‘You just prefer to die early!’: how socioecological context impedes treatment for people living with HIV in Iran

Abstract

IntroductionDespite the low prevalence of HIV and broad provision of antiretroviral therapy, the Middle East and North Africa (MENA) remains the only region where new HIV infections and AIDS-related deaths are not declining. There is a dearth of evidence from MENA on antiretroviral therapy engagement. In this qualitative study, we sought to identify the ways in which successful treatment is hindered in Iran, which is home to 24% of HIV infections in MENA.MethodsFrom August 2018 to January 2019, we used purposive sampling and conducted 12 individual interviews and 8 focus group discussions with 27 female and 31 male patients, in addition to 5 individual interviews with HIV care providers and 1 focus group discussion with 8 care providers. Social constructivism augmented with realist-informed thematic analysis was used to understand how the socioecological context triggers cognitive and affective mechanisms that disrupt antiretroviral therapy.ResultsThe use of Thematic Network Analysis resulted in the identification of three key cognitive and affective mechanisms that appear to shape treatment experience and are triggered via HIV’s socioecological context and changing economic conditions in Iran: denial in response to societal negative perceptions of HIV; fear in response to societal lack of awareness regarding HIV and misinformation; and despair in response to HIV-related stigma and enacted discrimination, economic insecurity and social support.ConclusionsTo our knowledge, this is the first study within MENA to identify pathways through which successful treatment is hindered. It appears that lack of societal awareness regarding HIV is specific to low prevalence settings, such as MENA countries, where negative perceptions, stigma, discrimination and misinformation regarding HIV and its treatment produce denial, fear and despair, acting as mechanisms that disrupt antiretroviral therapy. The experience of despair, in response to changing economic conditions and social support, further impacts treatment experience.

Barriers and Facilitators to HIV Treatment Adherence in Indonesia: Perspectives of People Living with HIV and HIV Service Providers

“…That HIV stigma is a major impediment to ART adherence is well established in the literature [ 9 , 13 , 39 ], as is the fact that HIV stigma in health care is highly prevalent and highly detrimental for PLHIV [ 40 , 41 , 42 , 43 ]. As such, our findings dovetail with previous studies reporting that stigma in any form hinders treatment adherence [ 3 , 11 , 27 , 30 , 31 , 32 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. PLHIV also often experience intersectional stigma or stigmatization due to multiple identities within marginalized groups (e.g., gender or sexual orientation) [ 60 , 61 ].…”

Factors Associated With Late Antiretroviral Therapy Initiation Among People Living With HIV in Southern Iran: A Historical Cohort Study

“…However, delay in the diagnosis of new cases and consequently delay in starting treatment is of the important problems of the HIV control program in Iran (20). Also, in Iran, due to negative perceptions, stigma, discrimination and misinformation about HIV and its treatment, life-long treatment among Iranians living with HIV is undermined (6,31). In the field of HIV control in Iran, PLHIV needs timely prevention, timely diagnosis, early and proper treatment, long-term care at home, and social and psychological support.…”

Complementary and alternative medicine use among people living with HIV in Shiraz, Southern Iran

“…Given the free provision of ART in Iran, health insurance and financial status do not determine the accessibility of ART and the choice of CAM cannot be due to unaffordability of ART. As opposed to financial, the challenges of living with HIV in Iran are largely socioecological and driven by stigma and low societal awareness of HIV ( 52 ). As such, socioecological determinants could be investigated in the future.…”