93.7%) were included in the analysis after excluding those who were living with HIV, or did not respond to the self-perception question. Most participants self-identified as men (94.0%), with a mean (standard deviation [SD]) age of 35.7 (9.3) years. Over half were married (50.4%), and 68.0% had low education levels. High-risk behaviors included condomless sex during their last sexual encounter (74.4%) and lifetime drug use (76.5%). However, only 11.9% reported a lifetime history of drug injection (Table听1).

Table 1 Baseline characteristics of participants and self-perception of risk for HIV acquisition among people in prisons in Iran in 2017

Overall, 6.8% of participants had a high self-perception of risk for HIV acquisition. High self-perception of risk for HIV acquisition was more common among those under 30 years (COR: 1.50; 1.20鈥�1.88), never married (COR: 2.16; 1.70鈥�2.75), or divorced/widowed (COR: 1.85; 1.38鈥�2.48). Other factors associated with higher risk perception included age鈥�<鈥�18 years at first sexual intercourse (COR: 1.54; 1.23鈥�1.93), history of sex with a non-primary partner in the last year (COR: 1.96; 1.53鈥�2.52), condomless sex in the last sex (COR: 1.47; 1.12鈥�1.94), and STI-related symptoms in the last 12 months (COR: 2.35; 1.49鈥�3.70). Among behavioral factors, drug injection (COR: 3.70; 2.91鈥�4.71) showed the strongest crude association with high self-perceived risk. Other correlates included lifetime histories of same-sex practices in men (COR: 3.19; 2.50鈥�4.08), drug use (COR: COR: 1.93; 1.43鈥�2.61), tattooing (COR: 1.54; 1.24鈥�1.90), and receiving opioid agonist therapy (COR: 1.88; 1.44鈥�2.45) (Table听1).

Factors associated with self-perception of risk for HIV acquisition

In the multivariable analysis, being under 30 years (AOR: 1.50; 1.13-2.00), never married (AOR: 1.58; 1.12鈥�2.23), and divorced/widowed (AOR: 1.79; 1.31鈥�2.44) were associated with higher odds of self-perception of risk for HIV acquisition. Among behavioral factors, lifetime same-sex practices (AOR: 1.90; 1.43鈥�2.51) had the strongest association with self-perception of risk for HIV acquisition. Other factors, such as condomless sex in the last sex (AOR: 1.56; 1.13鈥�2.16) and STI symptoms in the last 12 months (AOR: 2.18; 1.19鈥�3.57), a lifetime history of being in prison (AOR: 1.52; 1.12鈥�2.05), and receiving opioid agonist therapy (AOR: 1.65; 1.55鈥�2.71) were also significantly correlated with higher odds of HIV self-perceived risk (Table听2).

Table 2 Multivariable logistic regression analysis to identify correlates of self-perceived risk for HIV among people in prisons in Iran, 2017

HIV self-perceived risk by risky behavior status

Among participants, 19.3% reported no risky behaviors, 51.0% reported one, and 29.7% reported more than one risky behavior. The prevalence of high self-perception of risk for HIV was 3.6% among those with no risky behaviors, 5.2% with one, and 8.4% with more than one risky behavior (Fig.听1).

Fig. 1

Status of self-perception of risk for HIV acquisition among people in prison in 2017 in Iran, by a number of risky behaviors

Discussion

In our national bio-behavioral study across 33 prisons, we found that approximately about 7% of people in prisons in Iran had a high self-perception of risk for HIV acquisition. A number of demographic factors (e.g., younger ages and not being married), behavioral factors (e.g., history of being in prison and receiving opioid agonist therapy), and sexual factors (e.g., condomless sex in the last sex, lifetime history of STI symptoms, and same-sex relationships in men) were significantly associated with higher odds of HIV self-perceived risk. Moreover, about 4 in 5 participants reported at least one HIV-related risky behavior, while a minority had a high self-perceived risk for contracting HIV.

Our study revealed a low prevalence of high self-perceived HIV risk among people in prisons in Iran, with only one in 15 reporting a high-risk perception. While comparisons with regional studies are limited due to scarce evidence from the Eastern Mediterranean region, our findings are comparable with a study in Scotland, where 12.4% and 7.3% of people in prisons had a medium and high self-perception of risk for HIV acquisition, respectively [18]. However, these estimates contrast sharply with studies from the USA, where an estimated 78.2% of 855 people in prison had a significantly higher self-perceived HIV risk [19]. Several factors, including cultural, social, and healthcare system differences between Iran and the USA, likely influence this disparity. In liberal high-income settings, HIV awareness is promoted through public health campaigns, and individuals may have more access to HIV-related information and prevention resources. In Iran, however, the relatively lower level of HIV awareness, socio-cultural stigma around HIV testing, and limited funding and staffing allocated to HIV education in prisons may contribute to a lower perceived risk of acquisition among people in prisons. To address this low-risk awareness in Iranian prisons, implementing targeted interventions, including comprehensive HIV education, increased access to sterile tattooing and injection equipment, routine HIV testing, and peer education programs are warranted.

Our analysis of demographic variables showed that people under 30 years of age and those who were unmarried had significantly higher odds of perceiving themselves at high risk for HIV acquisition. These findings align with a cross-sectional study of 826 HIV-negative men in prisons in the USA, which demonstrated that younger age was associated with higher self-perceived HIV risk [19]. The elevated risk perception among younger and unmarried individuals may be attributed to their higher engagement in risky behaviors. For instance, a study on Iranian people in prisons found that those aged 18鈥�29 and single individuals had significantly higher odds of non-injection drug use in the month prior to being in prison [20]. Furthermore, the prevalence of lifetime tattooing among people in prisons in Iran during 2015鈥�2016 was higher in those under 35 compared to those 35 and older [21]. These patterns of risk behavior among younger and unmarried people in prisons likely contribute to their increased self-perceived HIV risk, underscoring the need for targeted interventions for these demographic groups within the prison population.

We also found that several behavioral factors were significantly associated with high self-perceived HIV risk among people in prisons. These included prior imprisonment, lifetime drug use or injection, tattooing, same-sex sexual practices among men, condomless sex, and STI symptoms. Interestingly, while previous studies in the USA have found that pre-incarceration HIV testing and drug use were associated with lower self-perception of the risk of HIV amongpeople in prisons [19], our study showed no significant association with HIV knowledge. However, we found that lifetime drug use significantly increased the odds of high self-perceived risk. The link between risky behaviors and self-perceived risk is further supported by evidence that individuals with a history of tattooing in prison have a higher prevalence of drug use, injection, and non-primary sexual partners [21]. Moreover, same-sex intercourse among men, especially without consistent condom use, is associated with higher HIV transmission rates, likely contributing to increased risk perception. Notably, we observed similarities between factors influencing self-perceived HIV risk and those affecting HIV testing uptake, suggesting potential synergies in interventions targeting both outcomes. Our finding that STI-related symptoms were associated with 2.18 times higher odds of high self-perceived HIV risk aligns with a previous study among Iranian people in prisons, which also found a significant association between STI symptoms and self-perceived HIV risk [15]. These findings collectively underscore the complex interplay of behavioral factors influencing HIV risk perception in prison populations and highlight potential targets for intervention.

We also observed a significant gap between actual HIV risk behaviors and self-perceived risk among people in prisons in Iran, with ~鈥�80% reporting at least one HIV-related risky behavior. We also noted a positive association between the number of risky behaviors and self-perceived HIV risk, with 8.4% of individuals engaging in more than one risky behavior reporting high-risk perception. While this may suggest some awareness of the cumulative impact of multiple risk factors, the overall low percentage is concerning, even among those with multiple risk behaviors. In contrast, a study of 501 HIV-negative men with harmful alcohol use reported a 30.9% prevalence of high self-perceived HIV risk [22], potentially due to increased awareness from targeted interventions or increased media exposure in that specific population. The disparity between our findings and those from other high-risk populations may be attributed to several factors. Cultural norms and societal stigma surrounding HIV in the conservative context of Iran may lead individuals, particularly in high-risk groups, to underestimate their vulnerability due to fear of discrimination [24,25,25]. Additionally, substance use can impair judgment, leading to high-risk behaviors without full acknowledgment of consequences [26], and may reduce engagement with educational or preventive interventions. These findings underscore the need for interventions that address cultural, societal, and individual influences on HIV risk perception to enhance prevention strategies. In the Iranian context, leveraging mass media as the primary source of HIV knowledge [27] could be particularly effective in improving risk awareness and prevention efforts among people in prisons.

We acknowledge the limitations of our study. First, we did not assess the sexual orientation of participants, as this could be a sensitive topic inside Iranian prisons. Second, other data, such as information on condom use, STI symptoms, having same-sex practice among men, and age at first sexual intercourse, were self-reported and thus subject to potential recall, reporting, and social desirability biases. These biases could have led to underreporting of high-risk behaviors. Moreover, social desirability bias may have influenced participants to report lower self-perception of HIV risk, particularly in a stigmatized prison environment. Variations in prison types, regional differences, and the diversity in incarceration conditions across Iran may affect the external validity of our results. Lastly, this was a cross-sectional study, making it challenging to determine the direction of the association and draw causal conclusions about the observed associations. Despite these limitations, our study has several strengths. It is one of the largest nationwide surveys conducted in Iranian prisons, offering robust data on self-perception of risk for HIV acquisition and its correlates in this understudied population. Using a multistage random sampling approach and face-to-face interviews enhanced the reliability and generalizability of the findings. Future research should explore longitudinal designs to better understand the causal pathways of risk perception and behavior. In addition, integrating methods to minimize biases, such as inclusion of peer interviewers, could improve data accuracy in future studies. Furthermore, using qualitative methods could provide deeper insights into the contextual and cultural factors influencing self-perception of risk for HIV acquisition among people in prisons.

Conclusions

Our study reveals a complex interplay of sociocultural, demographic, clinical, and sexual factors influencing HIV risk perception among people in prisons in Iran. Alarmingly, only less than 7% of people in prisons had a high self-perception of risk for HIV acquisition. Implementing targeted educational programs aimed at raising HIV awareness, including tailored interventions addressing the specific behaviors identified in this study, such as condomless sex, drug use, and STI symptoms are warranted. Regular and accessible health screenings should be prioritized, along with increased access to preventive measures, such as condoms and harm reduction strategies. Additionally, peer-led initiatives could be key in promoting risk awareness and safer behaviors. Policymakers could also consider integrating these interventions into broader prison health policies to improve overall HIV prevention efforts. By bridging the gap between actual and perceived risk, people in prisons could be empowered to make informed decisions about their health and contribute to the broader goal of reducing HIV transmission in high-risk settings in Iran. Future research should focus on developing culturally tailored qualitative studies to gain a deeper understanding of the sociocultural and psychological factors shaping HIV risk perception among people in prisons.