Sociocultural Determinants; a Missing Link to Control HIV Epidemic in Iran

Dear editor,

While the Iranian national plan for HIV/AIDS control concentrates on high-risk groups and harm reduction strategies, it is important to highlight the importance of sociocultural and structural determinants as key elements in the spread of AIDS, and the role of interventions at this level as a major step in AIDS prevention in Iran. In this country, over 28,000 people with HIV infection had been identified and registered by the end of 2014; this is less than 40% of the conservatively estimated number of 76,000 (1). There seems to be a large gap between Iran’s detection rate and the UNAIDS recommendation (90%) through the 90-90-90 strategy. HIV epidemic in Iran involves mainly high-risk groups such as injection drug users (IDUs) and female sex workers (FSWs). Although the HIV epidemic is largely driven by injection drug use, HIV transmission through high-risk sexual practices has recently increased (1).

In Iran, HIV/AIDS is considered mainly a medical and biological problem, although studies show a significant association between the risk of HIV infection and some fundamental factors including demographic (e.g., sex, age, marital status, mobility, and residence), socioeconomic (e.g. income, education, occupation, and poverty), and sociocultural (e.g. religion and ethnicity) characteristics of individuals (2). Thus far in Iran and many other countries in the world, HIV and AIDS prevention strategies have generally focused on health issues and on controlling viral transmission with little attention to cultural, social, and economic factors that influence the increase in high-risk behaviors which contribute to the prevalence of AIDS infection. Indeed, the main risk factors of HIV infection (unprotected sex and injecting drugs) are intermingled with social, economic, and behavioral factors to a great extent.

The ever-growing trend of marginalization in large cities in Iran is accompanied by increases in HIV high-risk behaviors. The risk of HIV infection among marginalized groups (FSWs, IDUs, Street Children) can be attributed to substance use and sexual risk behaviors mainly rooted in their social and economic situations (3). The latest evidence shows that HIV prevalence is 4.5% among street children, 4.5% among FSWs, and 13.8% among IDUs in Iran, whereas the rate for the age range of 15 to 49 years in the general population is 0.14% (4). More importantly, most of these high-risk populations have a low socioeconomic status (4, 5). Furthermore, there is intense HIV-related stigma and discrimination in Iran as in other religious societies. For example, the profound stigma against People living with HIV at different social and organizational levels, in addition to their limited awareness of HIV testing sites and services, create significant barriers to routine HIV testing amongst FSWs (1, 6).

Together, the facts outlined above favor the view that structural elements play a significant role in the control of the HIV epidemic in Iran. To increase awareness of this role and thereby enhance AIDS prevention strategies, we offer the following suggestions:

- Consider social determinants of HIV/AIDS as well as harm reduction strategies and prepare an intersectorial plan to reduce disparity with a focus on vulnerable populations.

- Manage religious beliefs with two purposes: 1) to strengthen these beliefs and prevent high-risk behaviors by promoting the ABC strategy (Abstinence, be Faithful, use a Condom), and 2) to advocate these beliefs in viewing people with HIV as patients who are in need of care.

- Put primary health care at the center of community-oriented programs to prevent transmission and promote healthy behaviors, community empowerment, and screening programs.