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: 6.1-7.5%) 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 <
30 years old (AOR: 1.50
95% CI: 1.13-2.00), having never got married (AOR: 1.58
95% CI: 1.12-2.23), engaging in condomless sex (AOR: 1.56
95% CI: 1.13-2.16), same-sex practices among men (AOR: 1.90
95% CI: 1.43-2.51), and recent sexually transmitted infection symptoms (AOR: 2.18
95% CI: 1.19-3.57). 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.