Challenges in the Area of Training and Prevention at the HIV Triangulation Clinic, Kerman, Iran.

BACKGROUND: Since 2000, Iran has been delivering training and treatment services, including methadone therapy, to human immunodeficiency virus (HIV) positive patients through triangular clinics. This study aims to evaluate the effectiveness of these activities at the HIV Triangulation Centre in the city of Kerman, Iran, through clients' views.
METHODS: Participants were recruited using a convenience sample and assessed through in-depth interviews, and observations. Data were analyzed using a thematic analysis, matrix based method.
FINDINGS: The results found problems in training and counseling which was described by the staff to be due to the effects of the economic difficulties of the clients, not being of the same sex as the consultant, and lack of utilization of a variety of training methods by the clients. Furthermore, the absorption of clients was perceived as being affected by the appearance of the center, gossip around the center, limited working hours, and interpersonal relations between clients and staff. The clients also criticized the building of the center as it failed to maintain anonymity of the patients. The need for supplementary services, such as dentistry, was perceived by many clients.
CONCLUSION: The application of appropriate strategies such as providing adequate training and removing the obstacles of absorption should be taken into account to increase the utility and coverage of the triangular clinic. These interventions could be a range of activities, such as relocating the center to a more decent place and encouraging the staff to appear in a professional white coat to help gain the trust of clients.

Introduction

Iran is a Middle Eastern country sharing a long border with Afghanistan and Pakistan, both of which are major producers of heroin. Since the Islamic Revolution of 1979, Iran has witnessed a high percentage of drug seizures, imprisonments related to drugs, and drug addiction.1 In response, a series of strategies, including harm reduction, were conducted by the Iranian Government.

Harm reduction is defined as a range of concepts and activities which aim specifically at reducing the consequences of drug use.2 Great stress is placed on the prevention of human immunodeficiency virus (HIV) infection as a short term goal of harm reduction programs. Therefore, services are provided for the target population, such as providing drug users with adequate information on the role of risky behaviors with respect to HIV transmission, HIV testing, distribution of sterile needles/syringes, and counseling. To achieve these aims, drug users are actively involved in the development of harm reduction plans.2

The harm reduction program in Iran involves different policy and enforcement groups, including governmental, welfare, drug control, prisoner, and law enforcement organizations.3 In alignment with harm reduction policies, the first triangular clinic was introduced in 2000 by the Iranian government. Triangular centers aim primarily to provide three main services: provision of treatment and diagnosis testing of HIV; treatment and diagnosis testing of STIs; and methadone therapy.4 However, as we observed in our study, they may have a higher level of activities, such as counseling and dentistry services. In a report published by the WHO, the development of triangular centers is recognized as the best practice for the application of harm reduction programmes.5 This has been explained through the advantages of the integration of prevention and treatment strategies and the avoidance of directly addressing HIV alone. This is recognized as effective in the reduction of stigma for service users.5 These centers are managed and supported technically and financially by the Iranian government, which also provides their specialists and staff.

This study is part of a larger case study and was conducted in the HIV Triangulation Centre in Kerman province (Kerman, Iran), Iran’s largest province. The main study was conducted in both a triangular and a drop-in center to ascertain the pattern of drug abuse among clients based on gender, and to become aware of the stigma surrounding HIV and drug use as barriers to using such services. We also explored the clients’ perspective on the factors affecting the effectiveness of services provided by the triangular center which is presented in the current study.

This piece of work is the first step in examining one such center and could provide the opportunity to discover the weaknesses and strengths of this system mainly through the clients’ point of view; focusing on counseling and ability of the center in absorption of new members and retention of current service users. As the problems related to drug trafficking and usage exist in many Middle Eastern countries, investigating both the barriers and the paths to success of controlling programs, such as harm reduction activities, could be useful for other countries in the region that share a common culture. Ultimately, the results could help policy makers improve this system and reduce high risk behavior.

Methods

Kerman is the largest province of Iran, located in the south east of Iran. The majority of drug seizures in Iran have occurred in Kerman, most likely related to its proximity to the Afghan and Pakistan borders, which are known transit points for drug trafficking.6 In Kerman the triangular HIV center was established in 2004 to provide specific services exclusively to HIV positive patients. These services include counseling, treatment, and methadone therapy. The center is situated in an old and low-level socioeconomic area of Kerman. The HIV center is separated from the footpath by a rusty fence and marked by a weatherworn signboard. In the main hall, a number of health and mental health messages decorate the wall. The staffs have access to the Internet. There are a number of clients who visit the center each day. Clients appeared to be comfortable in the center.

Participants were recruited to the study using convenience sampling method, with no inclusion or exclusion criteria, in September and November 2011. They were introduced to the interviewer through the general practitioner who had worked with them. Those clients who consented verbally to be interviewed were given a non-monetary incentive of food worth US$8.

In order to gain a deeper understanding of the center, we used a variety of methods to obtain data, including 25 in-depth interviews with clients, conducting follow up telephone calls with a couple of the interviewees, who provided the interviewer with their telephone numbers during the interview, further discussion with personnel, and observation of the environment of the center.

The clients’ view of the center was sought through open questions on their view of the function of the HIV center as a whole, followed by probing, which was used to gain further detail and clarification. Each interview took a total of approximately 45 to 60 minutes, with approximately 15 to 20 minutes devoted to their views of the center. All interviews were conducted in a private and peaceful room at the triangular center with no interruptions from staff or other clients. There was only one interviewer. The interviewees were ensured of confidentiality, which was important for them due to the stigma surrounding HIV infection. To ensure confidentiality, they were not questioned on their identities and other personal data by the interviewers, and the results were presented in such a way as to keep their identities hidden. All transcribes and records were labelled and stored in a password protected desktop. Ethical approval was provided by the Kerman University of Medical Sciences.

Most interviews were transcribed on the day of the interview. Using a thematic analysis, matrix based method, we sought to identify key themes and sub-themes.7 This was carried out by noting aspects of the interviews such as repetition, similarities and differences, and linguistic connectors. Eventually three main themes were developed: training and consulting; ability of the center in retention and absorption of clients; and personnel problems and expectations.

Results

The majorities of participants were men and had a history of drug use. They were of different ages, mostly either in their late twenties or between the ages of 30-45. Women were mainly widows and men were either divorced or single. Almost all of the men were infected through sharing syringes, while women through sexual contact with their infected husband.

The results are presented under the following headings

1) Training and consulting; and 2) ability of the center in retention and absorption of clients

1) Obstacles on training and consulting

Clients of the center and staff mentioned different problems affecting training and consulting. In the view of the client¢s should be removed it is just, being of the same sex as the consultant and utilization of a variety of methods were important. While from the staff’s perspective the clients have serious economic problems which prevent them from being motivated for further training and consulting.

Some of the participants, during the interview, had a range of questions on the source of infection and chances of contaminating others.

The question for me is if I marry and my husband wants to have a baby, can I have a baby?

Is hepatitis C virus (HCV) transmitted via urine?

Can I have oral sex?

When asked whether they have addressed their questions to the medics working in the HIV center yet, they explained that they were shy of asking medical personnel of the opposite sex sensitive sex-related questions.

A male client: I was too shy to ask the Dr. (female) that if I have sex, but there is no erection, is there a risk?

There was also a lack of absolute trust in the information they received.

In response to the question on whether HCV is transmitted through urine, I saw uncertainty in the eyes of the doctor when answering my question. Now I am still worried whether I can carry the virus through infected clothes.

Application of a single method for training, instead of using a variety of methods, was perceived as a further learning barrier.

In a discussion with a member of staff of the triangular clinic, she/he mentioned that the essential needs of the clients reduce their motivation in training and learning. During the interview, the majority of problems described by clients originated from economic hardship and included unemployment, homelessness, changing governmental policy with respect to financial assistance, and inadequate monitoring activities to ensure night shelters, free governmental accommodation for the homeless, are safe to live in.

2) Absorption and retention of clients

The ability of the center to absorb and retain clients is presented with respect to two domains: A) interpersonal relations and gossip; B) issues related to the HIV center including its appearance, rules, and regulations.

A) Interpersonal relations and gossip

The ability of the center to absorb new clients was described to be affected by gossip spread around the center and interpersonal relations.

While most interviewees acknowledge the friendly attitude of staff, it was mentioned that there were also some medical staff who displayed unfriendly attitudes and behavior towards clients.

When I had sores on my feet, nobody examined my sores; they did not even look at my sores and just prescribed medicine.

In a casual conversation with one of the medical staff it was argued that

These group [people living with HIV] have criminal history and do not really deserve to be helped.

In addition, there existed gossip around the center concerning personnel being infected with the virus. Moreover, the personnel’s appearance was described as a factor affecting the ability of the center to absorb and retain clients.

At the beginning when I became aware of my illness, I denied it and when I showed up here [HIV center], this rumor was spreading among patients that the personnel were ill and were infected with HIV. This made me feel insecure and it was difficult for me to trust them. When I heard gossip about the personnel, I evaluated them based on their appearance and realized they were careless about the way they dressed, they did not even wear white coats, and I concluded that the gossip could be true.

B) Issues related to the HIV center; appearance, rules, and regulations

In this section, the unappealing appearance of the building, limited working hours, limited times for blood tests, limited supplementary services, and concerns about anonymity, were the main findings.

Unappealing appearance of the building

Some participants described the HIV center as unattractive and explained that this could reduce the ability of the center in absorption of new clients.

It took me a huge amount of effort to convince my partner to come here for a HIV test, but she ran off as soon as she saw the appearance of the building with a group of addicts sitting nodding in front of the entrance.

It [HIV center] does not look like a clinic. I popped into another center in another city and it was a new and rather luxurious building, and I felt it was trustworthy.

Limited working hours and blood test times

Another factor that was perceived to be important in absorption of new clients was limited working hours and blood test times. The participants described this as an inconvenience and stated that the times coincided with their own working hours.

With huge effort, you convince your partner to take time off for a blood test. When you come you find there is no blood test that day.

Limited supplementary services

For many of the interviewees, some supplementary services were essential as a part of the HIV center; such as dentistry, due to being rejected by other dentists out of the center.

Wherever I went to have my teeth removed and told them I was HIV positive, no dentist would treat me.

A group of them expressed explicitly or implicitly that they injected drugs. Therefore, the necessity of availability of sterile syringes in the HIV center was mentioned by this group.

We need sterile syringes, some of us have injections in addition to methadone and we have to use used syringes

For example in a shared injection with my brother, we did not have a sterile syringe. I told him that he might get HIV, but he did not care, because of indifference.

Maintenance of anonymity, and fear of stigma

The majority of participants argued that the building of the HIV center is unable to maintain their anonymity, as it is only separated from the footpath by a fence, which makes them visible to the general public. They explained that this could cause scandal by disclosing their identity to the public.

These fences caused a scandal, everybody who passes by looks at us and says ‘they are HIV positive’.

This fence is so bad. We might be seen by our relatives and they will find out that we are HIV positive. If, for example my relatives, who I am living with, find out they will kick me out.

Discussion

The overall finding of this research shows that the triangular center is a noteworthy and useful initiative. However, the results of this study highlighted issues regarding the triangular HIV center in the city of Kerman. These issues include training and counseling activities, methadone therapy, the ability of the center to retain and absorb clients, and provision of adequate services.

One of the main conditions necessary for providing others with effective training is having access to correct information. The internet is a very useful and popular source of information due to its special features, such as providing quickly, available, varied, and wide ranging information. However, our results showed that although there is Internet accessibility there are problems with providing adequate information. This could be due to language barriers. Since most information on the Internet is in English, while the formal language of Iran is Persian. Second, in Iran, certain websites cannot be accessed as a result of restrictive regulations blocking websites, which are categorized as immoral, such as websites related to sex. This in turn limits access to websites on sex related topics, because of such terms as ‘sex’ and ‘HIV’. Limited access to the Internet, due to restrictive regulations, is discussed as a factor in the decline in the overall number of Internet users.8 Therefore, evidence of growing interest in the Internet as a source of information in developing countries might not be necessarily as efficient as expected in sensitive subjects such as sexually transmitted diseases.9 Therefore, there is a need to strengthen the infrastructure of Internet use, such as ability and access to relevant scientific websites.

Another factor affecting the transfer of knowledge from providers to clients is the way medical staff communicates with clients. Successful communication is highly dependent on the interpersonal skills of doctors and other staff members and their ability to treat clients with respect and understanding.10 In a study conducted in Los Angeles County, patients with HIV perceived stigma from health care providers in both baseline and follow up stages.11 This could have the effect of decreasing the number of patients seeking help and services and ultimately lead to delayed access with serious clinical symptoms and signs.

Being too shy to ask sensitive questions is an important training barrier. The proven connection between HIV infection and high risk sexual behavior, particularly in Middle Eastern countries, is highly stigmatized. People are too shy to ask questions about sex openly. In a study conducted in India, the results highlighted that shyness with respect to asking sensitive questions on sex related issues, particularly in women and students, is a training barriers with respect to HIV.12

The degree of absorption and retention of clients could be determined by the level of Trust of the patients in the health care workers. In this study, two main issues were recognized as indicators for being engaged in building trust; first, gossip and news spread around the center, and second, the client’s perception of the center and personnel. Gossip could be used to express a wide range of emotions, including fear, anger, and concern about other people. People experienced less anxiety and more support by using gossip.13 Furthermore, people relied on the advice and judgment of others in seeking health care. In discussions, it was stated that medical staff or therapies on offer for the patients were not medical staff or therapies by themselves were not the first motivation in seeking help for patients in seeking help. Indeed, they tended to seek health services based on other friends’ perceptions of that therapy.14

Therefore, knowing the network of clients and key client members could be helpful in providing clients with reliable news and information.

Second, patients trusted medical staff based on their attire and preferred personnel to be dressed in a professional white coat. The way doctors dress and its relation to confidence and trust of patients was explored in a study. The results found that patients preferred their doctor to dress professionally with a white coat and were less likely to choose those in casual dress. Their preference was highly connected to levels of trust and confidence. Furthermore, people preferred to share sensitive issues with a doctor dressed in a white coat.15

Another issue related to absorption and retention is the maintenance of confidentiality. In order to keep HIV positive people away from stigma and its impact, it has been discussed that patient notes should be disclosed only to a limited number of specific people. Such confidential disclosure is carried out to gain their support and help with counselling.16 Needless to say, centers with inadequate ability to keep confidentiality could lose their clients.

In addition, providing patients with adequate services could be an efficient incentive to absorb clients. Services such as dentistry are very useful, not only for HIV positive patients, but also for the health of the general population. It is likely that HIV positive patients will be rejected for dental treatment. Therefore, nondisclosure of their HIV status to the dentist was reported among them.17

Some of the problems noted in this study could be removed using simple and straightforward strategies. For example, taking into account the patients’ questions, a comprehensive and easy to understand booklet addressing these questions could be developed. This could be an effective way to enhance the ability of the center to provide the patients with accurate information. In addition, employing a variety of methods, such as CDs and pamphlets, information could be transferred to the clients. Regular periodical meetings of clients and authorities could also be helpful in providing patients with accurate news about the center. Furthermore, being aware of the key person in each group of clients and collaborating with them in order to send accurate information could be useful. In addition, in order to increase the ability of the center to absorb new clients, the improvement of the appearance of the building should be addressed. Personnel could be encouraged to dress in white coats to create a medical environment with an image of trust.

Although this study has the advantage of using in-depth interviews to gain deeper understanding, we acknowledge that there are limitations, such as the generalization of results. We used convenience sampling method, in which groups of clients who were not available or not willing to participant are not counted. Non-addicted clients and women in particular, make up a small percentage of the participants. This was due to the fact that they visited the center less frequently. The small proportion of non-addicts and women could not be redressed by our efforts to increase their participation through telephone contact requesting their participation.

Conclusion

This study highlighted problems related to absorption and maintenance of clients into the triangulation center. As with any disease surrounded by stigma and fear, specific consideration should be taken into account. This consideration could enhance patients' trust and their willingness to use such services. Ultimately it could improve knowledge and practice of this group toward safe practice; a goal that is desired for both patients and the general population.