Primary Health Care Strategic Key to Control HIV/AIDS in Iran.

Dear Editor-in-Chief

According to WHO report, the prevalence of HIV/AIDS in Iran has changed from low to concentrate. Despite the increase in awareness about HIV/AIDS in many countries including Iran, there is a tremendous gap between the estimated (93250) and registered (24735) number of HIV infected individuals in this country (1, 2). This lack of knowledge is due to the long incubation period before symptoms appear, the iceberg appearance of the disease, hiding the infection because of social stigma and shortage of public access to counseling services. Moreover, limited access to diagnostic testing in high risk groups and the general public along with under-reporting or non-reporting have resulted in detection of only a fraction of the people living with HIV. Although there is no prediction of a high peak occurring in the future in Iran, the likelihood of an unexpected outbreak cannot be ruled out (1).

“According to the first national strategic plan of Islamic Republic of Iran, main strategies are considered, including education and information, injecting drug, harm reduction and prevention of mother-to-child transmission, the latter being related more to case-finding and treatment “ (3).There are real examples of countries with similar epidemiological conditions to ours, which have experienced an increase in the incidence of HIV due to a lack of effective prevention and treatment in their health systems (1, 4).

Policy–makers have countered three main challenges in the field of HIV: diversity, complexity and change. The main risk factors of HIV infection (unprotected sex, injecting drugs) are mixed with social, economic and behavioral factors to a great extent. Epidemiological changes can be seen clearly in the case of HIV. An increasing percentage for sexual transmission of HIV has been observed recently in our country (2). In the field of HIV, the needs include prevention, diagnosis, treatment, long-term home care, as well as social and psychological support. High risk groups and asymptomatic individuals are scattered around the country and access to them is difficult. Due to social, cultural and economic barriers, high risk groups cannot easily communicate with health centers. Health care workers should be directly involved and have close contact to deliver health services to the high risk group. At the same time, they should be aware of the general population. Furthermore, the cost of HIV prevention with focus on high risk group is much lower than the cost of treatment of HIV infection.

The effective control of HIV can be achieved through: health education, condom promotion, social, economic and cultural interventions, promotion of health-care-seeking behavior and case management.

Delivering these services needs a comprehensive health system model which is effective, inexpensive and sustainable. This model was derived from “The Alma Ata Declaration” in 1978 later named Primary Health Care (PHC). The principles of PHC include inter-sectoral approach, community participation, appropriate methods, equity and comprehensive services such as promotion and prevention as well as therapeutic and rehabilitation interventions. These are the things that we are seeking to provide HIV/AIDS service. The current vertical HIV service has some disadvantages such as high cost, limited availability and coverage of population, poor sustainability, and case missing.

The current Iranian health network system was founded in 1980 based on the PHC approach. Numerous studies have shown the effectiveness of this network. Comparing key health indicators from 1984 to 2010 provided evidence for this success (5). All individuals have their first contact with the national health network system based on PHC, which has had good experience overcoming natural disasters and epidemics in Iran (6).

The successful integration of HIV harm reduction into PHC program in the Northwest of Iran is good evidence for this claim (7). Integration of a harm reduction program into main stream public health has been suggested in order to have greater outcome and higher coverage (8).

To conclude, integration improves access to services, use of resources, fairness, coverage, inter-sectoral programs, monitoring of drug usage and antibiotic resistance. PHC oriented health network system of Iran could play a key role in reaching out to high-risk groups, accelerating case findings and harm reduction intervention, and reducing high-risk sexual behavior in the HIV program.