Facilitators and barriers to community-led monitoring of health programs: Qualitative evidence from the global implementation landscape.

Achieving the global HIV, tuberculosis, and malaria targets will require innovative strategies to deliver high quality and person-centered health services. Community-led monitoring (CLM) is a rapidly proliferating health systems strengthening intervention for improving healthcare services and documenting human rights violations, through social empowerment and political accountability. Driven in part by increasing financial support from donors, a growing number of countries are implementing CLM programs. This study aimed to identify early challenges and lessons learned from CLM implementation, with the aim of informing and improving the implementation of CLM programs and ultimately achieving greater impact on the delivery of services. Twenty-five CLM implementors representing 21 countries participated in an interview. Early generation of buy-in from diverse stakeholders was noted as critical for CLM success. Leveraging existing networks of service users and community organizations to implement CLM also helped to maximize program reach and resources. Uncertainty around CLM's purpose and roles among CLM stakeholders resulted in challenges to community leadership and ownership of programs. Respondents also described challenges with underfunded programs, especially advocacy components, and inflexible donor funding mechanisms. Critical capacity gaps remain around advocacy and electronic data collection and use. With the rapid expansion of CLM, this study serves as an important first step in characterizing challenges and successes in the CLM landscape. Successful implementation of CLM requires prioritizing community ownership and leadership, donor commitment to sustainable and reliable funding, and strengthened support of programs across the data collection and advocacy lifecycle.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania.

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

Assessing inclusion of trans people in HIV national strategic plans: a review of 60 high HIV prevalence countries.

INTRODUCTION: Trans people are disproportionately impacted by HIV yet have not been adequately prioritized in national HIV responses or policy documents. This review aims to understand the extent of meaningful inclusion of trans people in national strategic plans (NSPs) for HIV/AIDS as an essential step in ensuring that HIV policy aligns with epidemiologic data, and trans-specific programming is funded, implemented and sustained. METHODS: HIV NSPs from 60 countries, across five global regions, were assessed for the level of inclusion of trans populations between January and March 2021. The most recently available NSP for each country, published after 2011, was obtained through publicly accessible online sources or through researcher networks. Data were manually extracted from NSPs using a framework of indicators focusing on trans inclusion in these five major sections of NSPs: (1) narratives; (2) epidemiological data; (3) monitoring and evaluation (M&E) indicators and targets; (4) activities; and (5) budgets. RESULTS AND DISCUSSION: Within all reviewed NSPs, 65.0% (39/60) mentioned trans people in at least one of the five key sections but only 8.3% (5/60) included trans people in all five key sections. Trans people were more commonly mentioned in the background/narratives of NSPs (61.7%, 37/60) but less commonly included NSP activities (38.3%, 23/60), in M&E indicators and targets (23.7%, 14/60), in epidemiological data (20.0% 12/60), and in NSP budgets (13.3%, 8/60). Countries in the Asia and Pacific region most frequently included trans people in all five key sections (38%, 5/13), while no countries in Eastern and Southern Africa included trans people in all NSP sections. CONCLUSIONS: This analysis finds substantial gaps in the inclusion of trans populations in NSPs globally. Results highlight the pressing need for states, technical partners, and international funders to engage with trans communities to improve trans-inclusion in all key sections of NSPs. Trans inclusion in NSPs is an essential step towards reaching the populations most at risk of HIV and ultimately achieving country-level epidemic control.

Current allocations and target apportionment for HIV testing and treatment services for marginalized populations: characterizing PEPFAR investment and strategy.

INTRODUCTION: The United States President's Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations' response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR's targets and resulting programming is crucial for successfully serving key populations. METHODS: Publicly available PEPFAR budgets for key populations' services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator. RESULTS: PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019. CONCLUSIONS: Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed.

The role of contraception in preventing HIV-positive births: global estimates and projections.

BACKGROUND: Meeting the contraceptive needs of women living with HIV (WLHIV) has primary health benefits for women, in addition to being a key element to prevent mother-to-child HIV transmission. This analysis will estimate the current number of infant HIV infections prevented by contraception in the era of increased HIV treatment coverage and; 2) model the additional HIV benefits of preventing unintended births to WLHIV. METHODS: Secondary data analysis was conducted using publicly available data from the United Nations Programme on HIV/AIDS (UNAIDS) and Population Division, Demographic Health Surveys, and peer-review literature. National data from 70 countries, that had a UNAIDS estimate for the number of WLHIV nationally, were combined into country-level models. Models estimated the current number of infant HIV infections averted by contraception annually and potentially averted if unintended births to WLHIV were prevented. Estimates take into account pregnancy and live birth rates, contraceptive coverage, contraceptive method mix and failure rates, and HIV treatment coverage during pregnancy to prevent mother to child transmission. RESULTS: Contraception use among WLHIV prevents an estimated 43,559 new infant HIV infections annually across 70 countries. Countries with the largest number of infant infections averted by contraception included South Africa (9441), Nigeria (4195), Kenya (3508), Zimbabwe (2586), and India (2145). Preventing unintended births to WLHIV could avert an additional 43,768 new infant infections per year, with the greatest potential gains to be made in South Africa (12,036), Nigeria (2770), Uganda (2552), and the Democratic Republic of the Congo (2324). CONCLUSIONS: Contraception continues to play an integral role in global HIV prevention efforts in the era of increasing HIV treatment coverage, especially in sub-Saharan Africa. Broad contraceptive availability, increased contraceptive voluntarism and method mix are key components to preventing unintended births and ending new infant HIV infections worldwide.

White Counties Stand Apart: The Primacy of Residential Segregation in COVID-19 and HIV Diagnoses.

Emerging epidemiological data suggest that white Americans have a lower risk of acquiring COVID-19. Although many studies have pointed to the role of systemic racism in COVID-19 racial/ethnic disparities, few studies have examined the contribution of racial segregation. Residential segregation is associated with differing health outcomes by race/ethnicity for various diseases, including HIV. This commentary documents differing HIV and COVID-19 outcomes and service delivery by race/ethnicity and the crucial role of racial segregation. Using publicly available Census data, we divide US counties into quintiles by percentage of non-Hispanic white residents and examine HIV diagnoses and COVID-19 per 100,000 population. HIV diagnoses decrease as the proportion of white residents increase across US counties. COVID-19 diagnoses follow a similar pattern: Counties with the highest proportion of white residents have the fewest cases of COVID-19 irrespective of geographic region or state political party inclination (i.e., red or blue states). Moreover, comparatively fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the US COVID-19 pandemic. Systemic drivers place racial minorities at greater risk for COVID-19 and HIV. Individual-level characteristics (e.g., underlying health conditions for COVID-19 or risk behavior for HIV) do not fully explain excess disease burden in racial minority communities. Corresponding interventions must use structural- and policy-level solutions to address racial and ethnic health disparities.

Assessing differential impacts of COVID-19 on black communities.

Purpose: Given incomplete data reporting by race, we used data on COVID-19 cases and deaths in U.S. counties to describe racial disparities in COVID-19 disease and death and associated determinants. Methods: Using publicly available data (accessed April 13, 2020), predictors of COVID-19 cases and deaths were compared between disproportionately (≥13%) black and all other (<13% black) counties. Rate ratios were calculated, and population attributable fractions were estimated using COVID-19 cases and deaths via zero-inflated negative binomial regression model. National maps with county-level data and an interactive scatterplot of COVID-19 cases were generated. Results: Nearly 90% of disproportionately black counties (656/677) reported a case and 49% (330/677) reported a death versus 81% (1987/2465) and 28% (684/2465), respectively, for all other counties. Counties with higher proportions of black people have higher prevalence of comorbidities and greater air pollution. Counties with higher proportions of black residents had more COVID-19 diagnoses (Rate Ratio (RR): 1.24, 95% confidence interval: 1.17-1.33) and deaths (RR: 1.18, 95% confidence interval: 1.00-1.40), after adjusting for county-level characteristics such as age, poverty, comorbidities, and epidemic duration. COVID-19 deaths were higher in disproportionally black rural and small metro counties. The population attributable fraction of COVID-19 diagnosis due to lack of health insurance was 3.3% for counties with less than 13% black residents and 4.2% for counties with greater than or equal to 13% black residents. Conclusions: Nearly 20% of U.S. counties are disproportionately black, and they accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationally. County-level comparisons can both inform COVID-19 responses and identify epidemic hot spots. Social conditions, structural racism, and other factors elevate risk for COVID-19 diagnoses and deaths in black communities.