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Spiritual interventions for preventing HIV/AIDS in Iran

Developing health programs based on the beliefs and values of communities has a great impact. Given the priority and importance of AIDS and its transmission through high-risk sexual behaviors, we sought to design a religious/spiritual intervention for preventing AIDS. Relevant statements were extracted from the literature and spiritual/religion documents, and the study questions were reviewed by a modified Delphi consensus panel. The statements were arranged in four areas of recipients, main components, providers, and settings for spiritual interventions. Using the existing capacities for Islamic spiritual interventions to prevent and control AIDS requires the development of executive factors along with underlying factors, such as infrastructure and facilities for the provision of interventions. The results of this study can lay the groundwork for supplementary studies.


INTRODUCTION
Known as the "plague of the century," HIV/AIDS is the most fatal infectious disease and one of the main barriers to the development of countries, in that it affects the majority of the active and productive population. [1] Statistics by the World Health Organization (WHO) show that 36.7 million people worldwide had been infected with HIV by 2016. [2] The prevalence of HIV was reported to be 15.07% among injectable drug users [3] and between 14.1% and 36.8% among those who acquired it through sex from 1986 to 2014 in Iran. [4] The WHO predicts that the rate of infection with HIV in Iran will have been reached 10% by 2020. [3] For all the effective efforts made by the mass media to raise awareness regarding HIV/AIDS among the Iranian general population, [5,6] the number of the identified cases of sexually transmitted infections has steadily risen, and there are now signs of high-risk sexual relationships among youths. [1,3,7] However, active measures have decelerated the pandemic rise in the number of injecting drug users. [3] Indeed, it is imperative that plans be devised so as to prevent high-risk sexual behaviors, particularly among the youth, and reduce prostitution. [8] Accordingly, health organizations and institutions have developed and implemented various programs aimed at preventing HIV/AIDS, and they have benefitted from the collaborations of religious organizations in the execution of these programs. In addition, by considering individuals' psychological and spiritual dimensions, religious organizations undertake the task of fostering psychological and spiritual empowerment and furnishing the skills required to eschew deviations and high-risk behaviors. [9] For example, effective measures have been taken to reduce HIV/AIDS among the African-American communities through a comprehensive program implemented by faith-based organizations. In tandem with the national health program, these organizations provide health and behavioral teachings for the community to reduce this disease. [10] Many researchers have also expressed the need for the implementation of these programs and confirmed the belief that spiritual and religious organizations can have an effective role in diminishing HIV/AIDS. [11][12][13] Although Muslims are involved in the implementation of this program, its content cannot be fully congruent with Islamic tenets, which calls for the development of a religion-based and culture-based program. For instance, compliance with Islamic teachings apropos sex, and above all, single people's abstinence and married couples' sexual fidelity are still regarded by Muslims as the best option for preventing the spread of HIV/AIDS. [14] Therefore, formulating health programs based on the beliefs and values of the Islamic community will be more effective.
To that end, the present study was conducted to design religious/spiritual interventions for preventing AIDS, to find the best recipients and providers of these interventions, and to determine the right settings for their provision. Since religious/spiritual concepts depend on cultures and beliefs, [15] interventions designed in the present study are based on Islamic instructions and teachings.

MATERIALS AND METHODS
The Spiritual Health Research Center of Iran University of Medical Sciences was commissioned by the Iranian Ministry of Health and Medical Education to conduct the present research project (Contract No.: 95, D,330,2985). The project was carried out through expert consensus. This method is used to design and develop the guidelines to address fundamental and complex issues, for which there is no documentation on the treatment or standard and applicable protocols. In this respect, various approaches have been utilized to design interventional and therapeutic guidelines, [16][17][18] which provide an effective method for such studies. [19] With a view to devising a roadmap, the following operational stages were decided and implemented. [20]

Selection of preliminary items
First, references of articles, reports, and documents published in reliable Iranian and international databases were searched. Next, unpublished evidence was collected through correspondence, databases presenting clinical guidelines (e.g., NGC, GIN, NICE, and SIGN), interviews with religious experts, and reviews of the literature on religion. Thereafter, based on the existing models and the models implemented in other countries, a pool of preliminary items was formed. Finally, through an exchange of views in the research team, a draft statement was prepared based on the study questions.

Expert panel
The statements raised in the preliminary draft were discussed one by one in a specialist panel with multidisciplinary experts, regarding the achievement of the specific goals of the research project.

Delphi survey
The statements were given a score by 24 experts and pundits in order for them to reach a consensus. [21] The detailsincluding name, specialty, and academic affiliation/career status-are shown in Table 1. Each statement was given a score based on a 3-point Likert scale. Further explanations or corrections were inserted by each member alongside poorly scored statements.

Data analysis
The median of the scores for each statement was determined, such that scoring options consisting of low, medium, and good were provided for each statement to show its favorability and practicability. The scores of each statement ranged from 1 to 9 points (for a 3-point range). The median score of 1-3 points denoted an inappropriate statement, 7-9 points an appropriate statement, and 4-6 points uncertainty in decision-making. The results were collected and analyzed in related domains with a view to answering the study questions. All the cases were approved by the majority of the experts following correction and revision in the specialist panel and the Delphi survey.

RESULTS
The statements were organized in four main domains of recipients, main components, providers, and settings for spiritual interventions. Each domain and its related statements are as follows:

Main statement: Providing spiritual interventions is essential for preventing HIV/AIDS
Rationale Different health organizations and institutions carry out a variety of AIDS prevention programs, and religious organizations assist in the implementation of these programs in various ways. In addition to facilitating the achievement of common goals, these organizations provide for the spiritual growth of individuals by taking into account their spiritual/religious dimensions and the necessary skills that they should acquire, thereby preventing deviations and high-risk behaviors.

Implications
Integrated spiritual interventions are possible with other preventive interventions or alone.

Auditable indicators
• The number of notified preventive spiritual interventions in the fields of health services.

Rationale
Despite effective efforts made by the mass media to raise awareness with respect to AIDS among the general population of Iran, the number of identified cases of sexually transmitted infections has continually increased and the signs of high-risk sexual relationships among adolescents are also observed. Hence, it is vitally important that a plan be formulated to prevent high-risk sexual behaviors, especially among young adults and adolescents, and reduce the incidence of prostitution.

Implications
Maximizing the participation of the intervention recipients requires an initial assessment based on the individual's desire to receive the spirituality-based interventions in the same center and by the providers of other services.

Rationale
Individuals' values, cognitive systems, behaviors, and emotions should be taken into account. As a primary meaningful system, emotion can be beneficial for individuals' adaptation. In fact, a feeling that is important for generating the meaning of an event is the outcome of the processing of an emotional experience in the brain, and its proper application boosts individuals' adaptation. Individuals' thoughts and beliefs exert a considerable impact on their behaviors and emotions, and emotion, cognition, and behavior interactively affect one another.

Implications
The motivation to attend and receive the spiritual interventions and, more importantly, to continue the sessions requires emotional control on the part of the attendees, who are adolescents and young adults. Providing the attendees with appropriate and rationale answers as regards their queries about pleasures and expectations of life and bringing up issues of interest are among useful participation and intervention tools.

Rationale
Taking heed of the cognitive dimensions of spirituality can affect individuals' concept of life and coping styles. Cognition refers to a set of thoughts, beliefs, and values held by individuals and their interpretations with respect to the events and phenomena that they face on a daily basis. Achieving a system of values and intrinsic and existential spiritual beliefs is consistent with the recommended frameworks.

Implications
Knowing God, spirituality, and values of human existence and dignity as well as seeking to have faith and achieve meaning and purpose in life are the deemed fundamental cognitive components, which will be taught and discussed after motivating the attendees to receive the services. (e.g., exercising, helping others, communing with God, choosing the right company, going to nature, and attending spiritual places and gatherings) d. Recommending controlling behaviors (e.g., self-care, regulating socialization, and managing sexual relationships).

Rationale
Individuals' personality and general framework of life can be affected by modeling and designing behaviors in line with the cognitive and emotional dimensions. Although these dimensions are separately assessed and described, there are complex relationships and interactions between them.

Implications
Providing desirable behaviors as a model to the attendees and informing them, especially about the consequences of high-risk behaviors, can be very useful. However, the consolidation of the recommendations should be accompanied by regular and planned practical exercises and elicitation of feedbacks.

Auditable indicators
• Number of the sessions allocated to the behavioral components out of the total number of the intervention sessions • Number of the practical programs (together with timetables) recommended to each intervention recipient.

Providers of the spiritual interventions for preventing AIDS: Statements
1. Providing recommended interventions that require a training course is essential 2. Individuals are selected from interested health experts for training courses 3. Periodical assessment of and feedback from the intervention providers are necessary.

Rationale
Using Islamic principles to empower individuals in emotional, behavioral, and cognitive terms in line with the country's health plans can be helpful. Collaborations with the Strategic National HIV Control can be effective in reducing high-risk sexual behaviors and ultimately AIDS. Implementing an integrated and multifaceted program enables AIDS prevention and control experts to respond to a wide range of clients' needs so that the services can be more effectively provided.

Implications
Providing services requires relevant training. Given that these services are time-consuming and need the spiritual readiness of the providers, selecting these service providers from among interested individuals will improve the efficacy of the interventions. Periodical biannual assessments of the service providers and recording some of the spiritual services will be useful for reviewing and resolving possible guide problems.

Auditable indicators
• Number of the trained health experts in spiritual interventions for AIDS prevention • Number of the training sessions held on this issue • Frequency of monitoring by the service centers • Number of the documented cases of interventions provided in each center.

Settings for providing the spiritual interventions for preventing AIDS: Statements
It is possible to provide interventions in the following settings: Health clubs, voluntary counseling and testing centers, counseling centers for vulnerable women, and other centers recommended by the Iranian Ministry of Health and Medical Education and related organizations.

Rationale
Furnishing the recipients of the interventions with an integrated and multifaceted program by AIDS prevention and control experts in the same service-providing centers will facilitate participation.

Implications
The programs of the proposed centers are somehow consistent with the designed interventions. With the establishment of each licensed center, services can be provided by trained experts in those centers.

Auditable indicators
• Number of the health clubs ready to receive the spiritual interventions • Number of the behavioral diseases counseling centers ready to receive the spiritual interventions • Number of the counseling centers for vulnerable women ready to receive the spiritual interventions.

DISCUSSION
Through an expert consensus approach in several stages, we sought to design a framework for spiritual interventions aimed at preventing HIV/AIDS among high-risk individuals. The present study boasts some outstanding features. First, we chose this subject because the existing literature had no similar studies on how to design spiritual intervention packages for high-risk individuals. The literature mostly contains activities at the level of providing health services by the team and members of religious and spiritual organizations and not as an integrated model of spiritual interventions in health programs. Second, our main focus in designing spiritual interventions was on the use of Islamic teachings, especially the texts from the Qur'an. Third, our spiritual intervention model is in line with comprehensive AIDS prevention programs, which cover religious/ spiritual dimensions. Fourth, our study type employed several appropriate methods that provide the possibility of arriving at a consensus on the subject in accordance with the literature on religion and belief. This method has been previously used in designing service and educational packages in the field of spirituality in Iran. [22,23] According to the results of the present study, it is essential to provide spiritual interventions for preventing HIV/AIDS. Meanwhile, most studies have revealed a positive relationship between spirituality/religion and absence of high-risk sexual behaviors and infection with AIDS. [24][25][26] Religion acts as a formidable shield against the spread of HIV/AIDS and encourages preventive behaviors. [27] Attending religious sites and adopting protective and religious behaviors are key factors in preventing high-risk sexual behaviors. [13] Accordingly, reliable clinical guidelines for preventing HIV/AIDS recommend that spiritual/religious dimensions be considered in health programs and services. [2,8,28] According to the present study, adolescents and young adults vulnerable to HIV/AIDS are suitable for receiving interventions. This result agrees with the preventive programs including faith-based organizations, which generally provide health education programs with various spiritual/religious dimensions for adolescents and young adults. [9,10] In line with the educational objectives of behavioral models in the community, these programs have been considered for the general public and those at risk, in that they draw upon individuals' spiritual power and dependence on religious centers for health programs. [29,30] Nonetheless, the Islam faithful has opposed this program from the outset because not only does it merely promote the use of condoms but it also encourages open discussions about sexual relationships and desires, which runs counter to Islamic teachings. [14] Therefore, adherence to Islamic teachings on sexual relationships and above all, avoiding sex by single people and sexual fidelity by married couples is still seen by Muslims as the best option for preventing HIV/AIDS. [31] Fortunately, many of the scientifically proven principles for preventing the spread of sexually transmitted diseases are concordant with religious values and principles, and Islam-in particular-has demonstrated its advantages through basic and scientific principles relating to disease. [32] Thus, taking advantage of Islamic principles for multidimensional empowerment of individuals in emotional, behavioral, and cognitive terms in line with the national health programs can be helpful and effective in accordance with the Fourth Strategic National AIDS Control Program of the Islamic Republic of Iran [3] by reducing high-risk sexual behaviors to prevent HIV/AIDS. Integrated and multidimensional implementation enables experts in AIDS control and prevention to respond to a wider range of clients' needs so that services can be provided more effectively. Many researchers and service providers have realized that multidimensional services are more effective when considering religious and spiritual dimensions [27] because values are the foundation of the integrity of personal identity and social adaptation. [33] The element of spirituality is indeed a huge force that can help the individual find a purposeful and coherent concept of the world and meaning of life. [34] Consequently, as health service providers consider the clients' attitude and performance with regard to their physical health, the value and cognitive system should also consider their behaviors and emotions. Considering the cognitive dimensions of spirituality can affect the individual's concept of life and coping styles. [35] Cognition denotes a set of thoughts, beliefs, and values held by individuals and their interpretations of events and phenomena with which they are faced every day. [36] Achieving an existential and intrinsic system of values and spiritual beliefs entails individuals' adaptation to ethical and social frameworks. [37] In agreement with the cognitive dimension, emotion as a primary meaningful system can also be effective in individuals' adaptation. Crucial to attaching meaning to an event, emotion results from the brain's emotional experience processing, and its proper function increases individuals' adaptation. [38] Individuals' thoughts and beliefs have a powerful effect on their behaviors and emotions, and emotion, cognition, and behavior interactively affect one another. According to Lazarus, the emotional dimension cannot be directly manipulated, and other dimensions such as biological or cognitive dimensions must be brought to bear to effect a change in it. [39] Ultimately, behaviors are the external intrapsychic manifestations in the interaction with cognitive and emotional structures. [40] In the present study, we designed the main components of our interventions according to the Qur'anic verses [41] and the extraction of fundamental concepts that contain these three dimensions.
Knowing of God and spirituality (Shora 28-31), existential human values and human dignity (Baghareh 30, Asra 70, Fater 10), and faith and finding meaning and purpose in life (Baghareh 177, Momenon 115, Malek 2) are the deemed fundamental cognitive components, which will be taught after motivating clients to receive a multitude of services, including spiritual interventions. The clients' knowledge of controlling pleasures, interests, and expectations (Hadid 22 and 23) based on emotion regulation can help advance the objectives of the intervention. As a result, individuals' personality system and general framework of life can be affected by behavioral planning vis-à-vis the cognitive and emotional dimensions. This will provide a model of desirable and undesirable behaviors (Araf 157); serve as a reminder of the consequences of high-risk behaviors (Araf 33); encourage positive behaviors (Faslat 46) such as exercise (Baghareh 247), helping others (Alomran 92), communing with God (Baghareh 152), choosing the right company (Forghan 27-29), going to nature (Baghareh 164), and attending spiritual places and gatherings (Araf 29); and advocate controlling behaviors such as self-care (Maedeh 105), socialization (Ehzab 23), and management of sexual relationships (Noor 31). Although these dimensions are independently and individually assessed and described, they have complex relationships and interactions. Generally, using this multidimensional and comprehensive interventional program by trained experts from national health organizations for vulnerable groups of adolescents and young adults interested in receiving health interventions can serve as a huge step toward the control and prevention of HIV/AIDS. Such guidelines require steps other than the initial stage of formulation, however. Clearly, training and motivating health service providers and providing the context for spiritual services by policymakers in health are necessary for the extensive implementation of these guidelines. Implementing this package and framework, based on Iranian/Islamic culture and value system, will tremendously boost the effectiveness and implementation of future programs based on this framework.
We recommend that applied studies be conducted and contents of an educational program for spiritual intervention be developed with a view to preventing AIDS according to this guideline in various areas of health services. This will significantly aid the development and reinforcement of the guideline.