This is an exploratory developmental study into crucial areas of drug use and HIV prevention in the Middle East and North Africa (MENA) region. We propose to examine two crucial but little understood transitions among young opioid users in Tehran, Iran: 1) from smoking opium to smoking (or sniffing) heroin; and 2) from smoking (or sniffing) heroin to injecting heroin. We also will identify and measure associated individual, familial, societal, and structural factors in association with these transitions. With a population of ~4 million opioid users (300,000 injectors), Iran is one of the MENA region countries most affected by the drug-use and HIV epidemics. Of the 19,000 people living with HIV/AIDS in Iran as of 2008, >19,000 are injection drug users (IDUs). More recently, use of kerack (a pure form of heroin) and heroin injection among young opioid users is growing rapidly along with the number new HIV-positive cases. Transition to heroin use and injection places opioid users at risk of severe social and physical harms, especially HIV and HCV infections from sharing paraphernalia. We will use qualitative and quantitative methods to assess associations between risk factors and crucial transitions in heroin use. Exploring this new territory can lead to novel prevention research in the MENA region. Our findings will inform interventions to interrupt the transmission of HIV and HCV among opioid users at risk of heroin use and injection. We first will conduct a qualitative study comprising in-depth interviews among opium users (OU); non- injecting heroin users (N-IHU), injecting heroin users (IHU) and health worker (HW) key informants to identify factors influencing the two transition periods. Results will help us generate hypotheses assessing the association between exposure to identified risk factors and transitions to heroin use, in addition to our two primary hypotheses. We also will assess barriers and facilitators to recruiting female drug users into HIV prevention research. We then will conduct a quantitative study to explore preliminary hypotheses listed below, and new ones generated by the qualitative study. Using modified respondent-driven sampling we will recruit and enroll 450 participants; 150 in each target group (i.e., OU, N-IHU, and IHU), to understand individual, familial, societal, and structural exposures. Participants will have structured face-to-face interviews and HIV and HCV serological testing, including pre- and post-test HIV counseling. Monetary incentives and referrals to HIV care and drug treatment services will be provided as needed. Our preliminary hypotheses are (1) the odds of transitioning from OU to N-IHU are decreased in association with a familial acceptance of opium use; and (2) the odds of transition drug use from N-IHU to IHU are increased in association with the availability of kerack. Our team of investigators has excellent collaborative associations between Iran and the United States and is uniquely well positioned to respond to NIH's program announcement: PAR-08-153: collaborative HIV/AIDS Studies in the Middle East and North Africa.

 We propose to conduct an exploratory study to qualitatively identify individual, familial, societal, and structural risk factors for two crucial drug-use transitions among young opioid users in Tehran, Iran, and quantitatively measure the association of those factors and transitions. The first transition is switching from smoking opium to smoking (or sniffing) heroin, and the second is switching from smoking (or sniffing) heroin to injecting it. This research will be conducted by a multi-disciplinary collaborative research group in the United States and Iran. Iran is facing simultaneous HIV and drug-use epidemics. Heroin use and injecting heroin have increased tremendously in Iran in recent years and have been acknowledged as a considerable public health problem; yet little is known about factors influencing these two transitions in Iran and other Middle East and North Africa (MENA) countries. Findings from the proposed study can inform HIV and drug-use prevention programs in Iran and the MENA region.