A randomized controlled intervention trial of a sexual health approach to long-term HIV risk reduction for men who have sex with men: effects of the intervention on unsafe sexual behavior.

This controlled prospective study assessed the effectiveness of a sexual health approach to HIV prevention for men who have sex with men (MSM). Participants (N = 422 Midwestern MSM) were randomly assigned to the intervention group, who participated in a 2-day comprehensive human sexuality seminar designed to contextually address long-term risk factors and cofactors, or to the control group, who watched 3 hours of HIV prevention videos. Risk behavior during the preceding 3 months was measured at baseline, 3-month follow-up, and 12-month follow-up. Any unprotected anal intercourse outside a long-term seroconcordant relationship was the dependent variable. Of the total, 14%-24% of the participants were considered at risk of acquiring or transmitting HIV. At the 12-month follow-up, the control reported a 29% decrease in the use of condoms during anal intercourse; the intervention group reported an 8% increase (t = 2.546; p = .015). The sexual health seminars appear a promising new intervention at significantly reducing unprotected anal intercourse between men.

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.

Progress in global blood safety for HIV.

OBJECTIVE: To assess progress toward ensuring a globally safe blood supply. DESIGN AND METHODS: We examined 2 global databases for blood safety: (1) that of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) blood safety indicator; and (2) that of the Global Database on Blood Safety (GDBS), a database developed by the World Health Organization. The UNGASS data were collected through the Ministry of Health based on the GDBS data, followed by a reconciliation and cross-checking of the data by World Health Organization and United Nations Programme on AIDS (UNAIDS). RESULTS: The proportion of United Nations member countries reporting UNGASS data for blood safety is among the highest of all UNGASS indicators: 147 of 192 United Nations Member States participated in UNGASS reporting in 2008 and 125 of them (85%) submitted data on blood safety. Ninety-one of the 125 countries (73%) reported that 100% of collected blood units were screened in a quality assured manner, but 34 countries did not screen all collected blood units in accordance with minimum quality standards. GDBS data showed that 80.7 million blood units were collected globally in 167 countries during 2004-2005, of which 77.3 million were tested for HIV and at least 0.6 million of the remaining 3.4 million donations went untested. CONCLUSIONS: Progress has been made toward eliminating blood transfusion as a significant cause of HIV infection globally. Screening all donated blood for HIV in accordance with minimum quality standards remains vital, however, as health care systems should, at a minimum, do no harm. This goal is achievable and would assist in reaching Millennium Development Goals by 2015.

Are we on course for reporting on the Millennium Development Goals in 2015?

OBJECTIVES: At the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), Member States agreed to regularly review progress made in national responses to HIV. This article provides (1) a brief overview of how the resultant global UNGASS reporting system was developed; (2) the origins, background, limitations and potential of that system; (3) an overview of the articles in this supplement; and (4) crosscutting institutional and methodological issues. METHODS: United Nations Member States biennially provide The Joint United Nations Programme on HIV/AIDS (UNAIDS) with data on 25 core indicators of national responses to HIV, collected in Country Progress Reports. This article critically reviews and interprets these data in light of international political considerations and overall data needs. RESULTS: There has been a considerable improvement in response rates, accompanied by an increase in data quality and completeness. Both nationally and internationally, the UNGASS process is viewed as being more substantial and important than a reporting exercise to the United Nations General Assembly. The process has catalyzed the development of national monitoring systems and has created opportunities for civil society to monitor and challenge government commitments and deeds. CONCLUSIONS: Although the UNGASS global reporting system now comprises an unequaled wealth of data on HIV responses, collected from a broad range of countries, it cannot yet answer several critical questions about the progress and effectiveness of those responses. Evaluation studies that go beyond indicator monitoring are needed, but they will take time to design, fund, implement and interpret. In the meantime, this global monitoring system provides a good indication of the overall progress in the global response to HIV and whether Millennium Development Goal (MDG) 6 (to halt and reverse the HIV epidemic) is likely to be reached by 2015.

Monitoring the 2001 Declaration of Commitment on HIV/AIDS.

OBJECTIVES: This article describes the development of the international reporting system to monitor the implementation of the Declaration of Commitment on HIV/AIDS that resulted from the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS). DESIGN: The UNGASS reporting system is based on the biennial submission of Country Progress Reports. These include data on a set of core indicators and are prepared and submitted by Member States using a transparent collaborative process. METHODS: This article reviews the evolution of the system and analyzes the quality and completeness of data from the most recent 2008 reporting round. RESULTS: Over the course of 3 rounds of reporting response rates increased from 54% to 77%. This increase occurred alongside an increase in the completeness of the reported data. Increases in reporting are consistent across countries regardless of the severity of the HIV epidemic. CONCLUSIONS: UNGASS reporting has resulted in an unparalleled body of evidence on the response to HIV. Data from 147 countries are now available on the patterns of HIV epidemics, the behaviors related to them, and the programmatic responses that have been mounted by countries. The ultimate goal is for national governments and their civil society partners to achieve ownership of the reporting process. The reporting system has provided a catalyst for the development of national systems for monitoring and evaluating HIV programs and for guiding more effective, efficient, and sustainable responses to the HIV epidemic.

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.

Estimating the level of HIV prevention coverage, knowledge and protective behavior among injecting drug users: what does the 2008 UNGASS reporting round tell us?

OBJECTIVES: The 2001 Declaration of Commitment from the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) set the prevention of HIV infection among injecting drug users (IDUs) as an important priority in the global fight against HIV/AIDS. This article examines data gathered to monitor the fulfillment of this commitment in low-income and middle-income countries (LMICs) where resources to develop an effective response to HIV are limited and where injecting drug use is reported to occur in 99 (of 147) countries, home to 75% of the estimated 15.9 million global IDU population. METHODS: Data relating to injecting drug use submitted by LMICs to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in the 2008 reporting round for monitoring the Declaration of Commitment on HIV/AIDS were reviewed. The quality of the data reported was assessed and country data were aggregated and compared to determine progress in HIV prevention efforts. For each indicator, the mean value weighted for the size of each country's IDU population was determined; regional estimates were also made. RESULTS: Reporting was inconsistent between countries. Forty percent of LMIC (40/99), where injecting occurs, reported data for 1 or more of the 5 indicators pertinent to HIV prevention among IDUs. Many of the data reported were excluded from this analysis because the indicators used by countries were not consistent with those defined by UNAIDS Monitoring and Evaluation Reference Group and could not be compared. Data from 32 of 99 countries met our inclusion criteria. These 32 countries account for approximately two-thirds (68%) of the total estimated IDU population in all LMICs.The IDU population weighted means are as follows: 36% of IDUs tested for HIV in the last year; 26% of IDUs reached with HIV prevention programs in the last year; 45% of IDUs with correct HIV prevention knowledge; 37% of IDUs used a condom at last sexual intercourse; and 63% of IDUs used a clean syringe at last injection. Marked variance was observed in the data reported between different regions. CONCLUSIONS: Data from the 2008 United Nations General Assembly Special Session reporting round provide a baseline against which future progress might be measured. The data indicate a wide variation in HIV service coverage for IDUs and a wide divergence in HIV knowledge and risk behaviors among IDUs in different countries. Countries should be encouraged and assisted in monitoring and reporting on HIV prevention for IDUs.

Estimating levels of HIV testing, HIV prevention coverage, HIV knowledge, and condom use among men who have sex with men (MSM) in low-income and middle-income countries.

BACKGROUND: HIV prevalence data suggest that men who have sex with men (MSM) in low-income and middle-income countries (LMIC) are at increased risk of HIV. The aim of this article is to present global estimates on key HIV prevention needs and responses among MSM in LMIC. METHODS: Data on HIV testing, HIV prevention coverage, HIV knowledge and condom use among MSM were derived from UNGASS country progress reports submitted in 2008. Eligible country estimates were used to calculate global and regional estimates, weighted for the size of MSM populations. RESULTS: Of 147 LMIC, 45% reported at least 1 indicator that reflects the HIV prevention needs and responses in MSM. Global weighted estimates indicate that on average 31% of MSM in LMIC were tested for HIV; 33% were reached by HIV prevention programs; 44% had correct HIV knowledge; and 54% used condoms the last time they had anal sex with a man. CONCLUSIONS: The 2008 UNGASS country reports represent the largest harmonized data set to date of HIV prevention needs and responses among MSM in LMIC. Although reporting is incomplete and does not always conform to requirements, findings confirm that, in many LMIC, HIV prevention responses in MSM need substantial strengthening.