HIV/AIDS has become a major obstacle to the development of human societies and a major concern for people around the world. HIV in all countries of the world, rich and poor, is not only a health problem but also a socio-cultural and economic problem for human societies.
In this study, 85.42% of all people living with HIV were men. According to the World Health Organization in 2018, of the 37.9 million people living with HIV, 18.8 million were women and 17.4 million were men (1). In a study of nine US patients, nearly a quarter of women were ill (16). The most important reason for the difference in the sex ratio of patients with HIV/AIDS in different countries is the way the disease is transmitted. In Iran, due to the fact that injecting drug use is the most common way of transmission, more than 80% of diseases are observed in men, but in recent years, with the change in the cause of infection and the increase in sexually transmitted diseases, the prevalence of HIV/AIDS in women is increasing quickly (9).
In this study, there was a significant relationship between gender and treatment status. Thus, receiving treatment and adhering to treatment was higher in women than men. The results of a study in the United States showed that women were less likely to receive treatment (17). In our study, the cessation of ARV in both sexes was consistent with the findings of similar studies (18-20). These gender differences are largely explained by social and behavioral factors. In addition to the regularity and high commitment of women versus men in adherence to treatment, antiretroviral treatment can be provided to prevent the transmission of HIV from mother to infant, which has been included in the national guidelines for care and treatment since 2016 (21).
There is a statistically significant relationship between education and treatment. As the rate of education increased, the treatment increased and the non-adherence to medication decreased, which was consistent with the results of the study (22). One of the reasons for non-adherence in illiterate people is not using daily calendars, reminder notes, diet instructions, and devices such as timers and alarms, which require minimal level of literacy.
In the study of marital status, there was a statistically significant relationship between marital status and adherence to treatment, so that adherence was higher in married people, which matched with the results of a similar study (23). Couples support may have increased the use of treatment after disclosure of the disease. This form of support may not exist in single people.
In this study, 59.05% had a history of imprisonment, of which 66.15% did not adhere to treatment. After controlling the confounding variables, the chance of cessation of treatment in patients with a history of the prison of 2.21 (1.35-3.61) was equal to that of patients without a history of the prison in compliance with treatment. In prisons, people are kept in a closed environment for a long time, and with conditions such as overcrowding, poor nutrition, lack of medical care and sexual contact with homosexuals, violence, rape, and tattooing with contaminated equipment, these people are prone to infection. They become infected with a variety of diseases and, after being released, they are distributed in the community and can spread these diseases in the community. To reduce the risk of transmitting the disease to prisoners, it has been suggested that measures such as informing and raising prisoners' levels of information, screening, providing sterile condoms and syringes, treating patients, and vaccinating individuals can reduce the risk of transmission. In two prisons in Germany, in addition to training and raising public awareness, sterile injections were also required, which reduced both the percentage of injecting drug use and the use of the shared needle and ultimately the chances of HIV, Hepatitis B and C transmission (24). Therefore, programs that ensure the continued care of HIV-positive patients after release, as well as awareness of the negative consequences of the cessation of ARV, require further development and evaluation.
After controlling the confounding variables of the drug, the chance of cessation of treatment in patients with a history of drug use 4.15 (2.37-7.25) was higher than without a history of drug abuse patients. The results of similar studies showed that drug use was associated with less adherence to antiviral treatment and accelerated the progression of HIV (25-27). For people who are taking drugs, special considerations such as the impact of their unstable lifestyles, problems with adherence to treatment, and the effect of methadone maintenance treatment on antiretroviral treatment are factors that should be considered. Also, although alcohol and non-injectable drugs do not expose a person to direct contact with other people's blood, they can impair their ability to think and reason and lead to dangerous behaviors (especially during sexual intercourse) that they do not perform under normal circumstances.
In the present study, 46.60% had unprotected sex. Due to the fact that one of the ways of HIV transition is through sexual contact, the correct use of condoms and the avoidance of multiple sexual partners are always recommended.
The results of multivariate logistic regression analysis showed a statistically significant relationship between non-adherence to ARV and unsafe sexual behavior, so that the chance of non-adherence to treatment in patients with unsafe sexual behavior was 1.53 times more than patients without unsafe sexual behavior. According to a study in Cameroon, patients who did not receive treatment reported unsafe sexual behavior from one and a half to three times more than their treated counterparts (28). Interventions can maintain the health of the individual and society by emphasizing commitment to treatment, and by knowing that antiretroviral treatment can significantly reduce the likelihood of HIV transmission through sexual behaviors (29).
The HIV/AIDS treatment diagram shows that the trend of receiving treatment has been on a rising steeply since 2005. With the introduction of the HIV epidemic in 1996 in some Iranian prisons, the number of identified cases suddenly increased dramatically, and this trend continued until 2004 when the total number of identified cases reached a maximum in one year (30-32).
VL levels was higher in patients at risk without ARV treatment than in patients at risk. When patients adhere to treatment properly, the immunodeficiency virus changes from a potentially deadly condition to a potentially controllable chronic disease (33). Therefore, creating a context for receiving treatment in patients with risk factors seems necessary.
Limitations and Strengths
The most important strength of this study is the high dimension of the sample and its population-based nature and the study of a long-term period, the collection of information by trained individuals and its accurate recording. The study was limited in that about 21% of patients who adhere to treatment have a history of drug use and are currently being treated with methadone or are currently taking drugs, so there is a need to accurately record drug abuse information. We didn’t ask participants about rape, forced sex, pressing, and tattooing as risk factors for HIV transmission. These factors were important in assessing the risk of HIV infection, or even for reasons such as the accusing and discrimination against people living with the disease, concomitant infections such as tuberculosis, sexually transmitted infections and hepatitis, the patients did not tend to laboratory tests and antiretroviral treatments; so they remained unknown.