HIV/AIDS Policy-Making in Iran: A Stakeholder Analysis CURRENT STATUS: POSTED

Introduction: HIV/AIDS phenomenon is one of the most serious public health challenges which includes wide range of epidemiological, social, economic and political dimensions. Therefore, its effective control requires involvement of different stakeholders. The present study aims to identify and analyze HIV/AIDS stakeholders in Iran. Methods: This qualitative stakeholder analysis was conducted in 2018 nationwide both retrospectively and prospectively. Identification and analysis of stakeholders was carried out by the review of related literature and policy documents and official websites, as well as holding semi-structured interviews with policy makers and other key informants. Purposive sampling was utilized and followed by snowball sampling until data saturation. Data were analyzed using framework analysis. Also, qualitative data analysis software MAXQDA (Version 11) and Policy Maker software (version 4) were applied. Findings: A total of 44 stakeholders were identified and categorized into 23 active and 21 inactive stakeholders. Despite the great importance of educating and informing pubic about HIV/AIDS, the Ministry of Education and Islamic Republic of Iran Broadcasting organization (IRIB), have moderate participation in this regard. Supreme Council of Health and Non-governmental organizations (NGOs) have low participation. The Ministry of Health and Medical Education (MoHME), State Welfare Organization of Iran, Iranian Blood Transfusion Organization, the State Prisons and Security and Corrective Measures Organization are interested in HIV/AIDS policymaking. The MoHME, as main body responsible for stewardship of the HIV/AIDS in Iran, does not have enough authority in handling the issue due to the low funding, institutional and structural deficits and insufficient human resources. Conclusion: The process of HIV/AIDS policy making is fragmented in Iran and despite multiple active and passive stakeholders in this field, there is no integrated system to involve all stakeholders in the process of AIDS policy-making. Therefore, given the importance of the issue, an upstream entity is needed in order to coordinate and mobilize all stakeholders associated with managing and controlling HIV/AIDS.


Introduction
3 Acquired Immune Deficiency Syndrome (AIDS) phenomenon is one of the most serious public health challenges, which not only affects individuals' health, but also impacts countries development and economic growth [1][2][3]. According to the latest report of the Joint United Nations Program on HIV/AIDS (UNAIDS), there are approximately 36.9 million people living with HIV/AIDS worldwide with 1.8 million new HIV cases and 940 000 AIDS-related deaths in 2017 [4].
Unfortunately, the HIV pandemic still rages through the world, especially in low-income countries and the vast majority of people living with HIV are in Low-and Middle-Income Countries (LMICs) [1]. This threat is dominant for countries in East Mediterranean Region such as Iran [5,6]. In 2017, the estimated number of people living with HIV and new HIV cases were 60000 and 4700, respectively [7,8]. Although, Iran is the only Fast-Track country in the Middle East and North Africa region and its national strategy is structured around the 90-90-90 targets and ending the AIDS epidemic by 2030 [9], the reduction of HIV/AIDS cases in Iran is lower than the global rate and since 2010, the worldwide reduction in new HIV infections was 18% while it was 10% for Iran [7,8].
All around the world, HIV/AIDS not only is one of the major health concerns but also is a social problem which should be addressed using a multidimensional approach such as epidemiological, social and political dimensions [10,11]. It has been proved that AIDS can be a threat to development, security, and economic growth [12]. HIV/AIDS is a major global public health threat particularly for young and active people [11,13]. The HIV epidemic, directly and indirectly, imposes high burdens on communities which is so hard to assess as it is a multifactorial complicated phenomenon. HIV/AIDS reduces the Gross Domestic Product (GDP) [14]. It is shown that 1% increase in total HIV/AIDS mortality rates will result in a 1.6% decrease in GDP [12].
Despite advances in knowledge on HIV/AIDS and the best practices to prevent and treat it as well as efforts by global health community, leading governments and civil society organizations, many people who are at risk of HIV or living with HIV still do not have access to preventive and therapeutic health services [15][16][17].
From the beginning, HIV/AIDS has been publicized as a disease related to sex and illegal drugs, and for this reason politics and ideology have had great influence on HIV/AIDS policy making processes. 4 Despite the political nature of HIV/AIDS policy making, there are little published materials on the political determinants of HIV/AIDS policy making in LMICs. As depicted by literature, no single determinant can explain HIV/AIDS policy making, however, it emerges from a unique interaction and configuration of institutions, ideas and interests [18]. Though it is accepted that interests and political incentives of stakeholders play an important role in understanding how and why HIV/AIDS policies and strategies are emerged and sustained, the number of papers that analyzed interests is insufficient [18].
Utilizing stakeholder analysis as a systematic tool to get insights about to a proposed policy reform is not a new concept and has been used in business, public policy, change management, health care management and development. Stakeholder analysis helps policy makers identify, categorize and analyze actors that can influence/be influenced by a proposed action [19][20][21]. Stakeholder analysis has been developed so as to understand the power and positions of stakeholders on specific new policies and evaluate the likely implications for the acceptability of new policies or interventions.
However, published literature concerning the utilization of/how to perform stakeholder analysis has been limited within the context of Health Policy and Systems Research (HPSR) [22]. Recently, the utility of this approach has been reiterated among scholars of HPSR [22][23][24]. Also, it helps policymakers and managers find out the potential misunderstandings about and/or resistance against a specific policy or program and devise and take the necessary actions to manage it [25,26].
Identifying and analyzing the role and impact of all HIV/AIDS related stakeholders is essential for a successful policy-making. The aim of stakeholder analysis is to provide policymakers with comprehensive information on interests, power, influence, and participation level of all individuals, groups or organizations that may affect the success or failure of a particular policy. Appropriate strategies should be developed for each stakeholder based on this analysis to change their interest, power, influence, and more importantly, participation in a way to get a better result in fighting against AIDS. Despite the fact that Iran is exposed to HIV/AIDS phenomenon, still, no comprehensive study has been carried out to identify and scrutinize the role of key stakeholders and actors related to the prevention and control of HIV/AIDS. Therefore, this study aims to identify and analyze the 5 stakeholders of HIV/AIDS policy-making in Iran.

Methods
This qualitative stakeholder analysis is a part of a larger qualitative exploratory study entitled "Policy Analysis of HIV/AIDS in Iran" conducted using health policy triangle framework [27] and Greene's conceptual framework. The aim of this study was to identify actors and stakeholders related to HIV/AIDS policy making in Iran, to provide a comprehensive analysis of the relationships, interests, power, and influence of all active and inactive stakeholders at present and to predict the future changes in HIV/AIDS policymaking nationwide. To do this, both retrospective and prospective approaches were applied.
Data collection was performed through semi-structured interviews with key informants. Document analysis including literature review, and formal websites of stakeholders was conducted to complete and enrich the data. After literature review and document analysis, key informant were identified and interviewed by purposive sampling and then it was accomplished by snowball sampling.
A stakeholders analysis guide and a policy documents checklist were used for data collection and data extraction respectively. This checklist consisted of items such as type and feature of the document, time and place of document publication, publishing organization and the content of the document. Varvasovszky & Brugha guide was used for stakeholder analysis [28]. This guide is suitable for conducting stakeholder analysis in health policies and has been used in similar policies and health issues, such as alcohol policies in some countries [29]. This guide was modified and finalized after three pilot interviews.
In order to predict the changes in stakeholders' position and influence, interviewees were asked whether their organization is going to participate in the field of HIV/AIDS in the future or not. To anticipate the future position of stakeholders several approaches were followed including reading current documents and programs, the current decisions of stakeholders mentioned especially in the Fourth Strategic HIV/AIDS Plan (which is in its final compilation and approval), (2016-2021) and applying policymaker software Version 4.
Data was analyzed using framework analysis and MAXQDA Version 11 qualitative data analysis 6 software. Policy Maker software (Version. 4) was used to analyze the results to guide stakeholders. In order to ensure the validity of the findings, at all stages, the researchers put aside their political tendency and biases; assured the heterogeneity of participants and collected data from different sources including key informant, relevant documents, and stakeholder's websites. Also, to make sure the accuracy of the researchers' interpretations about the content of interviews, they were sent to and rechecked by the interviewees.

Stakeholders Identification
A total of 36 participations including 12 mid-level state managers, 9 top governmental managers, 3 NGO members, 5 health professionals and lawyers, 3 specialists in infectious disease, 2 researchers, 1 excellent director of international organizations and 1 legislator were interviewed. Interviewees  Headquarters" is are currently participating at satisfactory level and the main concern in this regard should be to preserve this participation and improve it if possible. But before developing and proposing strategies to manage these stakeholders, their important features such as position and the level of influence must be well explained. Table 3 shows the features of the main stakeholders of HIV/AIDS in Iran. This table will be the basis for the compilation of necessary strategies to boost stakeholders' participation in the field of HIV/AIDS.

Participation/interest level in the issue
There are many stakeholders with regard to HIV/AIDS in Iran

The influence/power
Influence/power is defined according to the number of resources and the level of utilization of power by stakeholders, potential capacity and resources including money, authority, political power, knowledge etc. to influence policy decisions.
MoH is the main actor in the field of HIV/AIDS policy making, however, due to limited financial resources, not having legal and structural /supervising authority on the other actors and also shortages in human resources, it does not have enough power to influence other stakeholders.
Another reason for the low influence of the MoH on the other stakeholders is the lack of required authority and political and legal requirements to implement policies it formulates to combat HIV/AIDS.
In most cases the relationship between MoH and other institutions/organizations is interactive and not imperative, and it lessens the power and influence of MoH on other stakeholders in turn.
Iranian State Welfare Organization has moderate influence and power in spite of dealing with different vulnerable groups including addicts, prostitutes, and homeless children etc. The main reason for this moderate power goes back to the scarcity of resources and insufficient capacity as well as the lack of inter-sectoral collaboration with other stakeholders. Since, Iran Drugs Control Headquarter is one of the powerful organizations; its main responsibility is to compile strategies and assign budget to all its branches all over the country. So, it has a great influence on executive institutions which control addiction in the country. Therefore, utilizing this capability can be viable to fight against HIV/AIDS.

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Due to a close relationship with a large part of the country population, Ministry of Education has high potential in fighting against HIV/AIDS. But this ministry does not appropriately fulfill these potentialities owing to low motivation, lack of interest to participate and lack of management of available resources. IRIB as the only exclusive organization of radio and television networks has many resources and is highly powerful in the country to inform people. The Ministry of Interior as the HIV/AIDS is a socio-economic challenge rather than a health one. As a medical problem and due to the indifference to its social nature, HIV/AIDS has suffered from a lot of neglects in policymaking. On the other hand, problems such as being taboo of talking about AIDS and sexuality, and stigma and discrimination in the community have made barriers to the formulation of related policies that resulted in the insufficient implementation, ignoring the policymaking and hiding illness that contributed to the lower coverage of health care and increase in the number of unregistered patients and more transmission of diseases in the community. Unfortunately, in the current situation, there is no concentrated, specified and comprehensive mechanism to guide and coordinate the state-running organizations, institutions and NGOs to more effective control of HIV/AIDS and to prevent from new cases [17]. This issue has made different stakeholders to mainly work in a fragmented and nonintegrated manner. The cooperation between them is temporary, not permanent and more is in scientific and technical level not in the political and strategic one.

Policy Implications
The following strategies are required for appropriate management of HIV/AIDS active and inactive stakeholders. Regarding active actors; the necessary measures should take place to remove managerial, financial, human resources and facilities obstacles. In the case of less active actors, apart from requirement to increase their political and legal support, they should be encouraged to have more participation in HIV/AIDS policies through financial support and technical consultations.     Table 3: position, influence, and interest of stakeholders in the field of HIV/AIDS in Iran