HIV Response Research Articles

Presidential communication approaches and the impact on public health: a comparative analysis of three South African presidents’ communication on AIDS and COVID-19

The HIV response in the African continent over past decades demonstrates the potency that the words and actions of political leaders have in either expediting or impeding the implementation and adoption of preventive measures at the individual and community levels. The article explores the health communication approaches employed by two South African past presidents (Thabo Mbeki and Jacob Zuma) in responding to the HIV epidemic, and contrasts these with the communicative approach of President Cyril Ramaphosa during the COVID-19 pandemic. Approached from this understanding, this article provides a comparative analysis of the communication approaches of these three presidencies across the two pandemics, and considers the variously trusted sources of top-down, government-driven and bottom-up, community-informed approaches to health communication. Critical lessons that emerged in South Africa during the HIV epidemic regarding the need to include communities in communicating about risks and behaviour change have not been adopted into the COVID-19 response. Political leaders are not best placed to communicate about these issues, and, in the context of pandemics, there is a clear need to reconsider top-down communication approaches that are designed without the participation of communities and ignore the interconnected nature of health and other social determinants of health.

Fighting COVID-19 and HIV through community mobilisation: lessons from an integrated approach to the Africa CDC Partnership to Accelerate COVID-19 Testing (PACT) initiative in seven countries

Recent literature has shown how the HIV architecture, including community systems, has been critical for fighting COVID-19 in many countries, while sustaining the HIV response. Innovative initiatives suggest that fostering the integration of health services would help address the colliding pandemics. However, there are few documented real-life examples of community mobilisation strategies responding to COVID-19 and HIV. The African Union and Africa Centres for Disease Control and Prevention (Africa CDC) launched the Partnership to Accelerate COVID-19 Testing (PACT) in June 2020 with the goal of training and deploying one million community health workers across the continent. UNAIDS partnered with Africa CDC to implement the PACT initiative in seven countries, i.e. Algeria, Côte d’Ivoire, Gabon, Ghana, Madagascar, Malawi and Namibia. The initiative engaged networks of people living with HIV and community-led organisations to support two of its pillars, test and trace, and the sensitisation to protective measures against COVID-19 for the most vulnerable populations. It later expanded to improve access to COVID-19 vaccines. Based on the assessment of country projects, this article explains how PACT activities implemented by communities contributed to mitigating COVID-19 and HIV among vulnerable and marginalised groups. This article contributes to a better understanding of the impact of a community-based approach in responding effectively to emerging health threats and provides lessons from integrated COVID-19 and HIV community-led responses.

Russia's invasion of Ukraine threatens HIV response.

Russia's invasion of Ukraine threatens HIV response.

Protecting HIV service delivery for key populations in southern Africa in the context of the COVID-19 pandemic

The 2025 UNAIDS targets prioritize reaching all subpopulations living with HIV and those at risk for HIV as the only pathway to achieving control of the HIV epidemic. This has brought to the fore the importance of addressing the needs of key marginalized groups and placing such communities at the center of HIV response strategies. However, the COVID-19 pandemic has resulted in a setback in terms of confronting HIV. With this in mind, it is important not only to protect services within HIV responses among key populations, but also to expand such services to meet the UNAIDS 2025 targets. Without this, gains in controlling COVID-19 may be achieved at the expense of losses in controlling the spread of HIV, which had been achieved after sustained and resource-intensive actions.

Anachronic: Viral Socialities and Project Time among HIV Support Groups in Barbados.

From 2005 to 2015, up to five support groups for people living with HIV (PLHIV) operated in Barbados. However, by early 2020, all but one had disappeared. What caused the demise of these groups and why? What does this demise tell us about the HIV response in Barbados, and more particularly, everyday life for PLHIV? More generally, what does it tell us about “viral socialities” (ties formed between groups of people as they confront the lived effects of infection and discrimination attributable to HIV) and the effects of “project time” (a time frame delimited through the priorities of global HIV/AIDS agencies) on these socialities? Through ethnographic and archival research methods, this article reveals how multiple, unstable project times create and transform viral socialities of Barbadian PLHIV with anachronic effects for some—i.e., a sense of alienation or being “out of time” in relation to the priorities of the global HIV response.

A Longitudinal Analysis of SARS-CoV-2 Antibody Responses Among People With HIV.

BackgroundThe concentration and duration of antibodies (Ab) to SARS-CoV-2 infection predicts the severity of the disease and the clinical outcomes. Older people and those with HIV have impaired immune responses, worse outcomes after SARS-CoV-2 infection, and lower antibody responses after viral infection and vaccination. This study evaluated an Ab response to SARS-CoV-2 in people with HIV (PWH) and without HIV (HIV-) and its association with age.MethodsA total of 23 COVID+PWH and 21 COVID+HIV- participants were followed longitudinally for 6 months post-mild COVID-19. Immunoglobin G (IgG) and immunoglobin M (IgM) Ab responses were measured by an in-house developed ELISA. Time points and HIV status interaction were analyzed using Poisson generalized estimating equations, and correlations were analyzed using non-parametric tests.ResultsMedian age in PWH was 55 years with 28.6% women, while in the HIV- group was 36 years with 60.9% women. The mean time from COVID-19 diagnosis to study enrollment was 16 days for PWH and 11 days for HIV-. The mean CD4+ T-cell count/μl for PWH was 772.10 (±365.21). SARS-CoV-2 IgM and IgG were detected at all time points and Ab response levels did not differ by HIV status (p > 0.05). At entry, age showed a weak direct association with IgG responses (ρ = 0.44, p < 0.05) in HIV- but did not show any association in PWH. Similar associations between age, IgG, and HIV status emerged at day 14 (T1; ρ = 0.50, p < 0.05), 3 months (T3; ρ = 0.50, p < 0.05), and 6 months visit (T4; ρ = 0.78, p < 0.05) in the HIV- group.ConclusionThe Ab responses in the 6-month post-SARS-CoV-2 infection did not differ by HIV status, though a positive association was found between age and Ab response in older PWH. Results suggest that immune protection and vaccine responses are similar for PWH than for those without HIV infection.

Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis.

SummaryBackgroundThe identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV.MethodsUsing a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity.FindingsWe obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3–22·3) and 14·1% (10·8–17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5–29·7]) compared with the USA (7·5% [4·4–10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9–39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality.InterpretationMore than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients.FundingBill & Melinda Gates Foundation.TranslationsFor the French and Spanish translations of the abstract see Supplementary Materials section.

Increasing domestic financing for the HIV/AIDS response in Nigeria: a catalyst to self-reliance

BackgroundAlthough Nigeria has the second largest HIV-positive population in the world, the country relies mostly on external donors for its HIV control. International donors account for over 81% of Nigeria's HIV spending, which is unsustainable and creates funding gaps that can be closed by identifying alternative domestic financing sources. The Health Policy Plus Project (implemented by Palladium), funded by the US Agency for International Development, supported the Nigerian government between July, 2020, and June, 2021, to assess challenges to HIV financing and to collaboratively identify feasible strategies to raise domestic resources for HIV control. MethodsA two-pronged approach that included desk reviews of relevant literature and key interviews with fourteen major stakeholders from government, donor, private, partner, and civil society organisations was adopted. Stakeholders were selected on the basis of their knowledge and involvement in the country's HIV response or their history of supporting health-system strengthening activities. The multisectoral approach helped to identify robust and feasible strategies that can easily be implemented across the 36 states and the federal capital territory in the country. FindingsChallenges to HIV financing include inadequate budgetary allocation, mostly caused by government perception of the HIV programme as the responsibility of donors; delays in fund releases; inefficient use of the HIV funds; poor tracking of funds and commodity use; inadequate country ownership; and poor accountability structures. With these findings, through a collaborative and multisectoral process, 12 strategies that can mobilise up to US$ 662 million in 5 years for HIV control were identified and included in a National Domestic Resource Mobilisation Strategy, which has been adopted for implementation across the country. The strategies included increasing government budgets and execution rates for HIV control; integration of HIV into health insurance; increasing private sector and philanthropic contributions to HIV control; raising funds from diaspora bonds, local HIV commodity production; strengthening governance, efficiency, and accountability structures, and increasing Civil Society Organisations' involvement in HIV resource mobilisation and tracking. InterpretationOverdependence on donors for disease control programmes, especially in low-income countries, is a global health problem. A multisectoral approach can be adopted by global health stakeholders to review and select appropriate and effective domestic resource mobilisation strategies with reduced contextual barriers, such as HIV integration in key universal health coverage programmes, enhancing private sector contribution, and strengthening efficiency for implementation as a global policy to mobilise health resources. Implementation of the strategies will reduce dependence on donor funds, reduce out-of-pocket payments for HIV, improve access to HIV services, and subsequently lead to improved HIV outcomes. FundingUS Agency for International Development.

How do you expect us to survive? Lamentation of female sex workers in Zimbabwe during COVID-19 lockdown.

The restrictive measures taken to curb and mitigate the spread of the corona virus (COVID-19) had negative implications on the vulnerable populations. Of the latter, the most severely affected were sex workers, whose work venues and customers were locked down. This descriptive phenomenological study explored effects of COVID-19 on female sex workers in Bulawayo, Zimbabwe. Snowballing sampling was used to recruit participants. Data were collected through in-depth face-to-face individual interviews with ten female sex workers. The sample size was determined by data saturation. Colaizzi's seven-step content analysis approach was followed to guide data analysis. Rigour was ensured by adhering to Guba and Lincoln's trustworthiness criteria. The study found that the measures impacted negatively on sex workers' income, making it difficult for them to get money for food and rentals. In response, some sex workers adopted innovative entrepreneurship. Others engaged in risky sexual behaviours, further aggravating their situation emotionally and psychologically. It is recommended that the government and policy makers provide psychosocial and economic support to protect the rights of female sex workers in order to maintain the gains made in HIV response.

Removing the societal and legal impediments to the HIV response: An evidence-based framework for 2025 and beyond.

Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the '3 S's of the HIV response: Society, Systems and Services' was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.

A Systematic Review of Gender-Based Violence Prevention and Response Interventions for HIV Key Populations: Female Sex Workers, Men Who Have Sex With Men, and People Who Inject Drugs

Gender-based violence (GBV) is that perpetrated based on sex, gender identity, or perceived adherence to socially defined gender norms. This human rights violation is disproportionately experienced by HIV key populations including female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Consequently, addressing GBV is a global priority in HIV response. There is limited consensus about optimal interventions and little known about effectiveness. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in International Prospective Register of Systematic Reviews. Peer-reviewed and non-peer-reviewed literature were searched for articles that described a GBV prevention or response intervention specifically for key populations including FSW, PWID, and MSM. Results were organized by level(s) of implementation and pillars of a comprehensive GBV response: prevention, survivor support, and accountability/justice. Of 4,287 articles following removal of duplicates, 32 unique interventions (21 FSW, seven PWID, and nine MSM, not mutually exclusive) met inclusion criteria, representing 13 countries. Multisectoral interventions blended empowerment, advocacy, and crisis response with reductions in violence. Individual-level interventions included violence screening and response services. Violence-related safety promotion and risk reduction counseling within HIV risk reduction programming reduced violence. Quantitative evaluations were limited. Violence prevention and response interventions for FSW, PWID, and MSM span individual, community, and multisectoral levels with evidence of promising practices at each level. The strongest evidence supported addressing violence in the context of sexually transmitted infection/HIV risk reduction. As interventions continue to emerge, the rigor of accompanying evaluations must simultaneously advance to enable clarity on the health and safety impact of GBV prevention and response programming.

HIV and COVID-19 in Latin America and the Caribbean.

Purpose of ReviewLatin America and the Caribbean (LAC) has been hit hard by COVID-19 due to political instability, flawed health systems, and structural inequalities. The repercussion of the pandemic on vulnerable populations, like people living with HIV (PLWH), is complex. This review aims to explore the interactions between the HIV and COVID-19 pandemics in this region.Recent FindingsData regarding the interactions of HIV and COVID-19 in LAC is scarce. Only case reports or small case series have been published regarding the clinical course of COVID-19 in PLWH and regarding the clinical course of COVID-19 in PLWH, which appears to be similar to the general population. The pandemic has disrupted prevention and treatment of PLWH. However, there have been country efforts to counteract those effects. There are some lessons from the HIV response which have been effectively applied in the region to address COVID-19.SummaryCOVID-19 has had an unprecedented impact on the cascade-of-care among PLWH in LAC. There is a need for longitudinal studies that assess clinic implication of these pandemic interactions in LAC.

Utilization patterns of healthcare facility and estimated expenditure of PLHIV care under the Indonesian National Health Insurance Scheme in 2018

BackgroundThis study analyzed current patterns of service use, referral, and expenditure regarding HIV care under the National Health Insurance Scheme (JKN) to identify opportunities to improve HIV treatment coverage. As of September 2020, an estimated 543,100 people in Indonesia were living with HIV, but only 352,670 (65%) were aware of their status, and only 139,585 (26%) were on treatment. Furthermore, only 27,917 (4.5%) viral load (VL) tests were performed. Indonesia seeks to broaden its HIV response. In doing so, it intends to replace declining donor-funding through better coverage of HIV/AIDS services by its JKN. Thus, this study aims to assess the current situation about HIV service coverage and expenditure under a domestic health-insurance funded scheme in Indonesia.MethodsThis study employs a quantitative method by way of a cross-sectional approach. The 2018 JKN claims data, drawn from a 1% sample that JKN annually produces, were analyzed. Nine hundred forty-five HIV patients out of 1,971,744 members were identified in the data sample and their claims record data at primary care and hospital levels were analyzed. Using ICD (International Statistical Classification of Diseases and Related Health Problems), 10 codes (i.e., B20, B21, B22, B23, and B24) that fall within the categories of HIV-related disease. For each level, patterns of service utilization by patient-health status, discharge status, severity level, and total cost per claim were analyzed.ResultsMost HIV patients (81%) who first seek care at the primary-care level are referred to hospitals. 72.5% of the HIV patients receive antiretroviral treatment (ART) through JKN; 22% at the primary care level; and 78% at hospitals. The referral rate from public primary-care facilities was almost double (45%) that of private providers (24%). The most common referral destination was higher-level hospitals: Class B 48%, and Class C 25%, followed by the lowest Class A at 3%. Because JKN pays hospitals for each inpatient admission, it was possible to estimate the cost of hospital care. Extrapolating the sample of hospital cases to the national level using the available weight score, it was estimated that JKN paid IDR 444 billion a year for HIV hospital services and a portion of capitation payment.ConclusionThere was an underrepresentation of PLHIV (People Living with HIV) who had been covered by JKN as 25% of the total PLHIV on ART were able to attain access through other schemes. This study finding is principally aligned with other local research findings regarding a portion of PLHIV access and the preferred delivery channel. Moreover, the issue behind the underutilization of National Health Insurance services in Indonesia among PLHIV is similar to what was experienced in Vietnam in 2015. The 2015 Vietnam study showed that negative perception, the experience of using social health insurance as well as inaccurate information, may lead to the underutilization problem (Vietnam-Administration-HIV/AIDSControl, Social health insurance and people living with HIV in Vietnam: an assessment of enrollment in and use of social health insurance for the care and treatment of people living with HIV, 2015). Furthermore, the current research finding shows that 99% of the total estimated HIV expenditure occurred at the hospital. This indicates a potential inefficiency in the service delivery scheme that needs to be decentralized to a primary-care facility.

PROTOCOL: Social and behaviour change communication interventions for strengthening HIV prevention and research among adolescent girls and young women in low- and middle-income countries: An evidence and gap map.

Despite progress in several dimensions of the global HIV response, there seems to be a significant gender and age disparity. Numerous organizations consider it a top priority to accelerate HIV prevention programming among Adolescent Girls and Young Women (AGYW) as unequal gender norms, limited agency and voice, and reduced access to resources put them at higher HIV risk. Gender and age have also been identified as critical gaps within prevention research to ensure the development of biomedical interventions that are responsive to the biological and social needs of AGYW. Towards this, the objectives of the proposed evidence and gap map are to; identify and map existing evidence and gaps on the use of diverse Social and Behaviour Change Communication (SBCC) strategies to strengthen adoption of HIV prevention measures and participation in research among AGYW in LMICs; and, identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Baseline Plasma Metabotype Correlates With Direct-Acting Antiviral Therapy Nonresponse for HCV in HIV-HCV Coinfected Patients.

Introduction: With the advent of direct-acting antiviral (DAA) therapy for HCV, the cure is achieved at similar rates among HIV–HCV coinfected patients as in HCV mono-infected patients. The present study evaluates host plasma metabolites as putative indicators in predicting the treatment response in baseline HIV–HCV patients. Methods: Non-cirrhotic HIV–HCV (N = 43) coinfected patients were treated with sofosbuvir and daclatasvir for 12 weeks. Plasma metabolite profiling of pre- and post-therapy was analyzed in 20/43 patients. Of the 20 selected, 10 (50%) attained the sustained viral response [(SVR) (responders)] as defined by the absence of HCV RNA at 12 weeks after the treatment, and 10 (50%) did not attain the cure for HCV (nonresponders). Results: A total of 563 features were annotated (metabolomic/spectral databases). Before therapy, 39 metabolites differentiated (FC ±1.5, p < 0.05) nonresponders from responders. Of these, 20 upregulated and 19 downregulated were associated with tryptophan metabolism, nicotinamide metabolism, and others. Post therapy, 62 plasma metabolites (12 upregulated and 50 downregulated, FC±1.5, p < 0.05) differentiated nonresponders from responders and highlighted a significant increase in the steroid and histidine metabolism and significant decrease in tryptophan metabolism and ascorbate and pyruvate metabolism in the nonresponders. Based on random forest and multivariate linear regression analysis, the baseline level of N-acetylspermidine (FC > 2, AUC = 0.940, Bfactor = −0.267) and 2-acetolactate (FC > 2, AUC = 0.880, Bfactor = −0.713) significantly differentiated between nonresponders from responders in HIV–HCV coinfected patients and was able to predict the failure of treatment response. Conclusion: Increased baseline levels of N-acetylspermidine and 2-acetolactate levels are associated with the likeliness of failure to attain the cure for HCV in HIV–HCV coinfected patients.

PEPFAR's Role in Protecting and Leveraging HIV Services in the COVID-19 Response in Africa.

Purpose of ReviewWe describe the impact of COVID-19 on PEPFAR programs in Africa and how PEPFAR adapted and leveraged its interventions to the changing landscape of the COVID-19 pandemic.Recent FindingsTo mitigate the potential impact of COVID-19 on the HIV response and protect the gains, continuity of treatment was the guiding principle regarding the provision of services in PEPFAR-supported countries. As the COVID-19 pandemic matured, PEPFAR’s approach evolved from a strictly “protect and salvage” approach to a “restore and accelerate” approach that embraced innovative adaptations in service and “person-centered” care.SummaryThe impact of service delivery interruptions caused by COVID-19 on progress towards HIV epidemic control in PEPFAR-supported African countries remains undetermined. With COVID vaccine coverage many months away and more transmissible variants being reported, Africa may experience more pandemic surges. HIV programs will depend on nimble and innovative adaptations in prevention and treatment services in order to advance epidemic control objectives.

Ključne politike i mere za suzbijanje epidemije virusa humane imunodeficijencije/sindroma stečene imunodeficijencije na globalnom nivou

During the last 40 years, the development of medical HIV and AIDS related knowledge has been followed by a coordinated international HIV response, in terms of developing policies and measures for the HIV/AIDS prevention and control based on evidence from public health and clinical studies. The HIV response can be divided into three periods: the period of HIV response establishment (1981-1996); the period of multi-sectoral response (1996-2007) and the period of strengthening biomedical measures for HIV prevention (2007 and beyond). International policies and recommended HIV prevention measures have undergone a series of transformations, from the establishment of the first organized and coordinated national programs, to the design and implementation of innovative biomedical prevention measures, such as voluntary medical circumcision, pre-exposure prophylaxis and the implementation of the "test and treat" measure - the introduction of antiretroviral therapy immediately after diagnosing HIV infection to achieve undetectable viral load. New findings on successful use of antiretroviral therapy as prevention led to the formulation of goals for 2020: 90% of all people living with HIV to know their HIV status, 90% of them to receive antiretroviral therapy, and 90% of them to have viral suppression; to have less than 500 000 of both newly HIV infected persons, and AIDS related deaths. Despite of the HIV response major improvements, such as development and implementation of multisectoral national HIV/AIDS policies on prevention and control, the 2020 goals have not been meet. For achieving the main goal - ending AIDS as public health threat by 2030 - implementation of all recommended biomedical, behavioral and structural interventions should be intensified.

What will it take to achieve the sexual and reproductive health and rights of women living with HIV?

This article outlines progress in realizing the sexual and reproductive health and rights of women and girls living with HIV over the last 30 years from the perspective of women living with HIV. It argues that the HIV response needs to go beyond the bio-medical aspects of HIV to achieve our sexual and reproductive health and rights, and considers relevant Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization, United States President’s Emergency Plan for AIDS Relief (PEPFAR), Global Fund and other guidelines, what engagement there has been with women living with HIV and whether guidelines/strategies have been adopted. It has been written by women living with HIV from around the world and a few key supporters. Co-authors have sought to collate and cite materials produced by women living with HIV from around the world, in the first known effort to date to do this, as a convergence of evidence to substantiate the points made in the article. However, as the article also argues, research led by women living with HIV is seldom funded and rarely accepted as evidence. Combined with a lack of meaningful involvement of women living with HIV in others’ research on us, this means that formally recognized evidence from women’s own perspectives is patchy at best. The article argues that this research gap, combined with the ongoing primacy of conventional research methods and topics that exclude those most affected by issues, and the lack of political will (and sometimes outright opposition) in relation to gender equality and human rights, adversely affect policies and programmes in relation to women’s rights. Thus, efforts to achieve an ethical, effective and sustainable response to the pandemic are hindered. The article concludes with a call to action to all key stakeholders.

Identifying the challenges and the critical areas for mounting a better response against the HIV epidemic in low- and middle-income nations

HIV continues to remain one of the major public health concerns for more than 3 decades and has accounted for the deaths of 35 million people till date. Despite making considerable progress in the response against the disease, it continues to pose major threats across all the regions. This is mainly because the reach of services is inadequate and that the scale up plan is also slow. Another major challenge is the rise in the incidence of a number of conflicts and other humanitarian emergencies, which not only jeopardize the health delivery system, but also forces the people to migrate to other regions, which might again pose a major pressure on the health system of the recipient nations. This is a high time to focus on the critical areas and further strengthen the existing momentum of the HIV response by the nations. In conclusion, HIV infection is a major public health concern and all the involved sectors and stakeholders have to work together to keep the infection under check and improve the quality of life of the infected people.

Young key populations left behind: The necessity for a targeted response in Mozambique.

The first exposure to high-risk sexual and drug use behaviors often occurs during the period of youth (15-24 years old). These behaviors increase the risk of HIV infection, especially among young key populations (KP)-men how have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID). We describe the characteristics of young KP participants in the first Biobehavioral Surveillance (BBS) surveys conducted in Mozambique and examine their risk behaviors compared to adult KP. Respondent-driven sampling (RDS) methodology was used to recruit KP in three major urban areas in Mozambique. RDS-weighted pooled estimates were calculated to estimate the proportion of young KP residing in each survey city. Unweighted pooled estimates of risk behaviors were calculated for each key population group and chi-square analysis assessed differences in proportions between youth (aged less than 24 years old) and older adult KP for each population group. The majority of MSM and FSW participants were young 80.7% (95% CI: 71.5-89.9%) and 71.9% (95% CI: 71.9-79.5%), respectively, although not among PWID (18.2%, 95% CI: 13.2-23.2%). Young KP were single or never married, had a secondary education level or higher, and low employment rates. They reported lower perception of HIV risk (MSM: 72.3% vs 56.7%, p<0.001, FSW: 45.3% vs 24.4%, p<0.001), lower HIV testing uptake (MSM: 67.5% vs 72.3%, p<0.001; FSW: 63.2% vs 80.6%; p<0.001, PWID: 53.3% vs 31.2%; p = 0.001), greater underage sexual debut (MSM: 9.6% vs 4.8%, p<0.001; FSW: 35.2% vs 22.9%, p<0.001), and greater underage initiation of injection drug use (PWID: 31.9% vs 7.0%, p<0.001). Young KP also had lower HIV prevalence compared to older KP: MSM: 3.3% vs 27.0%, p<0.001; FSW: 17.2% vs 53.7%, p<0.001; and PWID: 6.0% vs 55.0%, p<0.001. There was no significant difference in condom use across the populations. There is an immediate need for a targeted HIV response for young KP in Mozambique so that they are not left behind. Youth must be engaged in the design and implementation of interventions to ensure that low risk behaviors are sustained as they get older to prevent HIV infection.