Principles for Ending Human Immunodeficiency Virus as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medical Association.

While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation.

Beyond the discourses of policy and power: HIV, AIDS, and community perspectives on the lived pandemic.

As HIV unfolded in the 1980s, HIV and AIDS were heard and seen through the lives of those whom it touched directly. Personal histories were foregrounded, centred by the inevitable mortality attached to HIV infection, the courage of circumstance in the face of illness, and the activism necessary to make a difference. In the later part of the decade, the impacts of HIV were most apparent in East Africa, where community responses and political leadership coalesced to reduce new HIV infections. The 1990s marked a turn towards centralised policy, funding, and the reification of biomedically oriented approaches and systems that are intrinsically top-down. This biomedical turn centred on foregrounding the widespread availability of low-cost antiretroviral therapy and was articulated in the 90-90-90 and subsequent targets. Biomedicalisation reinforces individualised approaches to health primarily focused on biomedical technologies and health service provision that do not rely on community or social organisation formats. Emphasis on HIV treatment, along with the promise of reduced HIV transmission through viral load suppression, contributed to limiting socio-behavioural approaches to HIV prevention. While the importance of community-led response was highlighted in the 2016 United Nations Political Declaration on Ending AIDS, community-led response has devolved towards concepts such as community-led monitoring and community-led response that frame responses in direct relation to the dominant biomedical paradigm. There are lessons in the history of the AIDS response that demonstrate that communities formulate responses to AIDS differently when there have been opportunities for community members to determine the pathways for action to address HIV independently. Older research studies offer retrospective insights into moments in the history of HIV when communities were foregrounded and highlighted the need to reconsider the current trajectory of the HIV response. Not only for history's sake but to acknowledge that community leadership remains overwhelmed by elites. While lofty targets and goals drive the contemporary HIV response, the way forward is mired by uncertainty. HIV prevention efforts remain uneven, and millions of people living with HIV depend on access to treatment for decades to come in the context of budgetary uncertainties. Changing the course of AIDS will not be achieved if we fail to ensure that communities occupy a genuine and unambiguous place in shaping HIV response.

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data.

Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women's stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06-0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06-0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.

Including transgender populations in mathematical models for HIV treatment and prevention: current barriers and policy implications.

INTRODUCTION: Mathematical models of HIV have been uniquely important in directing and evaluating HIV policy. Transgender and nonbinary people are disproportionately impacted by HIV; however, few mathematical models of HIV transmission have been published that are inclusive of transgender and nonbinary populations. This commentary discusses current structural challenges to developing robust and accurate trans-inclusive models and identifies opportunities for future research and policy, with a focus on examples from the United States. DISCUSSION: As of April 2024, only seven published mathematical models of HIV transmission include transgender people. Existing models have several notable limitations and biases that limit their utility for informing public health intervention. Notably, no models include transgender men or nonbinary individuals, despite these populations being disproportionately impacted by HIV relative to cisgender populations. In addition, existing mathematical models of HIV transmission do not accurately represent the sexual network of transgender people. Data availability and quality remain a significant barrier to the development of accurate trans-inclusive mathematical models of HIV. Using a community-engaged approach, we developed a modelling framework that addresses the limitations of existing model and to highlight how data availability and quality limit the utility of mathematical models for transgender populations. CONCLUSIONS: Modelling is an important tool for HIV prevention planning and a key step towards informing public health interventions, programming and policies for transgender populations. Our modelling framework underscores the importance of accurate trans-inclusive data collection methodologies, since the relevance of these analyses for informing public health decision-making is strongly dependent on the validity of the model parameterization and calibration targets. Adopting gender-inclusive and gender-specific approaches starting from the development and data collection stages of research can provide insights into how interventions, programming and policies can distinguish unique health needs across all gender groups. Moreover, in light of the data structure limitations, designing longitudinal surveillance data systems and probability samples will be critical to fill key research gaps, highlight progress and provide additional rigour to the current evidence. Investments and initiatives like Ending the HIV Epidemic in the United States can be further expanded and are highly needed to prioritize and value transgender populations across funding structures, goals and outcome measures.

Investigating zero transmission of HIV in the MSM population: a UK modelling case study.

BACKGROUND: UNAIDS 90-90-90 goals for HIV have been surpassed in the UK, with focus now moving to ending transmission by 2030. The concept of zero transmission is complex and many factors can influence transmission. We aimed to investigate how the target of zero transmission might be reached in the UK. METHODS: We developed a de novo Markov state transition open cohort model of HIV with a 50-year time horizon, which models six key screening, treatment and prevention parameters, including treatment-as-prevention (TasP) and pre-exposure prophylaxis (PrEP). We studied the anticipated HIV epidemic trajectory over time in men who have sex with men (MSM), with and without changing the six key parameters, defining zero transmission as a 60% reduction in incidence compared with 2010 incidence. RESULTS: Zero transmission in the MSM population was not achieved within the model's time horizon in our base case scenario, when the six key parameters were set to their 2019 values. Several future scenarios were explored, including a combination approach to preventing HIV transmission through increasing five key parameter values and considering three different TasP values; zero transmission was achieved by 2030 in the scenario where TasP was increased from its current level of 97-99%, avoiding 48,969 new HIV cases over the time horizon and reducing the lifetime risk of acquiring HIV for HIV-negative MSM not using PrEP from 13.65 to 7.53%. CONCLUSIONS: Zero transmission in the UK MSM population can be reached by the target year of 2030 with bold changes to HIV policy. A combination approach such as the UK Government's 'Towards Zero' Action plan, impacting multiple policies and including an increase in TasP, has the potential to achieve meaningful reductions in HIV transmission and meet this ambitious goal.

HIV self-testing for men who have sex with men in Sweden. A cross-sectional study concerning interest to use HIV self-tests.

BACKGROUND: HIV self-testing (HIVST) has been found to have high acceptability among men who have sex with men (MSM) internationally and might contribute to increase testing frequencies, but many countries, including Sweden, lack policies for using HIVST. OBJECTIVE: To examine interest to use and willingness to pay for HIVST, and associated factors, among MSM attending HIV testing venues in Sweden. METHOD: This cross-sectional study analyzed data from a self-administered survey, consisting of 33 questions, collected at six HIV testing venues in Sweden in 2018. The sample consisted of sexually active men who have sex with men, aged ≥ 18 years, and not diagnosed with HIV. Data were analyzed descriptively and by univariable and multivariable logistic regression. RESULT: Among 663 participants (median age 33 years), 436 respondents (65.8%) expressed interest to use HIVST. Among those interested, less than half, 205 (47.0%), were willing to pay for HIVST. Being interested in HIVST was found to be negatively associated with being in the 55 years or older age group (AOR 0.31, CI 0.14-0.71), and having had syphilis, rectal chlamydia, or rectal gonorrhea in the preceding 12 months (AOR 0.56, CI 0.32-0.99). In the sample of MSM interested in HIVST, willingness to pay was positively associated with being in the age groups 35-44 years (AOR 2.94, CI 1.40-6.21), 45-54 years (AOR 2.82, CI 1.16-6.90), and 55 years or above (AOR 3.90, CI 1.19-12.81), and negatively associated with being single (AOR 0.56, CI 0.36-0.88). CONCLUSION: This study found high interest for HIVST in a sample of MSM in Sweden. However, HIVST offered at a cost is likely to negatively affect uptake among MSM broadly, compared with free availability.

Investigating the implementation of differentiated HIV services and implications for pregnant and postpartum women: A mixed methods multi-country study.

Universal antiretroviral therapy (ART) for pregnant and postpartum women in sub-Saharan Africa has required adaptations to service delivery. We compared national policies on differentiated HIV service delivery with facility-level implementation, and explored provider and user experiences in rural Malawi, Tanzania and South Africa. Four national policies and two World Health Organization guidelines on HIV treatment for pregnant and postpartum women published between 2013 and 2017 were reviewed and summarised. Results were compared with implementation data from surveys undertaken in 34 health facilities. Eighty-seven in-depth interviews were conducted with pregnant and post-partum women living with HIV, their partners and providers. In 2018, differentiated service policies varied across countries. None specifically accounted for pregnant or postpartum women. Malawian policies endorsed facility-based multi-month scripting for clinically-stable adult ART patients, excluding pregnant or breastfeeding women. In Tanzania and South Africa, national policies proposed community-based and facility-based approaches, for which pregnant women were not eligible. Interview data suggested some implementation of differentiated services for pregnant and postpartum women beyond stipulated policies in all settings. Although these adaptations were appreciated by pregnant and postpartum women, they could lead to frustrations among other users when criteria for fast-track services or multi-month prescriptions were not clear.

Louisiana's Intentional Exposure to HIV Policy: The Social Construction of Target Populations.

In 1987, Louisiana became one of the first states to put laws in place to criminalize intentional HIV exposure. Unfortunately, the law does not correlate with science nor does it evidence any effectiveness in reductions in HIV transmissions. In spite of this, it took over 30 years before Louisiana's HIV exposure criminalization law was amended to be more scientifically accurate. There remains little research to determine the impact this policy has on public health efforts to reduce transmissions of HIV. This article will apply the social construction of target populations theory to Louisiana's HIV exposure criminalization law to explore the reasons for the action and inaction that led to the introduction and promotes the continued use of a law that does not demonstrate any effectiveness in actually reducing rates of HIV transmissions.

Economic and Policy Analytic Approaches to Inform the Acceleration of HIV Prevention in the United States: Future Directions for the Field.

The fields of economic and policy analysis have long played a role in quantifying the burden of the HIV epidemic and informing how to best deploy interventions and policies aimed at maximizing HIV care and reducing transmission. Looking towards the ultimate goal of ending the AIDS epidemic, we describe five areas for further development and application towards HIV policies: (1) setting measurable objectives to create a vision and monitor progress, (2) taking a health and wellness approach to goal-setting, (3) using impact matrices to inform quantitative analysis to explicitly address health disparities, (4) conducting budget impact analyses to project annual program costs and benefits, and (5) advancing the public health systems and services research agenda.

Can trained lay providers perform HIV testing services? A review of national HIV testing policies.

BACKGROUND: Only an estimated 54% of people living with HIV are aware of their status. Despite progress scaling up HIV testing services (HTS), a testing gap remains. Delivery of HTS by lay providers may help close this testing gap, while also increasing uptake and acceptability of HIV testing among key populations and other priority groups. METHODS: 50 National HIV testing policies were collated from WHO country intelligence databases, contacts and testing program websites. Data regarding lay provider use for HTS was extracted and collated. Our search had no geographical or language restrictions. This data was then compared with reported data from the Global AIDS Response Progress Reporting (GARPR) from July 2015. RESULTS: Forty-two percent of countries permit lay providers to perform HIV testing and 56% permit lay providers to administer pre-and post-test counseling. Comparative analysis with GARPR found that less than half (46%) of reported data from countries were consistent with their corresponding national HIV testing policy. CONCLUSIONS: Given the low uptake of lay provider use globally and their proven use in increasing HIV testing, countries should consider revising policies to support lay provider testing using rapid diagnostic tests.

Identifying gaps in HIV policy and practice along the HIV care continuum: evidence from a national policy review and health facility surveys in urban and rural Kenya.

The last decade has seen rapid evolution in guidance from the WHO concerning the provision of HIV services along the diagnosis-to-treatment continuum, but the extent to which these recommendations are adopted as national policies in Kenya, and subsequently implemented in health facilities, is not well understood. Identifying gaps in policy coverage and implementation is important for highlighting areas for improving service delivery, leading to better health outcomes. We compared WHO guidance with national policies for HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and retention in care. We then investigated implementation of these national policies in health facilities in one rural (Kisumu) and one urban (Nairobi) sites in Kenya. Implementation was documented using structured questionnaires that were administered to in-charge staff at 10 health facilities in Nairobi and 34 in Kisumu. Policies were defined as widely implemented if they were reported to occur in > 70% facilities, partially implemented if reported to occur in 30-70% facilities, and having limited implementation if reported to occur in < 30% facilities. Overall, Kenyan national HIV care and treatment policies were well aligned with WHO guidance. Policies promoting access to treatment and retention in care were widely implemented, but there was partial or limited implementation of several policies promoting access to HIV testing, and the more recent policy of Option B+ for HIV-positive pregnant women. Efforts are needed to improve implementation of policies designed to increase rates of diagnosis, thus facilitating entry into HIV care, if morbidity and mortality burdens are to be further reduced in Kenya, and as the country moves towards universal access to antiretroviral therapy.

A qualitative study of the determinants of HIV guidelines implementation in two south-eastern districts of Tanzania.

Current HIV policies in Tanzania have adopted the three long-term impact results of zero new infections, zero HIV deaths and zero stigma and discrimination. Strategies to reach these results include scaling-up HIV Testing and Counselling (HTC); Preventing Mother-To-Child Transmission (PMTCT); and strengthening Care and Treatment Clinic (CTC) services. Previous studies showed that HIV policy and guideline recommendations were not always implemented in rural South Tanzania. This study aims to identify the determinants of HIV guideline implementation. A qualitative study of 23 semi-structured interviews with facility in-charges; healthcare workers; district, regional and national HIV coordinators was conducted. Five health facilities were purposively selected by level, ownership and proximity to district headquarters. Interviews were analysed according to Fleuren's five determinants of innovation uptake related to: strategies used in guideline development and dissemination; guideline characteristics; the guideline implementing organization; guideline users; and the socio-cultural and regulatory context. None of the facilities had the HTC national guideline document. Non-involvement of providers in revisions and weak planning for guideline dissemination impeded their implementation. Lengthy guidelines and those written in English were under-used, and activities perceived to be complicated, like WHO-staging, were avoided. Availability of staff and lack of supplies like test kits and medication impeded implementation. Collaboration between facilities enhanced implementation, as did peer-support among providers. Provider characteristics including education level, knowledge of, and commitment to the guideline influenced implementation. According to providers, determinants of clients' service use included gender norms, stigma, trust and perceived benefits. The regulatory context prohibited private hospitals from buying HIV supplies. Being tools for bringing policies to practice, national guidelines are crucial in the efforts towards the three zeros. Strategies to improve providers' adherence to guidelines should include development of clearer guideline dissemination plans, strengthening of the health system, and possibly addressing of provider-perceived patient-level barriers to utilizing HIV services.

Policy-maker attitudes to the ageing of the HIV cohort in Botswana.

BACKGROUND: The roll out of antiretroviral therapy in Botswana, as in many countries with near universal access to treatment, has transformed HIV into a complex yet manageable chronic condition and has led to the emergence of a population aging with HIV. Although there has been some realization of this development at international level, no clear defined intervention strategy has been established in many highly affected countries. Therefore we explored attitudes of policy-makers and service providers towards HIV among older adults (50 years or older) in Botswana. METHODS: We conducted qualitative face-to-face interviews with 15 consenting personnel from the Ministry of Health, medical practitioners and non-governmental organizations involved in the administration of medical services, planning, strategies and policies that govern social, physical and medical intervention aimed at people living with HIV and health in general. The Shiffman and Smith Framework of how health issues become a priority was used as a guide for our analysis. RESULTS: Amidst an HIV prevalence of 25% among those aged 50-64 years, the respondents passively recognized the predicament posed by a population aging with HIV but exhibited a lack of comprehension and acknowledgement of the extent of the issue. An underlying persistent ageist stigma regarding sexual behaviour existed among a number of interviewees. Respondents also noted the lack of defined geriatric care within the provision of the national health care system. There seemed, however, to be a debate among the policy strategists and care providers as to whether the appropriate response should be specifically towards older adults living with HIV or rather to improve health services for older adults more generally. Respondents acknowledged that health systems in Botswana are still configured for individual diseases rather than coexisting chronic diseases even though it has become increasingly common for patients, particularly the aged, to have two or more medical conditions at the same time. CONCLUSIONS: HIV among older adults remains a low priority among policy-makers in Botswana but is at least now on the agenda. Action will require more concerted efforts to recognize HIV as a lifelong infection and putting greater emphasis on targeted care for older adults, focussing on multimorbidity.

Parents as partners in adolescent HIV prevention in Eastern and Southern Africa: an evaluation of the current United Nations' approach.

The United Nations's (UN) sustainable development goals (SDGs) include the target (3.3) of ending the HIV/AIDS epidemic by 2030. A major challenge in this regard is to curb the incidence of HIV among adolescents, the number two cause of their death in Africa. In Eastern and Southern Africa, they are mainly infected through heterosexual transmission. Research findings about parental influence on the sexual behavior of their adolescent children are reviewed and findings indicate that parental communication, monitoring and connectedness contribute to the avoidance of risky sexual behavior in adolescents. This article evaluates the extent to which these three dimensions of parenting have been factored in to current HIV prevention recommendations relating to adolescent boys and girls. Four pertinent UN reports are analyzed and the results used to demonstrate that the positive role of parents or primary caregivers vis-à-vis risky sexual behavior has tendentially been back-grounded or even potentially undermined. A more explicit inclusion of parents in adolescent HIV prevention policy and practice is essential - obstacles notwithstanding - enabling their indispensable partnership towards ending an epidemic mostly driven by sexual risk behavior. Evidence from successful or promising projects is included to illustrate the practical feasibility and fruitfulness of this approach.