This study estimates that the double counting of clients using harm reduction services in Iran may be substantial. Needle and syringe programs had the highest percentage of double counting of using services in each harm reduction center at different times and using services in different harm reduction centers. Methadone maintenance services had the lowest referral percentage with different identities to one or more centers. Our findings are robust in that they are based on the reports of a large sample of clients, the program staff, and experts in the field. To the best of our knowledge, this is the first study that estimates the double counting of clients in harm reduction services in Iran.
We consider several possible reasons for the double counting. First, because of the high mobility of the target population such as PWID, these people move between different centers. Second, providing services to these people is anonymous, and people tend to get services from different places. Third, because people can get from one service center several times, the services of one center may become unavailable or limited per client, and therefore people will go to other centers for this reason.
Our findings of substantial double counting of clients affect the assessment of meeting prevention targets for the reach and coverage of harm reduction programs. For example, the WHO recommends providing 200 sterile needles and syringes per PWID per year by 2020 and 300 needles and syringes per PWID per year by 2030 to effectively tackle HIV transmission via this route (11). By 2016, only 12 countries provided at least 200 clean needles per PWID per year, and Iran only provided 50 syringes and needles per PWID per year (12). While the number of needles and syringes provided to PWID in Iran is already low compared to the international standard, our results show that there may be a 17% double counting. Thus, the actual number of PWID serviced will be even lower than the reported number. Service providers should consider double counting when setting targets for clients reached and reporting progress towards these targets. The effectiveness of harm reduction programs depends on their reach and intensity. For example, supplying clean needles and syringes has been demonstrated to reduce heroin use, associated deaths, HIV risk behaviors, and criminal activity (13). In a study by Susan Hurley et al., HIV prevalence increased by 5.9% per year in cities without needle and syringe programs and decreased by 5.8% per year in the cities with such programs (14). Evaluation by WHO shows that needle and syringe exchange is effective, lacks negative consequences, is cost-effective relative to other interventions, results in cost-savings, and has positive externalities such as reduced crime (11, 15, 16). Also, according to condom programs, if the number of condoms distributed by PWID-targeted services per PWID is < 50, the coverage level is low (17). Data on condom distribution for PWID appears scant for the region. For example, in 2017, only four countries had program data in the Middle East and North Africa for condom distribution specifically for PWID (17). In our study, there is a potential 13% double counting in providing condoms to people in harm reduction centers, which affects accurate reporting of services.
We found that methadone services had the lowest level of double counting at one or more service centers. The requirement that people have to present their national cards to receive methadone at harm reduction centers is likely to prevent PWID from presenting with different alias at the same or different centers. Moreover, there is a centralized Iranian Drug Abuse Treatment Information System (IDATIS) to provide methadone maintenance services for drug users throughout the country. The system requires national identification numbers (18).
The use of unique codes can reduce the double counting of clients at other harm reduction services in Iran. For example in Uzbekistan, Tajikistan, and the Ferghana Valley region of Kyrgyzstan, a standard method to provide each client with a unique identifier code (UIC) can be expanded across multiple service centers and types. This UIC enables a service to record individual clients’ patterns of attendance. A UIC can reveal whether a client is reached regularly by a service such as a needle and syringe program without needing to collect personally identifying information such as names or government-issued national identification numbers. In particular, coverage of program types can be even more accurately measured if the same UIC is used across different service centers. Services in different countries have developed various but similar UIC systems ,(19, 20). The coding system should be easy for a client to recall and must protect clients’ confidentiality by ensuring that the UIC cannot be decoded to reveal the identity of the client.
The findings presented here should be interpreted with caution due to limitations. First, we do not have accurate key population size estimation such as PWID or other at-risk groups. Moreover, many individuals have dual risks of sexual and drug injection behaviors. Second, although efforts were made to recruit individuals from diverse geographical areas, this sample is not representative of all of Iran. However, we chose cities with regional, and geographical diversity to reduce this challenge. Third, recall bias may affect results as interviewing required the participants to recall and reflect on past events over time.