Global assessment of existing HIV and key population stigma indicators: A data mapping exercise to inform country-level stigma measurement.

BACKGROUND: Stigma is an established barrier to the provision and uptake of HIV prevention, diagnostic, and treatment services. Despite consensus on the importance of addressing stigma, there are currently no country-level summary measures to characterize stigma and track progress in reducing stigma around the globe. This data mapping exercise aimed to assess the potential for existing data to be used to summarize and track stigma, including discrimination, related to HIV status, or key population membership at the country level. METHODS AND FINDINGS: This study assessed existing indicators of stigma related to living with HIV or belonging to 1 of 4 key populations including gay men and other men who have sex with men, sex workers, people who use drugs, and transgender persons. UNAIDS Strategic Information Department led an initial drafting of possible domains, subdomains, and indicators, and a 3-week e-consultation was held to provide feedback. From the e-consultation, 44 indicators were proposed for HIV stigma; 14 for sexual minority stigma (including sexual behavior or orientation) related to men who have sex with men; 12 for sex work stigma; 10 for drug use stigma; and 17 for gender identity stigma related to transgender persons. We conducted a global data mapping exercise to identify and describe the availability and quality of stigma data across countries with the following sources: UNAIDS National Commitments and Policies Instrument (NCPI) database; Multiple Indicator Cluster Surveys (MICS); Demographic and Health Surveys (DHS); People Living with HIV Stigma Index surveys; HIV Key Populations Data Repository; Integrated Biological and Behavioral Surveys (IBBS); and network databases. Data extraction was conducted between August and November 2020. Indicators were evaluated based on the following: if an existing data source could be identified; the number of countries for which data were available for the indicator at present and in the future; variation in the indicator across countries; and considerations of data quality or accuracy. This mapping exercise resulted in the identification of 24 HIV stigma indicators and 10 key population indicators as having potential to be used at present in the creation of valid summary measures of stigma at the country level. These indicators may allow assessment of legal, societal, and behavioral manifestations of stigma across population groups and settings. Study limitations include potential selection bias due to available data sources to the research team and other biases due to the exploratory nature of this data mapping process. CONCLUSIONS: Based on the current state of data available, several indicators have the potential to characterize the level and nature of stigma affecting people living with HIV and key populations across countries and across time. This exercise revealed challenges for an empirical process reliant on existing data to determine how to weight and best combine indicators into indices. However, results for this study can be combined with participatory processes to inform summary measure development and set data collection priorities going forward.

Monitoring HIV-Related Laws and Policies: Lessons for AIDS and Global Health in Agenda 2030.

The National Commitments and Policy Instrument (NCPI) has been used to monitor AIDS-related laws and policies for over 10 years. What can be learnt from this process? Analyses draw on NCPI questionnaires, NCPI responses, the UNAIDS Law Database, survey data and responses to a 2014 survey on the NCPI. The NCPI provides the first and only systematic data on country self-reported national HIV laws and policies. High NCPI reporting rates and survey responses suggest the majority of countries consider the process relevant. Combined civil society and government engagement and reporting is integral to the NCPI. NCPI experience demonstrates its importance in describing the political and legal environment for the HIV response, for programmatic reviews and to stimulate dialogue among stakeholders, but there is a need for updating and in some instances to complement results with more objective quantitative data. We identify five areas that need to be updated in the next iteration of the NCPI and argue that the NCPI approach is relevant to participatory monitoring of targets in the health and other goals of the UN 2030 Agenda for Sustainable Development.

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.

Understanding and comparing HIV-related law and policy environments: cross-national data and accountability for the global AIDS response.

Law and policy differences help explain why, as HIV-related science has advanced swiftly, some countries have realised remarkable progress on AIDS while others see expanding epidemics. We describe the structure and findings of a new dataset and research platform, the HIV Policy Lab, which fills an important knowledge gap by measuring the HIV-related policy environment across 33 indicators and 194 countries over time, with online access and visualisation. Cross-national indicators can be critical tools in international governance-building social power to monitor state behaviour with the potential to change policy and improve domestic accountability. This new and evolving effort collects data about policy through review of legal documents, official government reports and systematic review of secondary sources. Alignment between national policy environments and global norms is demonstrated through comparison with international public health guidance and agreements. We demonstrate substantial variation in the content of law and policies between countries, regions and policy areas. Given progress in basic and implementation science, it would be tempting to believe most countries have adopted policies aligned with global norms, with a few outliers. Data show this is not the case. Globally, alignment is higher on clinical and treatment policies than on prevention, testing and structural policies. Policy-makers, researchers, civil society, finance agencies and others can use these data to better understand the policy environment within and across countries and support reform. Longitudinal analysis enables evaluation of the impact of laws and policies on HIV outcomes and research about the political drivers of policy choice.

HIV estimates at second subnational level from national population-based surveys.

OBJECTIVES: A better understanding of the subnational variations could be paramount to the efficiency and effectiveness of the response to the HIV epidemic. The purpose of this study is to describe the methodology used to produce the first estimates at second subnational level released by UNAIDS. METHODS: We selected national population-based surveys with HIV testing and survey clusters geolocation, conducted in 2008 or later. A kernel density estimation approach (prevR) with adaptive bandwidths was used to generate a surface of HIV prevalence. This surface was combined with LandScan global population distribution grid to estimate the spatial distribution of people living with HIV (PLWHIV). Finally, results were adjusted to national UNAIDS's published estimates and merged per second subnational administrative unit. An indicator of the quality of the estimates was computed for each administrative unit. RESULTS: These estimates combine two complementary approaches: the prevR method, focusing on spatial variations of HIV prevalence, as well as national estimates published by UNAIDS, taking into account trends of HIV prevalence over time. Seventeen country reports have been produced. However, quality of the estimates at second subnational level is highly heterogonous between countries, depending on the number of units and the survey sampling size. In some countries, estimates at second subnational level are very uncertain and should be interpreted with caution. CONCLUSION: These estimates at second subnational level constitute a first step to help countries to better understand their HIV epidemic and to inform programming at lower geographical levels. Further developments are needed to better match local needs.

Estimating future trends in paediatric HIV.

BACKGROUND: Paediatric treatment continues to lag behind adult treatment and significant efforts are urgently needed to scale up antiretroviral therapy (ART) for children. As efforts to prevent mother-to-child transmission expand, better understanding of future trends and age characterization of the population that will be in need of ART is needed to inform policymakers, as well as drug developers and manufacturers. METHODS: The Spectrum model was used to estimate the total number of expected paediatric infections by 2020 in 21 priority countries in Africa. Different ART scale-up scenarios were investigated and age characterization of the population was explored. RESULTS: By 2020, new paediatric infections in the 21 countries will decline in all the scenarios. Total paediatric infections will also decline in the 21 high-burden countries, but with a differential effect by scenario and age group. On the basis of the optimal scale-up scenario, 1 940 000 [1 760 000-2 120 000] children will be expected to be living with HIV in 2020. The number of children dying of AIDS is notably different in the three models. Assuming optimal scale-up and based on 2013 treatment initiation criteria, the estimates of children to receive ART in the 21 high-burden countries will increase to 1 670 000 (1 500 000-1 800 000). CONCLUSION: By 2020, even under the most optimistic scenarios, a considerable number of children will still be living with HIV. Age-appropriate drugs and formulations will be needed to meet the treatment needs of this vulnerable population. Improved estimates will be critical to guide the development and forecasting of commodities to close the existing paediatric treatment gap.