Abstract
The number of sexual transmission of HIV is increasing globally. Sexual and Reproductive Health (SRH) issues and HIV/AIDS related problems are rooted in common grounds such as poverty, gender inequality, and social exclusion. As a result, international health organizations have suggested the integration of SRH services with HIV/AIDS services as a strategy to control HIV and to improve people’s access to SRH services. The aim of this study was to evaluate the relationship between reproductive health and HIV/AIDS services at policy-making level in Islamic Republic of Iran (IRI). This study was conducted in 2011–2 and was a rapid assessment based on guidelines provided by the World Health Organization (WHO), United Nations Programme on HIV/AIDS (UNAIDS), Family Health International Association, and some other international organizations. In this rapid assessment we used different methods such as a review of literature and documents, visiting and interviewing professionals and experts in family health and HIV/AIDS programs, and experts working in some Non-Governmental Organizations (NGOs). Overall, based on the results obtained in this study, in most cases there was not much linkage between HIV/AIDS policies and SRH policies in Iran. Since integration of HIV/AIDS services and SRH services is recommended as a model and an appropriate response to HIV epidemics worldwide, likewise to control the HIV/AIDS epidemic in Iran it is required to integrate HIV/AIDS and SRH services at all levels, particularly at the policy-making level.
Keywords: HIV/AIDS, Reproductive Health, Rapid Assessment, Iran
Introduction
In the early years of 2000’s, AIDS was introduced as the leading cause of death from infectious diseases as well as the fourth leading cause of death worldwide (1). According to the latest report released by Joint United Nations Program on HIV/AIDS (UNAIDS) in 2012, the total number of people with HIV/AIDS worldwide was 35.3 million and the number of annual deaths from the disease was 1.6 million in 2011 and it is estimated that more than 35 million people worldwide have died so far due to the disease (2).
According to the statistical data published by the Ministry of Health and Medical Education (MoHME), by the end of March 2013 a total of 26,125 cases of HIV/AIDS have been identified in Iran, of which 89.8% were male and 10.2% were female (3).
The number of sexual transmission of HIV is on the rise across the globe (4). The importance of building a connection between HIV/AIDS and Sexual and Reproductive Health (SRH) services is now widely recognized (5,6). In case of integration of SRH and HIV, the capacity and experiences obtained in SRH program – concerning the promotion of condom use and utilization of vasectomy services – can be used to increase tendency of men with HIV/AIDS utilizing interventions designed for males.
The capacities and experiences obtained in SRH program can be utilized through SRH and HIV linkage to promote men to take more responsibilities for using condoms and take advantage of intervention methods designed for males. Also, by integrating these services and establishing shared service centers, HIV/AIDS people will not be obliged to refer to isolated locations to receive services and they will not be tagged as HIV/AIDS patients. This provides a better condition for patients both in terms of the elimination of stigma and keeping peoples’ privacy (7). It can be also noted that after the integration of SRH and HIV services, it would become easier and better to provide prenatal care and services to prevent the transmission of HIV from mother to child.
Over the past few decades more attention has been paid to SRH services in Iran. Because of the implementation of these programs, some of SRH services such as maternal and child health have been integrated with primary healthcare, leading to positive health outcomes (8).
Global experiences highlight the potential benefits of the integration. For example, findings of a study in Malawi showed that to control HIV/AIDS in this country, it was necessary to have specific strategies and programs for the integration of HIV and SHR (9). Moreover, the results of a similar study in Eastern Europe and Central Asia showed that despite international recommendations, although there was an improved quality and access to HIV services in these countries, their main challenge was to achieve greater levels of integration between HIV and SHR policies and programs (10).
During the past decade, HIV incidence has increased in Iran. However, while this increase is partly due to an actual incline in the number of new cases, it is mainly due to better testing, case finding, and reporting (11). Based on the experiences and suggestions of numerous international organizations, the integration of HIV care policies and SRH services and improved access to reproductive health services can be used as an important preventive strategy for controlling HIV/AIDS pandemic (12). Accordingly, the aim of this study was to determine the relationship between the policies designed for SRH programs and HIV/AIDS programs in the Islamic Republic of Iran (IRI) through a rapid assessment conducted in 2011–2.
Methodology
This study was a rapid assessment which was conducted using the guideline provided by international organizations concerned with health (8). The data was collected through six semi-structured interviews and four Focus Group Discussions (FGDs) with key individuals, policy-makers, experts, Non-Governmental Organizations (NGOs), and national and provincial authorities involved in different levels of SRH and HIV/AIDS programs. In addition, national programs, guidelines, and the required documents, articles, texts, and reports were examined by the researchers of this study as a desk review. The data collection method used in this study was based on the guidelines mentioned earlier which were designed to collect data on the relationship between SRH and HIV/AIDS policies (8). In order to better demonstrate the method used in this study, Figure 1 shows the general framework for assessing the relationship between policies of SRH and HIV/AIDS-related programs in IRI.
Figure 1.
Relationship between Sexual and Reproductive Health (SRH) and HIV/AIDS-related policies in IRI
Results
As shown in Figure 1, the results of this study are presented in two main categories of policy-making (guidelines/national policies) and investment/budgetary support; each of the two main categories has some sub-categories which are described in below.
1. Assessment of policy-making (guidelines/national policies)
1-1. Assessment of the relationship between Sexual and Reproductive Health (SRH) and HIV/AIDS in Islamic Republic of Iran (IRI)
According to the statement declared in the International Conference on Population and Development (ICPD) in 1994, it is critical to enhance people’s access to reproductive health programs and services for both genders, all ages, and in all countries (11,13). In view of that, the Department of Family Health and age offices (juvenile, young, middle-aged, and elderly) were gradually established in Iran. The establishment of age offices was in line with the new approach by the MoHME which tried to categorize the services by people’s ages. Hence, currently, the services are designed in age offices, instead of Family Health Center.
The Department of Family Health is at the highest level of planning and management of reproductive health programs in the country and it makes the related national policies in this field. Moreover, with the rise of HIV/AIDS cases, the Department of AIDS and Sexually Transmitted Diseases, which is placed at the Center for Disease Control, has become gradually responsible for making policies and plans at the national level for controlling HIV/AIDS. These two departments are located in two separate organizations and the policies and goals of each organization are not completely similar with those of the other organization. At the time of study, there was no mutual relationship between reproductive health and HIV/AIDS at the policy-making level in Iran, and each of these two departments was making, managing, and implementing its own policies separately and independently.
1-2. Assessment of policies on service protocols, clinical guidelines
1-2-1. SRH clinical guidelines for women living with HIV
The Iranian HIV/AIDS program has given a special attention to reproductive health. Reproductive and sexual health for people living with HIV during pregnancy has been included as a target in the strategic plan for HIV/AIDS and some related strategies and activities are also considered.
The strategies and activities include the provision of services provided by counseling centers for behavioral diseases. According to one of the key people participating in the study: “The behavioral disease counseling centers are the centers established by the Ministry of Health and Medical Education [MoHME] which provide services for HIV/AIDS prevention, Sexual Transmitted Infections counseling and treatment, and harm reduction. The behavioral diseases are the diseases that are transmitted through high-risk sexual behaviors, unsafe sex, intravenous drug abuse, etc”. These centers provide services including, but not limited to, counseling for family planning, counseling for the prevention of disease transmission, vaccination including hepatitis B, tetanus, influenza and pneumococcal vaccines, provision of antiretroviral treatment, and prevention of tuberculosis laboratory services, voluntary testing and follow-up tests of the disease, and promoting the use of condoms (14).
There are also some treatment programs and protocols for treating HIV patients in counseling centers. These treatments include the provision of antiretroviral therapy, prophylaxis, and other similar services. In addition to these counseling centers, there are some other centers which provide similar services, some of which are mentioned in this article. In Iran, HIV/AIDS services are not only provided in behavioral diseases counseling centers, but also in health houses, health centers, the centers providing family planning services, and maternal healthcare providers. Given the nature of the disease and the characteristics of the target groups, people suffering from the disease do not refer to health houses and health centers because of fear of stigma. In addition, the staff are also not trained about this topic (8).
1-2-2. Clinical guidelines for occupational and non-occupational Post-Exposure Prophylaxis (PEP)
Iran has a medicinal prophylaxis program for occupational exposures and free medicines are provided for exposed people. In addition, medicinal prophylaxis and free milk for infants and children of mothers with HIV are also available in the counseling centers.
1.2.3. Routine testing for HIV and syphilis among pregnant women
There is no routine testing for HIV among pregnant women in Iran and this test is only used for high-risk women. In some countries, these tests may be performed routinely for pregnant women, but these tests are not performed routinely in Iran. However in case of requesting the test by the patient or the physician, the test will be performed. According to one of the experts participating in the study: “The authorities of AIDS program in Iran believe that the disease is not at an epidemic stage, hence there is no need to perform HIV/AIDS tests for all population routinely; thus, testing for HIV/AIDS and syphilis is not mandatory”.
For several years prior to this study, syphilis test was available for all pregnant women; however, due to the low number of positive and suspected cases, it was removed from the national routine programs.
1.2.4. Legal age to receive services
In Iran, HIV testing does not require parental or guardian consent and there is no age limit, however sometimes cultural barriers prevent people from doing these tests. In addition, to access SRH services there is no limit in terms of age, gender, and marital status. For example, one of the participants noted some barriers to the program: “There are some obstacles, including: moral constraints and conventions about HIV/AIDS among Iranian families, obstacles in discussing sexual health and sexually transmitted diseases in the family and community, moral stigma and fear of rejection especially in women”.
1-3. Assessment of the National HIV Strategy
Iran has a five-year strategic plan on HIV/AIDS (2011-5) which includes the national strategy for prevention and control of HIV/AIDS. There are some evidences indicating that there has been a change in the pattern of HIV transmission toward sexual transmission; as a result there is a need for paying special attention to reproductive health (15).
With the increasing prevalence of HIV/AIDS among intravenous drug users in the early years of the new century, Iran entered the concentrated phase. Most of injecting drug users usually have experienced imprisonment for several times, as a result, in Iran injecting drug users are among the high-risk groups who may transmit HIV/AIDS (16). Therefore harm reduction programs can slow the pace of the epidemic in this population (17,18).
However, so far HIV/AIDS prevention priorities have been focused on drug abuse high-risk behaviors and there has been less attention toward controlling HIV/AIDS through sexual health.
As a result, the control of the epidemic among injecting drug users has been the major priority in HIV-AIDS Strategic Plan in Iran during the past years. Development of harm reduction programs could prove the authorities’ focus on this issue.
1-4. Assessment of national SRH strategy
The overall SRH program in national healthcare system has some strategies such as reducing maternal mortality, reducing child mortality, family health, promotion of breastfeeding, and other items. SRH programs do not include services related to HIV/AIDS treatment, HIV/AIDS support and care, and HIV/AIDS voluntary counseling. In other words, the provision of reproductive health services is included in HIV/AIDS programs while HIV/AIDS control strategies are not implemented in reproductive health programs in Iran.
1-5. Assessment of the design and implementation of policies by the government
At the time of the study there was no policy for connecting HIV/AIDS related services and reproductive health services at the macro level in the country. At the time of the study no particular coordination had been made between involved departments i.e. the Centers for Disease Control and the Population, Family, and School Health Office.
1-6. Assessment of non-disclosure laws to protect People Living with HIV/AIDS (PLHIV)
According to one of the experts participating in the study “Non-disclosure of information to protect PLHIV has not been yet translated into a specific law in Iran, but it is part of general medical ethics and law”. It is worth mentioning that in Iran the confidential information of patients is not given even to those organizations, like Welfare and Relief Committee, which need to have a list of people to provide financial and non-financial supports.
1-7. Assessment of methods to improve access, coverage, and quality of HIV services for different groups
The required services for the vulnerable groups and their families are provided in counseling centers, drop-in-centers for socially vulnerable women, selected counseling centers for behavioral diseases, reference centers for counseling, diagnosis, and treatment of HIV, Drug Information Centers (DICs), drop in centers established by NGOs and positive clubs.
1-8. Assessment of general components to protect the rights of individuals in receiving Sexual and Reproductive Health (SRH) and HIV related services
Under the national laws and policies in Iran, people with HIV, like other citizens, are entitled to social rights and citizenship privileges. If these people tend to become pregnant, they can take advantage of the continuous monitoring by behavioral disorder counseling centers. If the fetus is affected and the gestational age is less than four months, parents can request abortion under the legal justification.
1-9. Assessment of the effects of laws on key groups
Support provided for drug users is one of the most important advances in Iran. For example, if a drug user would be under the coverage of methadone or drop in centers, he/she will not be wanted by the police anymore.
1-10. Assessment of HIV and Sexual and Reproductive Health (SRH) strategies/policies about the structural factors of vulnerability
1-10-1. Gender inequality
In Iran, men and women are treated similarly in terms of reproductive health and HIV services provision. One of the participants said: “There is no law or program to limit the provision of services for HIV/AIDS infected men and women and both genders can access services equally; both genders are considered in the programs. There is no law or program to limit the provision of reproductive health services for either of the two genders. However, some of the organizations mainly provide services for vulnerable groups (women). For instance, Iran Family Planning Association mainly provides services for women in DIC centers and all the staff working in the centers are female”.
1-10-2. Stigma and discrimination associated with HIV
Stigma is a type of misbehavior toward infected or vulnerable people which usually emerges in form of disgrace or discrimination.
There is no systematic law in Iran about stigma and discrimination toward people living with HIV/AIDS, however the social and cultural stigma from the society and even healthcare staff against people living with HIV/AIDS are profound (19).
According to one of the HIV/AIDS experts, there is an intense stigma in community against HIV/AIDS: “Stigma and discrimination are now the major problem of all of our patients. We did not do so much to deal with this problem. The policies have not been so successful in removing the stigma in community because the efforts to eliminate stigma are not systematic and organized. The stigma and discrimination are clearly rooted in the views and attitudes of the people”.
Nonetheless, some organizations such as social welfare organizations, prisons, forensic medicine, and drug control headquarter have some regulations to support programs for eliminating stigma associated with HIV.
According to one of the key people participating in the study, the judiciary has announced that there is no need to test for HIV/AIDS for recruitment. Moreover, the welfare organization has some services for female sex workers; moreover, the police and Tehran municipality have some programs to support triangular centers (centers that provide services related to HIV/AIDS, sexually transmitted diseases, and drug abuse). There are also some NGOs providing services to protect individuals with HIV/AIDS.
1-10-3. Social, legislative, political, and public views toward the main target groups (homosexuals, female sex workers, people who injects drugs, sexual minorities, immigrants, refugees, homeless people, and youth)
In Iran, men who have sex with men and female sex workers are shunned and could be punished by law. Consequently, it is difficult to access these people in health systems. As a result, it is difficult for health systems to reach these people. These groups are among the most hidden layers of community and are not willing to reveal their sexual identity. Therefore, reaching them is extremely difficult for the healthcare system. On the other hand, there are few systems that provide appropriate counseling and care for these people.
2. Investment/budget support
2-1. Core funding for SRH and HIV
The governmental funds of the MoHME are the main financial resource for reproductive health programs. The funding for HIV/AIDS program is mainly provided by governmental budget and other resources provided by the United Nations (UN) agencies and international organizations (such as GFATM, UNFPA, UNDP UNAIDS, UNICEF, WHO, UNODC).
Other governmental departments such as the Ministry of Welfare, Interior Ministry, Prison Organization, Municipality, and Education Ministry provide limited financial supports for HIV/AIDS programs. These funds are not integrated and are allocated separately for each program.
Some organizations that are active in this field obtain their financial resources in various ways. For example, the Family Planning Association is a NGO which is supported by international organizations, however it receives some training and financial supports from the public sector, such as municipalities.
2-2. Share of HIV and Sexual and Reproductive Health (SRH) funding in other programs
Although HIV and reproductive health programs are funded separately, a part of the HIV/AIDS program budget is spent on reproductive health services including free distribution of condoms in HIV/AIDS counseling centers and for examination and treatment of sexually transmitted diseases.
As said by one of the policy-makers: “A little amount of reproductive health budget is spent on HIV/AIDS services”. However the exact amount of budget spent in this field is not known.
2-3. Role of charities in joint activities on Sexual and Reproductive Health (SRH) and HIV in a joint program
The role of domestic donors and charities, like Relief Committee and Welfare organization, in the joint activities on reproductive health and HIV programs is limited. Basically, the lack of information about HIV/AIDS and its transmission and the victim blaming approach has led donors and charities to be reluctant to help related programs. It is possible for the Family Health Association to receive some helps indirectly from charities and spend them on integrated activities on HIV/AIDS.
Discussion and conclusion
Overall, based on our findings, there was no relationship between HIV and SRH programs and policies during the period of study in Iran, or it was very weak. Reproductive health policies are designed in the MoHME and the Office of Family, Population, and Schools Health, while policies to fight and control HIV/AIDS are determined at the Center for Communicable Disease Control. Until the time of study there was no commitment, statement, strategy, or plan to integrate the two programs.
As the findings of this study showed there is no proper linkage between HIV/AIDS and SRH programs at the policy-making level. The results of a similar study in Eastern Europe and Central Asia also showed that the integration of these services led to improved access to HIV services. However, as a big challenge for these countries, they did not achieve full integration of HIV and SRH policy programs (20). According to a report released by UNFPA, a rapid assessment has found that 16 countries which had integrated HIV/AIDS and SRH policy programs, had gained achievements in the promotion of SRH and HIV/AIDS services; Botswana, Tanzania, Russia, Vietnam, Uganda, and Burkina Faso were among those countries (21). In sum, we can say due to the capacity of the health system in Iran, the integration of HIV/AIDS and SRH programs requires more attention from policy-makers and managers. To achieve this goal, this study suggests the following recommendations:
Advocacy from policy-makers and senior executives of the country by academic, international, and national figures; presenting the subject in decision-making centers such as the Health Policy Council in the MoHME, the Council of Health and Food, and Health and Medical Care Commission in Parliament.
Because of the novel and specialized nature of this issue, parliament members may not be familiar with the subject. Hence it might be useful to promote the advocacy for policy-makers. The managers and experts working in MoHME might be aware of the need for the linkage, however, based on our review, these groups are still one of the barriers to integration.
Moreover the following items must be considered: training managers of the Center for Communicable Diseases Control and the Bureau of Family Health and Education and other experts in the MoHME; establishing a National Committee for guiding and writing guidelines about the methods of service integration at all levels and also the methods of policy integration; preparing a policy statement linking the policies of the two parts and integrating some services.
It is necessary to integrate HIV/AIDS and SRH services at ministerial level at the relevant departments. International recommendations and experiences of other countries imply the need to adopt an integrated policy in this context. Adopting an integrated policy by various agencies is difficult.
In case of integration, it is essential to make total revision in the structures of AIDS and Family Health Division in the MoHME.
This study had some limitations; for instance, it was not possible to reach and visit some of the managers and informed people or receive their support. Additionally, it was a rapid assessment which was prepared based on the guidelines by international organizations; therefore it is likely that all aspects of the subject would have not been covered completely and accurately.
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
GM participated in designing and developing the study, conducting data analysis, and witting up of the manuscript. SK and MH participated in data analysis, and witting up of the manuscript. All authors contributed to subsequent and final drafts of the paper and approved its final version.
Authors’ affiliations
1Kurdistan Research Center for Social Determinants of Health (KRCSDH), Kurdistan University of Medical Sciences, Sanandaj, Iran. 2Department of Epidemiology and Biostatistics, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran. 3Faculty of Management and Medical Informatics, Tabriz University of Medical Science, Tabriz, Iran.
Citation: Moradi G, Khoshravesh S, Hosseiny M. Situation of linkage between sexual and reproductive health and HIV-related policies in Islamic Republic of Iran – a rapid assessment in 2011–2. Int J Health Policy Manag 2015; 4: 131–136. doi: 10.15171/ijhpm.2015.30
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