Identifying structural barriers to an effective HIV response: using the National Composite Policy Index data to evaluate the human rights, legal and policy environment.

INTRODUCTION: Attention to the negative effects of structural barriers on HIV efforts is increasing. Reviewing national legal and policy environments with attention to the international human rights commitments of states is a means of assessing and providing focus for addressing these barriers to effective HIV responses. METHODS: Law and policy data from the 171 countries reporting under the Declaration of Commitment from the 2001 United Nations General Assembly Special Session on HIV/AIDS were analyzed to assess attention to human rights in national legal and policy environments as relevant to the health and rights of key populations such as people who inject drugs, men who have sex with men and sex workers. RESULTS: Seventy-eight governments and civil society in 106 countries report the existence of laws and policies which present obstacles to accessing HIV services for key populations. Laws and policies which positively affect access to HIV-related services, in and of themselves constituting structural interventions, were also reported. The dissonance between laws and how this impacts the availability and use of HIV-related services deserve greater attention. CONCLUSIONS: Recognition of the harms inherent in laws that constitute structural barriers to effective HIV responses and the potential positive role that a supportive legal environment can play suggests the need for legal reform to ensure an enabling regulatory framework within which HIV services can be effectively delivered and used by the populations who need them. Moving beyond laws and policies, further efforts are required to determine how to capture information on the range of structural barriers. Teasing apart the impact of different barriers, as well as the structural interventions put in place to address them, remains complicated. Capturing the impact of policy and legal interventions can ultimately support governments and civil society to ensure the human rights of key populations are protected in national HIV responses.

Evaluating HIV prevention effectiveness: the perfect as the enemy of the good.

There is a need to better understand the effectiveness of HIV-prevention programs. Cluster randomized designs have major limitations to evaluate such complex large-scale combination programs. To close the prevention evaluation gap, alternative evaluation designs are needed, but also better articulation of the program impact pathways and proper documentation of program implementation. Building a plausible case using mixed methods and modeling can provide a valid alternative to probability evidence. HIV prevention policies should not be limited to evidences from randomized designs only.

Human rights in the global response to HIV: findings from the 2008 United Nations General Assembly Special Session Reports.

BACKGROUND: Every country in the world has made human rights-related commitments in relation to HIV, yet assessment of the extent to which HIV-related rights are indeed respected, protected and fulfilled remains relatively new. Civil society has, in some places, highlighted the strengths and shortcomings of government action, but attention to governments' own reports of their performance vis-à-vis their HIV-related human rights obligations offers an important and inadequately explored data source. METHODS: We reviewed National Composite Policy Index data from 133 United Nations General Assembly Special Session Country Progress Reports and examined their narrative reports for text relating to human rights. FINDINGS: 2008 National Composite Policy Index data show an increase in the number of countries reporting on human rights issues since 2006. These reports offer important information, even when they are internally inconsistent. Almost all reporting countries (94%) note that their national HIV policies explicitly mention the promotion and protection of human rights, yet only 22% of these countries report performance indicators to assess human rights compliance. In addition, 71% of countries report protective laws or regulations for vulnerable subpopulations, yet 63% of those same countries report the existence of laws or policies that hinder access to HIV services for vulnerable subpopulations. INTERPRETATION: Because they include data that have been provided or approved by governments, the United Nations General Assembly Special Session Country Reports provide critical information to support national legal and policy reform and implementation of a human rights-based approach to HIV. By identifying shortcomings in the fulfillment of human rights, a refocusing of efforts is possible, which can aid both governments and civil society in achieving an effective and appropriate response to HIV through advocacy for and implementation of laws, policies and programs that support human rights.

Are the investments in national HIV monitoring and evaluation systems paying off?

BACKGROUND: Concerted efforts and substantial financial resources have gone toward strengthening national monitoring and evaluation (M&E) systems for HIV programs. This article explores whether those investments have made a difference in terms of data availability, quality and use for assessing whether national programs are on track to achieve the 2015 Millennium Development Goal (MDG) of halting and reversing the HIV epidemic. METHODS: Descriptive analyses, including trends, of the National Composite Policy Index data and M&E expenditures were conducted. Global Fund funding continuation assessments were reviewed for concerns related to M&E. Availability of population-based survey data was assessed. RESULTS: There has been a marked increase in the number of countries where the prerequisites for a national HIV M&E system are in place and in human resources devoted to M&E at the national level. However, crucial gaps remain in M&E capacity, available M&E data, and data quality assurance. The extent to which data are used for program improvement is difficult to ascertain. There is a potential threat to sustaining the current momentum in M&E as governments have not committed long-term funding and current M&E-related expenditures are below the minimum needed to make M&E systems fully functional. CONCLUSIONS: There is evidence of rapid scale-up of basic HIV M&E systems, but if M&E is to fulfil its role in guiding optimal use of resources, ensuring effective HIV programs and providing evidence of progress toward the Millennium Development Goal of halting and reversing the HIV epidemic, essential data gaps will need to be filled urgently and those data will need to be used to guide decision making.

Increasing civil society participation in the national HIV response: the role of UNGASS reporting.

BACKGROUND: The 2001 Declaration of Commitment on HIV/AIDS provided impetus for strengthening collaboration between government and civil society partners in the HIV response. The biennial UNGASS reporting process is an opportunity for civil society to engage in a review of the implementation of commitments. METHODS: Descriptive analyses of the National Composite Policy Index from 135 countries; a debriefing on UNGASS reporting with civil society in 40 countries; and 3 country case studies on the UNGASS process. FINDINGS: In the latest UNGASS reporting round, engagement of civil society occurred in the vast majority of countries. The utility of UNGASS reporting seemed to be better understood by both government and civil society, compared with previous reporting rounds. Civil society participation was strongest when civil society groupings took the initiative and organized themselves. An important barrier was their lack of experience with national level processes. Civil society involvement in national HIV planning and strategic processes was perceived to be good, but better access to funding and technical support is needed. Instances remain where there are fundamental differences between government and civil society perceptions of the HIV policy and program environment. How or whether differences were resolved is not always clear, but both government and civil society seemed to appreciate the opportunity for discussion. CONCLUSIONS: Collaborative reporting by government and civil society on UNGASS indicators is a small but potentially valuable step in what should be an ongoing and fully institutionalized process of collaborative planning, implementation, monitoring, assessment and correction of HIV responses. The momentum achieved through the UNGASS process should be maintained with follow-up actions to address data gaps, formalize partnerships and enhance active and meaningful engagement.

International collaboration in conducting systematic reviews: the Cochrane Collaborative Review Group on HIV Infection and AIDS.

To make sound health care decisions, policy makers, providers and researchers need access to relevant research findings. The role of systematic reviews is increasingly acknowledged as an important contribution in evidence-based health care decision making, and several review efforts, including that of the international Cochrane Collaboration, are under way. The Cochrane Collaborative Review Group on HIV Infection and AIDS (CRG on HIV/AIDS), conducts systematic reviews on the prevention and the treatment of HIV infection and AIDS and is guided by the Cochrane Collaboration's principles, which include minimizing potential bias, ensuring quality in the review process, keeping reviews up to date, and enhancing collaboration. The CDC HIV/AIDS Prevention Research Synthesis (PRS) project is working closely with the CRG on HIV/AIDS to produce Cochrane reviews of behavioral prevention interventions and on development and maintenance of a centralized, cumulative electronic database of HIV/AIDS behavioral prevention studies. Systematic reviews can play an important role in advancing evidence-based policy and practice in HIV/AIDS prevention and care.

The HIV/AIDS Prevention Research Synthesis Project: scope, methods, and study classification results.

In 1996, the Centers for Disease Control and Prevention (CDC), in collaboration with many partners, initiated the HIV/AIDS Prevention Research Synthesis (PRS) project to accumulate HIV prevention research studies and analyze their effectiveness in reducing sexual and drug-related risk behaviors for HIV transmission. The PRS team developed standardized guidelines and procedures for the systematic reviews, conducted systematic searches for pertinent studies, characterized the selected studies, analyzed effectiveness data, and established a cumulative database. As of June 1998, the database contained more than 5000 reports: 4068 were reports that met the PRS scope criteria for inclusion and 586 of those reports contained outcome data from an intervention study. Of the 586 reports that included outcome data, 276 have been reviewed: 223 (81%) included measures of PRS-specified behavioral or biologic HIV-related outcomes, and 124 of the 223 (56%) used PRS-defined rigorous study designs. The PRS database is a valuable resource for accessing and integrating the literature on HIV prevention research. CDC is committed to 1) updating the database; 2) producing systematic reviews, including meta-analyses, related to key research questions; and 3) disseminating findings to encourage and facilitate the use of science-based research in preventing HIV infection.

Acquisition and review of non-U.S.-based HIV risk reduction intervention studies.

In response to the HIV/AIDS epidemic, many governments and nongovernmental organizations have supported numerous HIV prevention intervention studies in both the United States and in other countries. To understand which intervention approaches have worked outside the United States, the Centers for Disease Control and Prevention extended the scope of its HIV/AIDS Prevention Research Synthesis (PRS) project to include non-U.S.-based studies. We describe briefly the PRS experience with the challenges of acquiring and reviewing those studies, and some of the specialized efforts to find them. The ultimate goals of the PRS project related to international prevention research are to include all available reports of non-U.S.-based studies in the PRS database and to provide comprehensive reviews of those studies. The findings of the reviews would not only highlight common themes of effectiveness or research gaps in the international arena but could also be useful for improving prevention research and programs in the United States.

Review and meta-analysis of HIV prevention intervention research for heterosexual adult populations in the United States.

A meta-analysis was performed to examine the effects of 14 behavioral and social interventions for heterosexual adults on their adoption of safer sex behaviors or incidence of sexually transmitted diseases (STDs). The intervention studies were identified through a systematic search and review strategy. Data were extracted and combined by using well-defined methods and appropriate statistical techniques. For inclusion in this article, studies had to be based in the United States, written in English, first reported between 1988 and 1996, and aimed at reducing sex-related HIV risks. In addition to measuring behavioral or STD incidence outcomes, studies also had used experimental or quasi-experimental designs with control or comparison groups and reported sufficient outcome data to allow calculation of odds ratios. The meta-analytic results show statistically significant effects in reducing sex-related risks (10 studies; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.69-0.95), particularly non-use of condoms (8; OR, 0.69; 95% CI, 0.53-0.90). The interventions also had significant effects in reducing STD infections (6 studies; OR, 0.74; 95% CI, 0.62-0.89). These analyses indicate that science-based prevention interventions have positive effects among populations at risk through heterosexual transmission and that these positive effects are found with biologic and self-reported behavioral measures.

A profile of U.S.-based trials of behavioral and social interventions for HIV risk reduction.

We describe 99 (experimental and certain quasi-experimental) U.S.-based trials, reported or published since 1988, of behavioral and social interventions that measured prespecified behavioral and biologic outcomes and aimed to reduce risk for HIV infection. Studies identified through June 1998 by the HIV/AIDS Prevention Research Synthesis project were grouped into 4 risk behavior areas: drug-related (k [number of studies] = 48), heterosexual youth (k = 24), heterosexual adult (k = 17), and same-sex (k = 10). We compared the studies in the 4 areas by variables key to the development, evaluation, and transfer of interventions. Participants comprised injection drug users (43% of studies), drug users out of treatment (29%), African Americans (18%), clinic patients (18%), youth in schools (10%), and drug users in treatment (10%). Most studies were randomized (85%), provided another intervention to the control or comparison groups (71%), and evaluated behavioral interventions (92%). On average, interventions were conducted in 5 sessions (total, 8 hours) during 3 months. The theoretical basis of the intervention was not noted in 57% of the reports. At least one variable from each of the 3 outcome classifications was measured in 8% of the studies: behavioral, biologic, and psychosocial. Distinct profiles exist for the 4 risk areas. Addressing gaps in research and reporting would be helpful for analytical and program activities. This sizable portfolio of evaluated interventions contributes to effectiveness reviews and to considerations of transfer to program practice.