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

doi:10.21203/rs.3.rs-16014/v1

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

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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.

Health Economics & Outcomes Research

Health Policy

HIV/AIDS

IRAN

Stakeholder analysis

policy analysis

policy making

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 [1–3]. 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[15–17].

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. 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 [19–21]. 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 [22–24]. 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 stakeholders of HIV/AIDS policy-making in Iran.

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 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.

Key actors and stakeholders of HIV/AIDS in Iran

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 included 25 men and 11 women. The mean age and mean work experience of the interviewees were approximately 48 and 14 years, respectively.

HIV/AIDS is a multidimensional phenomenon and for this reason, multiple stakeholders and actors involve in different areas (prevention, treatment, rehabilitation and other supportive interventions) of HIV/AIDS policymaking

Table 1 & 2 show the present stakeholders involve in the field of AIDS in Iran and their present/active and absent/inactive presence, respectively.

Figure 1 indicates specific plans and strategies must be formulated to increase participation on behalf of institutions like Ministry of Science, Ministry of Sport and youth and Iranian Red Crescent as well as to improve the participation of IRIB and Ministry of Education and the Ministry of Interior. Institutions such as “State Prisons and Security and Corrective Measures Organization” and “Iran Drugs Control 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.

Features of AIDS Stakeholders

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 Ministry of Health, State Welfare organization of IRAN, Iranian blood transfusion organization, State Prisons and Security and Corrective Measures Organization are intersted to participate in the field of HIV/AIDS policy-making as they are directly involved in the treatment process and dealing with patients and high-risk groups. NGOs dealing with addiction and HIV/AIDS have high interest to participate in this issue, although they do not play a considerable role in policymaking. Most of these associations and NGOs are managed by the patients themselves or their families; so they are highly interested in getting involved in this field.

Addiction is a major risk factor for getting and spreading HIV/AIDS. For this reason, Staff Drug Addiction, as the main body responsible for policy-making of the addiction, is indirectly involved in the field of HIV/AIDS. Staff Drug Addiction participation needs to be increased owing to indirect involvement and medium interest in the field of HIV/AIDS. The Ministry of Interior which is responsible for organizing NGOs and is involved in social problems through its “Social Affairs Office” can be very helpful in the prevention and controlling HIV/AIDS but it is fairly interested in getting involved in the field of HIV/AIDS like Staff Drug Addiction.

Being involved in social problems and injuries, Ministry of Labor and Social Affair also shows partial interest in getting involved in the field of HIV/AIDS. IRIB and the Ministry of Education are interested to play role in the field of HIV/AIDS, but like above mentioned organizations, this participation is also partial. The participation on behalf of these organizations is only limited to deliver health education and information regarding the nature of the disease and the ways that HIV/AIDS might spread, and they do not have an active role in promoting preventive ways and safe sexual behaviors.

Despite the involvement of several institutions in the field of HIV/AIDS policymaking, their engagement is in very low level in Iran and is often limited to the development of the National Strategic Plan for HIV/AIDS. For instance, Secretariat of the Supreme Council for Health and Food Security only participates in cases that require overview and approval of the strategic plan. “Healthcare Armed Forces”, “Ministry of Science, Research and Technology” and “Ministry of Sport and Youth” do not participate in the implementation of policies related to prevention and training as they are not mainly responsible for the control of HIV/AIDS, and consequently they are partially interested in getting involved in the field of HIV/AIDS.

Finally, despite the great power of Islamic Consultative Assembly (Iranian Parliament) in legislation and monitor of executive agencies, so far, its involvement in HIV/AIDS policy making has not been in satisfactory level and has shown low interest in this area.

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.

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 administrator of ‘Iran Drugs Control Headquarters’ organizes the NGOs and has a nationwide network with required resources and authorities to address directly social affairs in the country. Like the Ministry of Education, Armed Forces of the Islamic Republic of Iran have many resources to influence army forces and their dependents but does not benefit from the allocation of available resources to fight against HIV/AIDS. However due to their low level of interest, it seems that they are not interested in allocating their resources to control HIV/AIDS. Finally, despite its unique authority in making laws and other executive institutions/organizations, the Islamic Consultative Assembly (Iranian Parliament) has high potential in solving problems in this area but it is not directly involved in the field of HIV/AIDS.

Position

The majority of active stakeholders in the field of HIV/AIDS policy making have a supportive position in hitting HIV/AIDS but they showed different degrees of support. A number of stakeholders including the Ministry of Health, the Blood Transfusion Organization, associations and NGOs, which are directly deal with HIV/AIDS patients and preventive measures, strongly support HIV/AIDS programs. Iran Drugs Control Headquarters, State Welfare Organization and Ministry of Interior, which their departments have, direct involvement with the subject, have a medium supportive position in this regard.

However, some other organizations such as the Ministry of Education and the IRIB support the subject slightly and sometimes oppose some policies due to their low interest to participate in AIDS-related policies. The degree of support of other stakeholders is low and often they have neutral position and low participation in this area because they do not have direct responsibility or duty to fight against HIV/AIDS. Nonetheless, it can be transformed into a high supportive position by clarifying the duties and responsibilities of each organization.

Predicting the changes in stakeholders’ position and influence

Predicting the changes in stakeholders’ position and influence takes place based on their current decisions and plans for the future (at least over the next five years). This anticipation is vogue because unpredictable future events possibly lead to unpredictable changes in stakeholders’ position and influence in the future.

Given the weakening of the National HIV/AIDS Committee's position due to its integration into the Supreme Council for Health and Food Security, it is likely that the power and influence of the Ministry of Health will be diluted in the future. Ministry of Interior would remain in the low supportive position. Also, the medium supportive position of the Iran Drugs Control Headquarters Organization will be probably reduced in the next few years. The only positive and hopeful change can be the increase in the amount of power, influence and supportive position of NGOs (Figure 2)

The supportive position of IRIB and Ministry of Education as main stakeholders in the field of education and information on HIV/AIDS policy is generally low, but with respect to some contents, even in some specific politics, especially those related to sex, they have an opposite and stubborn position.

The multidimensional nature of HIV/AIDS and the closed relationship between HIV/AIDS and other social problems like addiction requires a wide intersectoral collaboration among stakeholders. The Supreme Council of AIDS was formed to formulate the policies of the executive organizations and stakeholders and to coordinate them. However, in recent years, intersectoral collaboration mechanisms have been weakened due to the displacement of the Supreme Council of AIDS into the Supreme Council for Health and Food Security. As the Supreme Council for Health and Food Security is the main responsible body in regulating and addressing all health issues and is busy with several agendas, insufficient concentration is given to the HIV/AIDS when compared to the other health problems such as increasing the prevalence of Non-Communicable Diseases, lifestyle and food security issues. In Iran, the key role of actors and the effectiveness of their activities have always been controversial because there is always a loose coordination and interaction between stakeholders and which has not changed over the years [30].

Despite the high interest and high supportive position to participate in the field of HIV/AIDS, MoH as the main body responsible for HIV/AIDS has not enough power and authority to force other organs to work for HIV/AIDS. In contrary, powerful institutions such as the legislative and judiciary systems or the Ministry of Interior, despite having high power, have very low interest and participation in policy-making process. However, in a country like Vietnam which is similar in terms of legal status and social problems to Iran, the ruling party and then National Assembly are directly provide guidelines, legislations’ approvals and oblige most of stakeholders to cooperate and accomplish their duties concerning national policies and in this way most of problems regarding intersectoral collaboration are solved (23).

However, in most of countries, due to the high importance of the HIV/AIDS, a definite mechanism has formed to facilitate stakeholders’ coordination. The main actor in the field of AIDS is the government in the countries such as Vietnam, Ukraine, and Tanzania. These countries have assigned the duty stewardship of AIDS to any institutions and ministries and are directly responsible through the AIDS Commission in Tanzania [31], the National Council of the Ukrainian and National Committee of the prime minister's office in Vietnam [32]. Since the government has set up an institution for actors’ management and their coordination it shows the high importance of the HIV/AIDS for these governments (22)

Ancker et al. in Kyrgyzstan, surveyed a number of policy initiatives to deal with an accelerating HIV/AIDS epidemic. Their results emphasized on the important and supportive role of stakeholders regarding the HIV/AIDS policies, but their level of participation in/and influence on the HIV/AIDS policy process were different. The critical problem was that several important governmental institutions showed some resistances to some initiative that lead international organizations and NGOs to conceptualize some appropriate policies. Consequently, result showed that without a prospect, definite and clear leadership by the government, the stability of National Response to deal with HIV/AIDS will be doubtful in Kyrgyzstan [33]. Experiences in many other countries including Brazil, Thailand, and Uganda, showed that strong national leadership is an essential ingredient of successful responses to the HIV/AIDS epidemic [34].

However, in Iran owing to the absence of the former Supreme Council of AIDS, the only way to enhance collaboration among stakeholders is the preparation, compilation, monitoring, and evaluation of national HIV/AIDS strategic plan. Nevertheless, in Iran, participation and cooperation are at the level of middle managers and technical experts rather than the various institutions of higher authorities. In fact, the partnership and cooperation between different institutions in the field of HIV/AIDS is only limited to intermediate managers and technical experts and it is not in the scope of engagement and commitment of the top managers at the highest possible political level[17].

Here an important question comes to the surface that whether it is possible to reduce the incidence of new cases to zero in Iran regarding to the current structure of HIV/AIDS policymaking and the relationships among stakeholders?

Some of the actors found the solution of the current situation in re-establishment of the Supreme Council of AIDS. Some others have raised existing challenges at the time of the National Committee and Supreme Council of AIDS activity, and considered insufficient influence and power of a governmental institution (Ministry of Health) on the other institutions and as the reason they suggested the creation of a similar structure of the Iran Drugs Control Headquarters that would be active under the direct supervision of the President.

Some other interviewees considered HIV/AIDS as a complex issue, and they believed that a national supreme institution (for instance administered directly by the parliamentary, the judiciary or the executive branches) with enough power and authority should be established to supervise and obligate other executive agencies to follow and implement HIV/AIDS policies.

In Pakistan, due to an extensive delegation system extended from the national level to provincial level, governors and managers have a key role in all stages of the policy-making process and extensive participation in financing (34% of total AIDS’ resources in 2013). Other institutions usually coordinate with the Ministry of Health regarding compilation and the implementation of multi-sector policies. In Brazil, ministries concerning women's affairs, youth, social welfare and human rights have high influence in policymaking and indicate high participation in specialized fields at all stages of the policy-making process. Furthermore, in Brazil a large number of NGOs are greatly influential and powerful in all fields.

Ukraine also tries to attract multiple stakeholders’ participation in a National Assembly committee under the supervision of the Cabinet. Although, these structures are highly governmental, some non-governmental or semi-governmental institutions such as the Ukrainian Institute play an active role in social research. In Tanzania, the leading point is high influence and power of institutions and international organizations such as United Nations and the United States Agency for International Development (USAID) that have high impact and participation at all stages of the policy-making process in this country.

Another important issue in this regard is that Iran has not been able to properly use the support of international organizations in this regard. In a comparative study of AIDS policies in the selected developed and developing countries (three developed countries including USA, United Kingdom (UK), Australia; and three developing countries including Sudan, Nigeria and India), it was revealed that the involvement of the international and national Non-Profit Government Agencies (NGOs) can affect different outcomes of the HIV/AIDS prevention programs [35].

In a study in Brazil, the results showed that within the framework of the National AIDS Program, the level of involvement and collaboration between public actors and NGOs deeply affected the population coverage and sustainability of HIV/AIDS control programs. Non-governmental organizations, particularly non-governmental HIV/AIDS organizations, are required to ensure mobilization at the preliminary stage of programs [36].

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 non-integrated manner. The cooperation between them is temporary, not permanent and more is in scientific and technical level not in the political and strategic one.

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. Regarding inactive actors; firstly, it is necessary that their neutral position should be transformed into the supportive position by designing a suitable training package, and secondly engage them actively in playing more direct role via proposing suitable informational, financial and technical incentives. It is recommended that HIV/AIDS trustee such as the Ministry of Health and The Ministry of Labor and Social Affair should empower financing, human resources, technical knowledge of NGOs which are working in the field of addiction and HIV/AIDS and give them the opportunity of greater participation in policy making process.

The main limitation of the study was limited access to policy documents and key informants inside the country. In order to reduce these limitations, some measures were done including signing a memorandum of cooperation with the management of communicable diseases, Ministry of Health, receiving a letter from the management of communicable diseases and offering it to organizations, institutions and centers as well as the cooperation with AIDS Research center for complete access to policy documents and key participants. Despite taking these measures, the limitations were not fully solved and comments of some key informants as well as the content of some of the related documents or reports were not utilized in this study.

Ethics approval and consent to participate: Ethical approval for the study (with code number 8921557002) was received by Ethics Committee in Research Affairs, Tehran University of Medical Sciences. As it was a qualitative study, we obtained verbal informed consent from all participants to participate in the study. Verbal informed consent is acceptable by the Ethics Committee in Research Affairs.

Consent for publication: Not Applicable

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: No conflict of interest was declared.

Funding: This work was supported by the Tehran University of Medical Sciences.
Authors' contributions: RKZ, HR and AM: Conceptualization. RKZ, HJ and MB: Draft preparation and reviewing and editing the manuscript. HR and AM: supervision. All authors reviewed the final version of the manuscript. All authors read and approved the final manuscript.

Acknowledgements: This article is part of a doctoral thesis entitled ‘AIDS Policy Analysis in Iran’, conducted with the support of Tehran University of Medical Sciences.

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Table 1: present/active stakeholders and their roles in HIV/AIDS policymaking in Iran

Agencies / organizations		Role
Governmental organizations:
1	Ministry of Health and Medical Education	stewardship of HIV / AIDS in the country, the provision of prevention, diagnosis and treatment services for the patients
2	Ministry of Labor and Social Affair	Participation in the program of poverty alleviation, social protection and health insurance for the patients
3	Ministry of Education	Training and informing of students
4	Ministry of Interior	Management of NGOs and activity in the social activity
5	Ministry of Science, research, and technology	Training and informing of university students
6	Ministry of Sport and Youth	Devising and implementing training and informing programs for young people
7	Iran Drugs Control Headquarters	stewardship in the field of addiction
8	State Welfare Organization of IRAN	Management of high-risk groups and delivery of preventive, diagnostic and curative services
9	Iranian Blood Transfusion Organization	Refining and screening blood and blood products
10	Iranian Research Centre for HIV/AIDS (IRCHA)	Research, consultation and participation in diagnostic, curative and supportive programs
11	IRANIAN NATIONAL CENTER FOR ADDICTION STUDIES	Research, consultation and participation in diagnostic, curative and supportive programs
12	Islamic Consultative Assembly (Iranian Parliament)	Upstream legislation and resource allocation for the executive agencies
13	Expediency Discernment Council of the System	General policies about addiction and other related affairs
14	Judiciary (judicial system in Iran)	Settlement of prisoners' laws and regulations and providing services to prisoners
15	State Prisons and Security and Corrective Measures Organization	Provision of diagnostic, curative and consultative services to prisoners
16	Armed Forces of the Islamic Republic of Iran	Training and providing preventive programs for the armed forces
Semi-governmental Organizations:
1	IRIB (Islamic Republic of Iran Broadcasting)	Producing and broadcasting educational and informative programs
2	Tehran Municipality	Participation in the training of citizens
3	Imam Khomeini Relief Foundation	Poverty alleviation and supportive programs
NGOs:
1	Iranian Red Crescent	Participation in training of volunteers and young people and provide diagnostic and therapeutic services
2	Positive Clubs	Supportive programs for patients
International organizations:
1	The Joint United Nations Program on HIV/AIDS (UNAIDS)	Management and coordination of HIV/AIDS international programs and allocate AIDS international funding
2	The World Health Organization	Working closely with the Ministry of Health and UNAIDS

Table 2: absent/inactive stakeholders and their potential role in HIV/AIDS policymaking in Iran

Agencies / organizations			Potential role
government or state agency:
1	Prayer Office	Sermonizing and informing the public about the disadvantages and risks of HIV/AIDS and restoring to Islamic principles as a safe way to reduce the incidence of HIV / AIDS and supporting patients
2	Friday Prayers office	Sermonizing and informing the public about the disadvantages and risks of HIV/AIDS and restoring to Islamic principles as a safe way to reduce the incidence of HIV / AIDS and supporting patients
3	Office of Mosques Affairs	Sermonizing and informing the public about the disadvantages and risks of HIV/AIDS and restoring to Islamic principles as a safe way to reduce the incidence of HIV / AIDS and supporting patients
4	Islamic Development Organization IR IRAN	Sermonizing and informing the public about the disadvantages and risks of HIV/AIDS and restoring to Islamic principles as a safe way to reduce the incidence of HIV / AIDS and supporting patients
5	Abrahamic religions minorities of Iran	Sermonizing and informing the public about the disadvantages and risks of HIV/AIDS and restoring to religious principles as a safe way to reduce the incidence of HIV / AIDS and supporting patients
6	Iran's Endowment and Charity Affairs Organization	Fundraising and attracting financial support and charity aids to prevent HIV/AIDS and support people with HIV/AIDS.
7	Ports and Maritime Organization of Iran (PMO)	Training, informing and monitoring the incidence and prevalence of HIV / AIDS
8	Iran Road Maintenance & Transportation Organization (RMTO)/ (IRI Transport Company)	Training, informing and monitoring the incidence and prevalence of HIV / AIDS
9	Refugees Affairs Office	Training, informing and monitoring the incidence and prevalence of HIV / AIDS
10	Provincial Government Governorates	Advertising and Informing
11	Administrative and Recruitment Affairs Organization of Iran (ARAO) or Department of State for Administration and Employment Affairs	Providing training programs for managers and public employees
Semi-government organizations:
1	Municipalities	Participation in training of the citizens
2	Social Security Organization	Providing preventive, curative and supportive programs for the workers in its own health care facilities
NGOs:
1	Pharmaceutical companies	Participation in policy making and providing required/needed drugs for the HIV/AIDS patients
2	Private insurances	Covering uninsured services
3	Sāzmān-e Basij-e Mostaz'afin	Inclusive/ comprehensive Educate and inform, Mobilizing, organizing and training volunteers for the social objectives
4	Iran scientific association commission (I.S.A.C)	Consultation, production of evidence and participation in policy making
5	Experts, researchers, and academics	Consultation, production of evidence and participation in policy making
6	Iranian Organization of Cinema and Audiovisual Affairs	Advertising and comprehensive information in the field of art
7	sport clubs	Advertising and comprehensive information in the field of sport
8	AIDS population	Participation in the production of evidence, policy-making, and advising on the implementation process

Table 3: position, influence, and interest of stakeholders in the field of HIV/AIDS in Iran

position	influence/ power	Interest	Stakeholder
high supportive	Medium	high	Ministry of Health
Medium supportive	Medium	high	Ministry of Labor and Social Affair
high supportive	Medium	high	Iranian blood transfusion organization
low supportive	High	Low	Judiciary
Medium supportive	High	Medium	Iran Drugs control Headquarters
low supportive	Medium	Low	Ministry of Education
low supportive	High	Low	IRIB
Medium supportive	High	Medium	Ministry of Interior
Non-mobilized	Medium	Low	Ministry of Sport and Youth
Non-mobilized	Medium	Low	Ministry of Science
Non-mobilized	High	Low	Armed Forces of Iran
high supportive	Low	high	Associations and NGOs
low supportive	High	Low	Islamic Consultative Assembly (Iranian Parliament)

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

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