Factors Influencing Access and Use of Care and Treatment Services among Iranian People Living with HIV and AIDS: A Qualitative Study.

Dear Editor-in-Chief

The number of people living with HIV is increasing in the eastern Mediterranean region and the world (1) but still the coverage of anti-retroviral therapy in the region is very low (1). In Iran, there are many observed gaps in the process of HIV testing, treating and retaining cascade (2). Iran has a long way to achieve the goals published by the UNAIDS fast- track, accordingly, by the year 2020, 90% of people living with HIV and AIDS have to know their HIV status; 90% of people who know their status be on treatment; and 90% of people on treatment have suppressed viral loads (3). From about 95000 people living with HIV and AIDS in Iran, only 28.5% knew their status, 16.5% of them are on ART with an estimated adherent rate of 67.8% (2).

Anti-retroviral therapy in Iran is free of charge for all of the patients in the governmental settings known as Behavioral Disease Counseling Centers that provides related services in the field of diagnosis, prevention, care and treatment (4). HIV/AIDS epidemic in Iran is in concentrated phase among people who inject drugs with the average rate of 15.2% (5).

Prevention strategies alone are not enough to stop or reverse HIV epidemic (6), on the other hand, treatment as prevention is a successful strategy in countries with adequate resources that are in concentrated epidemic stage (7).

Despite enormous efforts and interventions, many of people living with HIV and AIDS do not yet have access to health services in the world (1).

This research is one of the very few studies conducted in Iran to find what barriers influencing access and use of health services among Iranian people living with HIV and AIDS.

This study was conducted using focus group discussion (FGD). The participants were recruited from the patients attending behavioral disease counseling center of six largest cities in Iran (Isfahan, Mashhad, Bandar Abbas, Kermanshah, Rasht and Urmia) in 2010.

Sixty-eight (50 males, 18 females) HIV positive patient, participated in the study. Level of education among male participants were higher than female participants were (average years of education: Male 6.9, female 4.3) but the average of the age was lower among male participants (35 for male vs. 41.8 for female participants).

Eight domains can influence access and use of care and treatment services among Iranian people living with HIV and AIDS. These domains each one take effects from many of the other subdomains (Fig. 1).

Fig.1:

Schematic view of factors influencing care and treatment access and use among Iranian PLHIVs

Supports from peer groups, non-governmental organizations, receiving needed education, access to integrated services, considering social circumstance of all patients, continuity of the services and social supports from the responsible organizations for welfare are the factors that overall can promote care and treatment services.

In addition, access and use of outpatient services influenced by other factors, such as addiction, long distance and transportation problems, economic problems of patients, lack of knowledge and information and unavailability of services in small towns. Among these factors addiction, transportation problems, and economic limitations were also identified in quantitative studies (8–9).

There are some recommendations for improvement of access and use of care and treatment services that should be considered by responsible authorities. This recommendation listed below without considering their importance:

Considering the role of people who inject drugs in the HIV epidemic in Iran and role of methadone interaction with anti-retroviral therapy it is highly recommended that other opioid drugs such as buprenorphine with less interactions with anti-retroviral therapy drugs except of atazanavir/ritonavir (10) considered as first line for opioid substitution therapy for people living with HIV and AIDS; Integration of high-quality mental health services and HIV psychiatrist in behavioral diseases counseling centers; Patients empowerment to have their self-help groups and peer educators; Establishment of a mechanism to involve the other non-governmental organizations that are working in the other field especially social supports and drug abuse prevention; Establishment of a mechanism to ensure efficacy of a referral system; Increase in the coverage of medical insurance for the services that are not available free of charge such as dentistry, advanced laboratory and radiology procedures; Feasibility study on the integration of anti-retroviral therapy in the primary health care to increase access and use of services in small towns and rural areas; Establishment of a mechanism that ensures availability of anti-retroviral therapy drugs to avoid treatment discontinuity; Using more efficient and interactive education methods for patient education; Reducing health providers’ stigma and discrimination toward the patients; Establishment of faith and spiritually based programs for the patients and their families.