Unmet needs for opioid agonist therapy in Iranian prisons: a cross-sectional study

PURPOSE: This study aims to estimate the prevalence of inadequate opioid agonist therapy (OAT) uptake and explore associated factors among people who use nonmedical opioids inside prisons in Iran. DESIGN/METHODOLOGY/APPROACH: Using data from a national bio-behavioral surveillance survey, the authors conducted a multi-stage random sampling of 5,785 people in prison in 33 major prisons. Of these, 2994 (51.8%) participants with regular (i.e. at least weekly) nonmedical opioid use in the past month before entering prison or in the previous month inside the prison or prior OAT access before or during incarceration were eligible. The authors built multivariable logistic regression models to assess factors associated with limited OAT uptake inside prisons, reporting adjusted odds ratio (aOR) with 95% confidence intervals (CI). FINDINGS: Participants averaged 36.1 years (SD: 8.6); 97.2% were male. Overall, 32.5% (95% CI: 30.8%, 34.2%) of eligible participants for receiving OAT inside prison, had no OAT uptake. Of those previously on OAT, 40.8% discontinued treatment after incarceration. Factors associated with no OAT uptake included: age ≤ 30 (aOR = 1.74; 95% CI: 1.47, 2.07), recent prison drug use (aOR = 1.56; 95% CI: 1.29, 1.88), insufficient HIV knowledge (aOR = 1.67; 95% CI: 1.32, 2.11). Protective factors included lifetime injection drug use history (aOR = 0.43; 95% CI: 0.34, 0.55), HIV testing history (aOR = 0.78; 95% CI: 0.66, 0.92) and current depression/anxiety (aOR = 0.61; 95% CI: 0.52, 0.72). ORIGINALITY/VALUE: Despite OAT availability in Iranian prisons, one-third of eligible participants did not access treatment. Prior harm reduction engagement was consistently associated with uptake, supporting the need for systematic screening at prison entry, strengthened community-to-prison care continuity and integrated mental health services.