HIV Policy Research Articles

The impact of the world Workshops on oral health and disease in HIV and AIDS (1988-2020).

The first World Workshop on Oral AIDS was held in San Diego in 1988, organized by John and Deborah Greenspan who saw the need and advantages of getting together all those health workers globally who were interested in oral aspects of HIV with a common purpose of advancing the field collectively and collaboratively. Since that time and over the following 30years, World Workshops on oral HIV have been held every four years or so. The aims of the first and all subsequent Workshops were to bring together clinicians and non-clinical scientists who have an interest in the oral manifestations of HIV disease, to share worldwide perspectives, knowledge and understanding of oral health and disease in HIV infection, to agree on global definitions and classifications of oral diseases and to identify research needs taking account of the worldwide perspectives and opportunities. Thus, there have been clinical science, social science and basic science aspects of each World Workshop. The Workshops have achieved their aims and have had impact in all three fields, leading to robust research agendas, changes in national HIV policies and international collaborations. They have led to policy declarations of access to oral care as a basic human right for both HIV-positive and HIV-negative individuals and advancing the rights of all HIV-positive healthcare workers to perform clinical practice.

Influence of evolving HIV treatment guidance on CD4 counts and viral load monitoring: A mixed-methods study in three African countries

ABSTRACT Little is known about how CD4 and viral load testing have evolved following implementation of universal test and treat (UTT) in African settings. We reviewed World Health Organization (WHO) guidance from 2013 to 2018, and compared it against national HIV policies in Malawi, Tanzania and South Africa. Three surveys rounds were conducted in 2013, 2016 and 2017–2018 in 33 health facilities across the three settings to assess implementation of national policies on the use of biological markers. Qualitative interviews were conducted with 26 HIV policymakers or programme managers, 21 providers and 66 people living with HIV to explore understandings and experiences of these tests. Various factors influenced adoption and implementation of WHO guidance, including historical policies on CD4 counts, governance issues, supply chain challenges and funding mechanisms. Facility-level practices relating to the use of these tests often diverged from national policies. Patients and providers valued both tests, but did not always understand their roles. In addition to continued support for scaling-up viral load testing, renewed focus should be placed on the ongoing value of point-of-care CD4 tests in the UTT era, including its role in assessing disease progression and informing clinical management of cases to reduce HIV-related mortality.

Prohibitionist Drug Policy in South Africa—Reasons and Effects

The moral approach that has been used to interpret and implement the Single Convention on Narcotic Drugs exacerbates the health burden faced by people who use drugs. Drawing on our experience in research, programming and policy relating to drug use and health in South Africa, we illustrate the negative consequences prohibition has had for the health of people who use drugs in our country. We argue that South Africa illustrates how approaches that stigmatise people who use drugs are morally justified at the expense of human rights and public health outcomes. We highlight how South Africa is perpetuating prohibitionist approaches on international platforms and question why this has endured. Conflicting health and law enforcement policies, local conservatism and donor conditionality have thwarted harm reduction expansion and evidence-based drug policy development, resulting in notable harms. Persistent morally-based perspectives contribute to stigma and discrimination in healthcare facilities and negatively affect treatment-seeking by people who use drugs. Criminal justice responses have increased TB exposure and entry into correctional centres that do not offer evidence-based drug treatment services. Encouragingly, progressive health and HIV policy affecting people who use drugs has recently been developed, and the recent decriminalisation of cannabis opens a door for policy debate. We recommend that to improve health, the Single Convention on Narcotic Drugs should be challenged to prioritise rights and health and that the personal use of drugs be decriminalised. We also highlight the need for mechanisms to hold health and other actors accountable for ensuring that the health and rights of all people are prioritised and strengthened.

HIV Policy Advancements in PEPFAR Partner countries: a review of data from 2010–2016

ABSTRACT This paper aims to describe and analyse progress with domestic HIV-related policies in PEPFAR partner countries, utilising data collected as part of PEPFAR’s routine annual program reporting from U.S. government fiscal years 2010 through 2016. 402 policies were monitored for one or more years across more than 50 countries using the PEPFAR policy tracking tool across five policy process stages: 1. Problem identification, 2. Policy development, 3. Policy endorsement, 4. Policy implementation, and 5. Policy evaluation. This included 219 policies that were adopted and implemented by partner governments, many in Africa. Policies were tracked across a wide variety of subject matter areas, with HIV Testing and Treatment being the most common. Our review also illustrates challenges with policy reform using varied, national examples. Challenges include the length of time (often years) it may take to reform policies, local customs that may differ from policy goals, and insufficient public funding for policy implementation. Limitations included incomplete data, variability in the amount of data provided due to partial reliance on open-ended text boxes, and data that reflect the viewpoints of submitting PEPFAR country teams.

COVID-19 and the HIV care continuum in Uganda: minimising collateral damage

The novel coronavirus, SARS-CoV-2, has spread across the world within months of its first description in Wuhan, China in December 2019, resulting in an unprecedented global health emergency. Whilst Europe and North America are the current epicentres of infection, the global health community are preparing for the potential effects of this new disease on the African continent. Modelling studies predict that factors such as a youthful and rural population may be protective in mitigating the spread of COVID-19 in the World Health Organisation (WHO) African Region, however, with 220 million infections and 4.6 million hospitalisations predicted in the first year of the pandemic alone, fragile health systems could still be placed under significant strain. Furthermore, subsequent disruptions to the provision of services for people living with HIV, or at risk of acquiring HIV, are predicted to lead to an extra 500,000 adult HIV deaths and a 2-fold increase in mother to child transmission of HIV in sub-Saharan Africa in 2020-2021. Ignoring these predictions may have severe consequences and we risk “stepping back in time” in AIDS-related deaths to numbers seen over a decade ago. Reflecting on our current experience of the COVID-19 pandemic in Uganda, we explore the potential impact of public health measures implemented to mitigate spread of COVID-19 on the HIV care continuum, and suggest areas of focus for HIV services, policy makers and governments to urgently address in order to minimise the collateral damage.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

Give the community the tools and they will help finish the job: key population-led health services for ending AIDS in Thailand.

The invisible intersectionality of female gender in Thailand’s response to the HIV epidemic

This article uses feminist perspectives to analyse Thailand’s response to the HIV epidemic from its inception in 1984 until today. In particular, it applies the WHO Gender Responsiveness Assessment Scale to explain how and to what degree gender considerations have been integrated into successive HIV policies and programmes. Findings show that, from 1984 to 1996, HIV prevention policies were generally insensitive to gender and only started to pay limited attention to women’s needs between 1997 and 2011. Gender sensitivity increased in the 2012–2019 period, but the focus then was more on ‘men who have sex with men’ and the transgender communities than on women. In general, Thailand’s HIV responses has overlooked gender power relations and the adverse effects of the intersection between women’s gender and their other disadvantaged social statuses.

Risk taking sexual behaviors among young adults – findings from a cross sectional population based survey in Barbados

Background: The National Strategic Plan for HIV Prevention and Control 2014-2018 recognized the need for the utilization of research findings to guide the development of HIV policies, programs and interventions for the general population and key population groups and to inform the allocation of government resources to the areas of greatest impact and need. To this end, a Knowledge, Attitudes, Beliefs and Sexual Practices Survey (KABP) was conducted among adults’ ages 15 to 49 years

Factors associated with first heterosexual sex; sexual coercion and sexual risk behaviors among adolescents in Botswana

Although early sexual debut is highly prevalent in Botswana, its link to sexual risk practices has not been explored at the national level. The aim of this paper was to investigate the association between age-at-first-sex, experience of sexual coercion and subsequent sexual practices. We used data derived from the 2013 Botswana AIDS Impact Survey (BAISIV)—a fourth and latest in a number of nationally representative, population-based surveys meant to measure the sociodemographic and other effects of the HIV/AIDS epidemic in Botswana. A sample of 3796 adolescents in ages 10–24 years who had successfully completed BAISIV individual questionnaire were selected and included for analysis. Data was analyzed using descriptive and multivariate statistical methods. All comparisons were considered statistically significant at p < 0.05. Mean age at first sex for the sampled adolescents was 17.9 years. Using binary logistic regression analysis, results indicate that females (AOR1.16, CI = 1.08–1.63), adolescents who did not belong to any religious affiliation (AOR = 1.71, CI = 1.03–2.86) and those who started sexual activity earlier (AOR = 1.53, CI = 1.02–2.56) were more likely to report to have experienced sexual coercion. Moreover, the odds of reporting multiple sexual partnerships were significantly high among adolescents who started sexual activity earlier (AOR = 1.71, CI = 1.03–2.86) and those who resided in cities/towns (AOR = 1.61, CI = 1.08–2.38). There is need for adolescent HIV policies and programs to address circumstances around young people’s initiation into sexual intercourse, as well as the psychosocial, and cultural norms pertaining to initiation of sex.

HIV Care Continuum and Meeting 90-90-90 Targets: Cascade of Care Analyses of a U.S. Military Cohort.

The new initiative by the Department of Health and Human Services (DHHS) aims to decrease new HIV infections in the U.S. by 75% within 5years and 90% within 10years. Our objective was to evaluate whether the U.S. military provides a good example of the benefits of such policies. We conducted an analysis of a cohort of 1,405 active duty military personnel with HIV enrolled in the Natural History Study who were diagnosed between 2003 and 2015 at six U.S. military medical centers. The study was approved by institutional review boards at the Uniformed Services University of the Health Sciences and each of the sites. We evaluated the impact of Department of Defense (DoD) HIV care policies, including screening, linkage to care, treatment eligibility, and combined antiretroviral therapy (cART) initiation on achieving viral suppression (VS) within 3years of diagnosis. As a secondary outcome, we evaluated the DoD's achievement of UNAIDS 90-90-90 targets. Nearly all (99%) were linked to care within 60days. Among patients diagnosed in 2003-2009, 77.5% (95% confidence intervals (CI) 73.9-80.6%) became eligible for cART within 3years of diagnosis, 70.6% (95% CI 66.6-74.1%) overall initiated cART, and 64.2% (95% CI 60.1-68.0%) overall achieved VS. Among patients diagnosed in 2010-2015, 98.7% (95% CI 96.7-99.5%) became eligible for cART within 3years of diagnosis, 98.5% (95% CI 96.4-99.4%) overall initiated cART, and 89.8% (95% CI 86.0-92.5%) overall achieved VS. U.S. military HIV policies have been highly successful in achieving VS goals, exceeding the UNAIDS 90-90-90 targets. In spite of limitations, including generalizability, this example demonstrates the feasibility of the DHHS initiative to decrease new infections through testing, early treatment, and retention in care.

Louisiana’s Intentional Exposure to HIV Policy: The Social Construction of Target Populations

ABSTRACT In 1987, Louisiana became one of the first states to put laws in place to criminalize intentional HIV exposure. Unfortunately, the law does not correlate with science nor does it evidence any effectiveness in reductions in HIV transmissions. In spite of this, it took over 30 years before Louisiana’s HIV exposure criminalization law was amended to be more scientifically accurate. There remains little research to determine the impact this policy has on public health efforts to reduce transmissions of HIV. This article will apply the social construction of target populations theory to Louisiana’s HIV exposure criminalization law to explore the reasons for the action and inaction that led to the introduction and promotes the continued use of a law that does not demonstrate any effectiveness in actually reducing rates of HIV transmissions.

The uptake of population size estimation studies for key populations in guiding HIV responses on the African continent

There has been a heightened emphasis on prioritizing data to inform evidence-based HIV responses, including data focused on both defining the content and scale of HIV programs in response to evidence-based need. Consequently, population size estimation (PSE) studies for key populations have become increasingly common to define the necessary scale of specific programs for key populations. This study aims to assess the research utilization of these size estimates in informing HIV policy and program documents across the African continent. This study included two phases; Phase 1 was a review of all PSE for key populations, including men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD), and transgender persons in the 54 countries across Africa published from January 2009-December 2017. Phase 2 was a review of 23 different types of documents released between January 2009 -January 2019, with a focus on the US President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria investments, for evidence of stakeholder engagement in PSE studies, as well as key population PSE research utilization to inform HIV programming and international HIV investments. Of 118 size estimates identified in 39 studies, less than 15% were utilized in PEPFAR Country Operational Plans or national strategic health plan documents, and less than 2% in Global Fund Concept Notes. Of 39 PSE studies, over 50% engaged stakeholders in study implementation and identified target population stakeholders, a third of studies identified policy or program stakeholders, and 15% involved stakeholders in study design. The past decade has seen an increase in PSE studies conducted for key populations in more generalized HIV epidemic settings which involve significant investments of finances and human resources. However, there remains limited evidence of sustained uptake of these data to guide the HIV responses. Increasing uptake necessitates effective stakeholder engagement and data-oriented capacity building to optimize research utilization and facilitate data-driven and human rights-affirming HIV responses.

When does evidence from clinical trials influence health policy? A qualitative study of officials in nine African countries of the factors behind the HIV policy decision to adopt Option B+

Introduction The appropriate role of evidence in health policy decision making is controversial and requires more data on how decisions are actually made. Option B+ is a strategy to prevent mother to child transmission (PMTCT) of HIV that involves starting pregnant, HIV-positive women on triple drug antiretroviral therapy (ART) and continuing for life. It was rapidly adopted by sub-Saharan African countries with limited scientific evidence for its efficacy and safety, without waiting for the results from an ongoing randomised controlled trial (RCT) comparing PMTCT strategies. Methods We interviewed 14 senior HIV policymakers in nine sub-Saharan African countries about factors influencing their adoption of Option B+. ResultsWhile scientific evidence was important to the decision to adopt Option B+, policymakers were persuaded by data that did not come from RCTs. Other factors also played an important role including: evidence for ancillary benefits, simplicity, alignment with other values and priorities, and ease of integration with existing programmes. ConclusionsIn adopting Option B+, gold-standard scientific evidence played a relatively minor role; other considerations were more important. Future research could help researchers determine whether these factors are influential in other contexts and to develop evidence that is more responsive to the needs of policymakers.

Knowledge, information needs and behavior regarding HIV and sexually transmitted infections among migrants from sub-Saharan Africa living in Germany: Results of a participatory health research survey.

BackgroundA total of 3,419 new HIV diagnoses were reported in Germany in 2016, with migrants from sub-Saharan Africa (misSA) accounting for 14.1%. To understand the driving factors behind the epidemiological situation, we conducted a quantitative cross-sectional survey on knowledge, attitudes, behavior, and practices regarding HIV and sexually transmitted infections (STIs) among misSA living in six German cities utilizing participatory health research.MethodsParticipants were recruited by peer researchers. Levels of knowledge, information needs, and preferred methods of information dissemination were analyzed to inform future prevention planning. Additionally, we analyzed sexual behavior and other risk factors for contracting HIV and STIs. The results may facilitate the formulation of targeted prevention messages in the future.ResultsWe included 2,432 participants in the analysis. General knowledge about HIV was adequate, as 86.9% were aware of the presented information. Statements about HIV co-infections were prior knowledge for 53.4% of the participants and about German HIV policies and HIV testing for 54.7%. Knowledge about other STIs differed, ranging from 69.6% who have ever heard of gonorrhea to 23.8% who have ever heard of genital warts. Groups with particular knowledge gaps were i) younger misSA, ii) recent migrants, iii) misSA without regular access to the German health care system, iv) misSA of lower socioeconomic status, and v) misSA with Muslim religious affiliation. The majority of participants reported information needs (72.8%), and 71.3% wanted to obtain this information from health professionals. Male misSA were more likely to report five or more sexual partners compared to females. Less than half of participants reported always using condoms with non-steady sexual partners (46.8%). Reasons for not using condoms differed between males and females. A considerable proportion of females (16.3%) and males (6.8%) experienced sexualized violence. More than one fourth of women (26.9%) were affected by female genital mutilation/cutting.DiscussionFuture prevention planning should focus on sub-groups with particular knowledge gaps, recognizing their preferred methods of information dissemination. Prevention messages for male misSA should focus on their own risk perception and for female misSA on empowerment, e.g. to negotiate condom use.

Implementation of HIV and AIDS Management Policies in the City of Bandung

Patients with HIV and AIDS in Bandung are problems that need treatment so that the number of people with HIV and AIDS decreases. This study aims to find out how the implementation of HIV and AIDS prevention policies in the city of Bandung and the driving and inhibiting factors by using the theory of Van Metter and Van Horn policy implementation. This study uses qualitative methods with a purposive sampling technique in determining informants and uses triangulation techniques in data analysis. The results of the study revealed that the implementation of HIV and AIDS prevention policies in the city of Bandung is still not going well because of the factors that have not been externally driven by a boost program, lack of public understanding and the absence of HIV AIDS drugs to cure the disease completely.

Is the Philippines ready for HIV self-testing?

BackgroundThe Philippines is facing a rapidly rising HIV epidemic among young men who have sex with men (MSM). Testing rates among young populations is poor. HIV self-testing (HIVST) is a promising strategy to address this testing gap. The study’s purpose was to explore the perceived acceptability, feasibility and programmatic challenges of HIVST among key informants and target users.MethodA qualitative study involving semi-structured interviews and focus group discussions (FGD). We interviewed 15 key informants involved with HIV testing programs or policies and 42 target users in six FGD in Metro Manila. We held separate discussions with high socio-economic MSM (n = 12), urban poor MSM (n = 15) and transgender women (TGW) (n = 15). Results were analysed using a thematic framework approach.ResultsMSM and TGW welcomed the convenience and privacy HIVST could provide. They preferred an inexpensive accurate blood-based kit attained from reputable sites. Key informants at national and local level equally welcomed HIVST but identified a number of policy and regulatory issues. Both groups articulated the challenge of enrolling those who test reactive using HIVST to further testing and treatment in an environment characterised by acute stigma around HIV.ConclusionsHIVST was found to be highly acceptable to target users and was welcomed as an additional testing approach at national level. Strategic alliances are now needed between stakeholders to proactively deliver a patient-centred HIVST program that could provide an effective, safe means of increasing testing coverage in this escalating context.

Quantifying pediatric patient need for second- and third-line HIV treatment: A tool for decision-making in resource-limited settings

As national HIV programs across the world mature and continue to scale up towards UNAIDS’ 90-90-90 targets, it is increasingly important to accurately estimate HIV treatment needs in pediatric patient populations to prepare for anticipated increases in demand. This is particularly vital in sub-Saharan Africa, where the bulk of the global pediatric HIV burden remains concentrated, and for treatment-experienced populations, for which data are severely limited. This article discusses the conceptual framework behind and application of a five-year country-level quantification and decision-making tool aimed at providing national HIV programs and their partners with a better understanding of their evolving national HIV treatment and programming needs for second-and third-line pediatric populations. The conceptual framework of the algorithm which undergirds the tool is the patient pathway, along which key influencing factors that determine whether pediatric HIV patients are linked to care, remain in treatment, and are appropriately switched to later lines of treatment are accounted for quantitatively. Excel-based and arithmetic, the algorithm is designed to use available national, regional, and global data for factors impacting patient estimates including treatment coverage; routine viral load testing; viral load non-suppression; confirmed treatment failure; and patient loss to follow up—outcomes for which data are generally very limited in this patient population. The ultimate output of the tool is an estimate of the aggregate annual number of patients by treatment line. Given the limitations in available data for pediatric HIV, particularly for patients on second- and third-line treatments, this tool may help fill a data gap by providing a mechanism for policymakers to scenario plan, thus aiding resource allocation decisions for pediatric HIV program scale-up. The tool may be used to streamline national antiretroviral procurement of later lines of treatment, especially in resource-limited settings, and may also be used to add value to broader HIV policy and planning processes at the national level.

Accessing Medical Care After a Needlestick Injury: First Responders' Perception of HIV Risk and Attitudes Toward Syringe Service Programs.

First responders have an increased risk of occupational exposure to HIV as the result of a needlestick injury (NSI) because of the chaotic prehospital environment in which they provide care. Approximately 2.3 of every 1000 first responders (0.23%) who are exposed to HIV via a NSI risk seroconversion if left untreated. Participants completed a 28-question online survey examining level of concern about HIV, thoughts about injection drug use, number of accidental NSIs, and medical services received after a needlestick. First, all data were analyzed descriptively. Second, a multiple linear regression model was used to explore the level of concern about HIV as a function of the predictor variables. Nearly half of the respondents worked as paramedics (n = 141, 23.5%) or emergency medical technicians (n = 154, 25.7%), followed by 15.5% (n = 93) and 11.3% (n = 62) who indicated their primary first responder affiliation as "firefighter" or "police," respectively. The majority of the study population identified as male (75%, n = 450); 24.8% identified as female (n = 149). Slightly more first responders reported receiving no medical services after a needlestick (9.8%, n = 59) than received an HIV screening (9.5%, n = 57), and only 3.2% (n = 19) of those who experienced a needlestick reported receiving post-exposure prophylaxis. The results suggest that perceived risk of HIV infection via needlestick ultimately influences follow-up medical screening. Greater concern about HIV is significantly associated with HIV screening and willingness to obtain post-exposure prophylaxis. Future research should examine the impact of continued HIV education and policies outlining medical evaluation and other post-exposures procedures.

The Relationship between Awareness of HIV and AIDS Workplace Policy and Consultation on HIV and AIDS Policy Development among Staff of Moi University, Kenya

The unprecedented effect of HIV and AIDS in Africa cannot be over-emphasized as it takes its toll mainly on the active age population of 15-49 years. This age group is the main workforce of any nation and, unfortunately, the most vulnerable to infection of HIV. There has been growing concern about the devastating impact of HIV and AIDS in many workplaces. In response, many universities have developed university specific HIV and AIDS policies for impact mitigation in the workplace. Moi University is a public institution with a large workforce hence targeted in the current study. Realizing the negative impact that HIV and AIDS has on workplaces and the importance of having an HIV and AIDS workplace policy, this study sought to determine the relationship between awareness of HIV and AIDS workplace policy and consultation on HIV and AIDS policy development among staff of Moi University. The study, whose main concern was about Moi University HIV and AIDS workplace policy, targeted teaching staff, non-teaching staff and senior management. To achieve this objective, the study used ex-post facto research design and stratified sampling technique in the selection of the study sample. A study sample made up of 330 participants was used for the study. The study utilized both qualitative and quantitative methods in data collection. These included Workplace Testing Questionnaire, document analysis and semi-structured interviews. Primary data was collected by use of self-administered questionnaires and interview schedules, while secondary data was collected from libraries. The study used the Statistical Package for Social Sciences (SPSS v 22.0) program to analyze the data collected. Qualitative data was analyzed thematically through coding. Both descriptive and inferential statistics were used. The descriptive statistics included frequencies and means. Correlation analysis was used to test hypotheses (to test the relationship between the independent and dependent variables). The findings revealed that Moi University had an HIV and AIDS workplace policy. It also emerged that lack of consultation on HIV policy development, was an impediment to successful implementation of the policy. The study concluded that HIV and AIDS workplace policy is a vital document in HIV and AIDS impact mitigation and, therefore, requires serious consultation among all employees of Moi University for purposes of ownership by every employee. Following this, the study recommended that consultation of all of all employees about HIV and AIDS workplace policy development be undertaken and worker’s views and opinion be considered when developing an HIV and AIDS workplace policy. The study is, therefore, expected to be of great significance to universities in addressing some of the HIV and AIDS workplace policy related implementation challenges.

Living with HIV as Donor Aid Declines in Tanzania

ABSTRACTFluctuations in global health funding can significantly impact the lives of people who depend on donor-funded programs for life-long care. In this article, I examine shifting HIV policies that expanded antiretroviral therapy (ART) while reducing “care” services meant to improve ART access and adherence. I describe how these changes were experienced by HIV+ women accessing ART at a hospital in Tanzania in 2011–2012, highlighting their increasing precarity and uncertainty for care amidst donor instability and eroding program services. This research suggests that stable funding in support of long-term care services is important to help HIV+ people maintain life-long ART.