Global HIV Policy Report 2022 by blueandyellow.design

GlobalHIVPolicyReport: FindingsfromtheHIVPolicyLab March2022

Toaccessthereportaswellascompletedataon33 hivpolicylab.org

policiesacross194countries,goto:

TableofContents ExecutiveSummary 1 1.IntroductiontotheHIVPolicyLab 3 2.MappingHIVPolicies:TheTopTakeaways 7 3.TheCaseforTwoPoliciesforHIVandCOVID-19 19 4.ProgressTowardsthe10-10-10Targets 23 References 30 AppendixA:RegionalMaps31 AppendixB:CountryPolicyProgress34

FollowusonTwitterat @hivpolicylab.

Withincountries,somepopulationsremainfarmore vulnerablethanothers.Globally,theriskofacquiringHIV isabout35timeshigherforpeoplewhoinjectdrugsthan peoplewhodonotinjectdrugs;34timeshigherfor transgenderwomenthanforotheradults;26timeshigher forfemalesexworkersthanforotherwomen;and25 timeshigherforgaymenandothermenwhohavesex withmenthanforheterosexualmen.

Further,peoplelivingwithHIV (PLHIV),especiallythosewithweakenedimmune systems,aremoreatriskofsevereillnessanddeathfrom COVID-19,whichintensifiestheneedtoensuretimely androbustHIVcareandtreatment.

ThenumberofnewHIVinfectionshasdeclinedbyonly 31%since2010(farshortofthe75%targetsetbytheUN GeneralAssembly)andprogressinpreventingnew infectionshaslargelystalledoverpastfouryears.6

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Thepercentagesofpeople livingwithHIV(PLHIV)whoknowtheirstatus,whoare receivingART,andwhoarevirallysuppressedareall 30-40percentagepointshigherinEasternandSouthern AfricaandWesternandCentralEuropeanandNorth AmericathanintheMiddleEastandNorthAfrica.

Theimpactoflawsandpoliciesonhealthoutcomesin general,andHIVoutcomesinparticular,hasbeen demonstratedbyresearchersanalyzingthe“legal determinantsofhealth.”Forexample,researchshows thateliminatingparentalconsentpoliciesislinkedto increasedratesofHIVtesting,thatcountrieswitha constitutionalrighttohealthhavebetterhealthoutcomes, andthatcriminalizationofsexworkisassociatedwith significantlyhigherHIVprevalenceamongsex workers.10–13 Likewise,analysisofHIVPolicyLabdata showsthatcountrieswithpunitivelawswhichcriminalize same-sexsexualrelationships,sexwork,anddruguse havemadesignificantlylessprogresstowardsthe 90-90-90targetsthancountrieswhichdonotcriminalize them.Conversely,countriesthatadoptlawsandpolicies thanprotectpeoplefromdiscriminationandgender-based violencehavemadegreaterprogresstowardsthese

hisreportpresentsthestateofHIVpolicyfromthe HIVPolicyLab,acollaborativeprojectofacademic, civilsociety,andmultilateralorganizations,which compilesandmeasurestheHIV-relatedpolicy environmentincountriesaroundtheworld.Overallit showsthatpolicybarriersexistthroughouttheworldthat underminethequalityofHIVtreatmentandprevention, undermineaccesstoHIVtreatmentandprevention,and increasethevulnerabilitytoHIVinfectionandAIDS death. Inthenearlyfourdecadessincetheidentificationofthe humanimmunodeficiencyvirus(HIV),thescienceofHIV hasneverbeenbetter.Today,thereisabetter understandingofhowthevirusfunctionsandhowtotest, treat,andpreventHIVinfectionandHIV-relateddeaths. Thereisclearevidenceonthebiomedical,social,and structuraldriversofnewHIVinfectionsanddeaths,and newtoolstohaltthem.Antiretroviralmedicines(ARVs), forexample,areavailabletosavelivesandcurb transmission,andnewformsofpre-exposureprophylaxis (PrEP)arebeingdevelopedandbecomingmorewidely available.ThereisclearevidencethatdifferentiatingHIV servicesinordertofitthelivesofpeopleonantiretroviral therapy(ART)works,thatself-testinghelpsreach populationspoorlyservedbyothermethods,that healthcareuserfeesblockentryintoHIVcare,that criminalizationofkeypopulationsunderminesaccessto services,drivesHIVincidence,andisassociatedwith poorerHIVoutcomes,includingfailuresacrossthe90-9090cascadeandmuchmore.

8,9

1–4

Despiterapidscientificadvances,theworldfailedto achievethe2020globalHIVgoalsandisnotontrackto endacquiredimmunodeficiencysyndrome(AIDS)asa publichealththreatby2030.

ExecutiveSummary

Insub-Saharan Africa,86%ofinfectionsamongadolescentsgirls(aged1519),andthatyoungwomen(aged15-24)aretwiceas likelytobelivingwithHIVthanyoungmen.

Beneaththeglobalstatisticsonprogresstowardsending AIDS,therearesignificantdifferencesacrosscountries andregions.Forexample,from2010-2020,thenumberof newinfectionsdeclinedby38%inEasternandSouthern Africabutincreasedbyastaggering72%inEastern EuropeandCentralAsia.

Disruptionsandresourceconstraintscausedbythe COVID-19pandemicarepushingusevenfurtherfrom thatgoal.TheGlobalFundtoFightAIDS,Tuberculosis andMalariareportsthat,since2019,thenumberof peoplereachedbyHIVpreventionprogramsandservices hasdeclinedby11%andthenumberofHIVteststaken hasdeclinedby22%.

By2020,onlyeight countrieshadachievedthe90-90-90testingandtreatment targetsadoptedbytheUNGeneralAssemblyin2015 (althoughmanymorecameclose),whichaimedfor90% ofallpeoplelivingwithHIVtoknowtheirstatus,for90% ofallpeoplewithdiagnosedHIVinfectiontoreceive sustainedantiretroviraltherapy,andfor90%ofallpeople receivingantiretroviraltherapytohaveviralsuppression.6

Thesedisparitiescanbeexplained,atleastinpart,bythe significantgapthatremainsbetweenscienceandlawand policyinmuchoftheworld.Lawsandpoliciesdrivewho hasaccesstothebenefitsofscience,howpeopleliving withandaffectedbyHIVaretreated,howhealthsystems arestructured,howofficialsengagewithcommunities, andthebarriersthatpeoplefaceinaccessingcare.Laws andpoliciescanfacilitateaccesstoHIVprevention, testing,andtreatment,ortheycriminalize,stigmatize,and furthermarginalizevulnerablepopulations,leavingthem morelikelytobeexposedtoHIVandlesslikelytoreceive careandservices.

•Theregionswiththehighestratesofpolicyadoption areEasternandSouthernAfricaandWesternand CentralEuropeandNorthAmerica.

•Thispolicygapexistsevenforthemostcritical preventioninterventions,likePrEP.Lessthanhalfof countrieshaveadoptedorpartiallyadoptedPrEP policiesalignedwithWHOguidelines.

•Nocountryintheworldhasadoptedallsevenofthe non-criminalizingandrights-supportinglawsand policiescalledforinthe10-10-10targetsand2021UN PoliticalDeclarationonHIV/AIDS.Onaverage, countrieshaveadoptedthreeoftheseven(i.e.,noncriminalizationofsame-sexsex,sexwork,druguse, andHIVexposure/transmission/non-disclosure; redressmechanismsforhumanrightsviolations; protectionsagainstdiscriminationonthebasisof sexualorientation,genderidentity,andHIVstatus; andprotectionsagainstgender-basedviolence.)

•Nocountryintheworldhasfullyaligneditslawsand policieswiththe33keyevidence-basedlawsand policiesrecommendedbyinternationalauthorities.On average,countrieshaveadoptedjustoverhalfofthese recommendedpolicies.

•Over100countriesrequireadolescentstohave parentalconsentbeforetheycanaccessHIVtesting and/ortreatment,andsomecountriesallowsome adolescentstoaccessonebutnottheother.

•DisruptionscausedbytheCOVID-19pandemicmake differentiatedservicedelivery(DSD)moreessential thanever,includinginhigh-incomecountries.Nearly 60%ofcountrieshavepartiallyadoptedDSDpolicies (specifically,communityARTdistribution,reduced frequencyofclinicalvisits,andmulti-month dispensing).However,only13%havefullyadoptedall threepolicies,andthemajorityoftheseareinEastern andSouthernAfrica.

•Everycountryintheworldhasatleastonelaw criminalizingsame-sexsexualrelations,sexwork, druguse,orHIVexposureortransmission,despite evidencethatcriminalizationiscounterproductive.

TheHIVPolicyLabisaresearchandaccountability platformthatrigorouslyanalyzesnationalHIV-related lawsandpoliciesin194countriesandmonitorswhether countrieshaveadopted33keyevidence-basedlawsand policiesthathavebeenrecommendedbytheWorld HealthOrganization(WHO),theJointUnitedNations ProgrammeonHIVandAIDS(UNAIDS)andother internationalauthoritiesandendorsedbynational governmentsinUnitedNationsPoliticalDeclarationsand similarinstruments.Thisreportreflectsthestateof nationalHIVlawsandpoliciesasoftheendof2021.

Keyfindings:

2 GlobalHIVPolicyReport targets.14 Atthe2021UNHigh-LevelMeetingonAIDS, countriesadoptedaPoliticalDeclarationendorsingan ambitiousnewsetoftargets,calledthe10-10-10societal enablertargets,aimedatrepealingpunitivelaws, combatingstigmaanddiscrimination,andprotecting againstgender-basedviolence.35,36

•Atleast134countrieshavenotadoptedoronly partiallyadoptedWHOrecommendationsonpediatric testingandtreatment,including64countriesthathave adoptedWHOtreatmentguidelinesforadultsbutnot forchildren.

•Morethan70countries,includingmoreone-thirdof countriesinWesternandCentralEuropeandNorth America,havenotyetupdatedtheiradultHIV treatmentguidelinestoalignwithcurrentWHO guidelinesontheuseofDTG-basedregimensor improvedregimensasthepreferredfirst-lineART regimenforalladultsandadolescents,including peoplewhoarepregnantormaybecomepregnant. Morethan100countrieshavenotyetupdatedtheir pediatrictreatmentguidelines.

•Onlythreecountries(theNetherlands,Portugal,and SouthAfrica)haveadopted“Most”(≥80%)ofthe internationallyrecommendedlawsandpolicies.

•Thereisasignificantdisparityinprogressacross policycategories.Clinicalcareandtreatmentpolicies havethehighestratesofadoption(85%,onaverage), whiletestingandpreventionandstructuralpolicies havethelowestrates(both49%onaverage). Structuralpoliciesdescribethebroaderlegal environmentaffectingPLHIV,keypopulations,and HIVprograms,suchascriminalizationlaws,legal protectionsagainstdiscriminationandgender-based violence,andlawsgoverningtheoperationof community-basedorganizations.Healthsystem policiesfallinbetween,withanaverage60%adoption rate.

•Countrieshaveadoptedroughlyhalfofthe internationallyrecommendedtestingandprevention andstructuralpolicies,ascomparedwithnearly70%of clinicalcareandtreatmentpolicies.

•EasternandSouthernAfricancountrieshavehigh ratesofpolicyadoptionoverall,butlagbehindwhenit comestoadoptingstructuralpolicies,particularly repealingpunitivelawsthatcriminalizePLHIVand keypopulations.

Itwouldbetemptingtothinkthat,severaldecadesintoa trulyglobalAIDSresponse,mostcountrieshavealigned theirlawsandpolicieswithcurrentscienceandevidence, andthatthequalityofimplementationiswhatexplains differencesbetweencountries.DatafromtheHIVPolicy Labshowthisisnotthecase,thatpolicyandlawreform remainanessentialtaskoftheglobalAIDSresponse. Dataalsoshowthatcountrieshavemuchtolearnfrom eachother.

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heHIVPolicyLabisauniquecollaboration betweencivilsocietyorganizations,United Nationsagencies,academics,clinicians,and networksofpeoplelivingwithHIVtomonitor,reporton, andimprovetheHIV-relatedlawandpolicyenvironment incountriesaroundtheworld.TheHIVPolicyLab researchandaccountabilityplatformsystematically identifiesandvisualizespoliciesadoptedbycountries aroundtheworldandhowthosealignwithevidencebasedpolicyguidelinesissuedbyWHO,UNAIDS,and otherinternationalauthoritiesandinternationalnorms andcommitmentscontainedinUNPoliticalDeclarations andsimilarinstruments.Itisanopen,livingglobalpublic resourcethatdrawsinformationfromnationallawsand policydocuments,governmentreporting,and independentanalysestocreatedatathatcanbecompared acrosscountriesandacrossissues.TheHIVPolicyLab seeksnotjusttodocument,butalsotoimprovethepolicy environmentbypartneringwithvariousactorsfromthe public,academic,andcivilsocietysectorstosupport learningacrosscountriesandscience-basedpolicy change.

TheHIVPolicyLabalsoprovidesresearcherswithcrossnationaldataonpoliciessotheglobalhealthcommunity canlearnmoreabouttheimpactsanddriversofpolicy choices,recognizingthatwhatworksinaresearchsetting mightnotworkwhentakentoscalethrough policymaking.HIV-relatedlawsandpoliciescanhavelife anddeathconsequences.Suchpoliciesneedtobe measured,evaluated,andchangedinordertomeetthe evolvingcontextonthepathtowardsendingtheglobal AIDSpandemic.TheHIVPolicyLabResearchNetwork bringstogetheracommunityofresearchersfromacross disciplinesandgeographieswhocollaborateandutilize HIVPolicyLabdataintheirownwork.TheHIVPolicy LabisproducedbyGeorgetownUniversity’sO’Neill InstituteforNationalandGlobalHealthLawwithTalus Analytics,inpartnershipwithUNAIDS,theGlobal NetworkofPeopleLivingwithHIV,andagrowingsetof partnersaroundtheworld,andwithsupportfromtheU.S. President’sEmergencyPlanforAIDSRelief(PEPFAR).

OntheHIVPolicyLab’sonlineplatform,userswillfind notonlysummariesandvisualizationsacross33different policies,butalsoagrowingreferencelibraryofpolicy documents.Usersareinvitedtohelpupdatethedatabase bysharinglawandpolicyinformationwiththeHIVPolicy Labteamtohelpkeepthesiteuptodate.

nthisreportandonlineathivpolicylab.org,readers willfindnewdatafrom2021andanalysisonthelaw andpolicyenvironmentineachregionoftheworld andeveryWorldHealthOrganization(WHO)member state.Thirty-threedifferentspecificlawsandpolicies, groupedintofourpolicycategories,aretrackedacross countries,withthemostup-to-dateinformationpublicly available.Togetherwiththeanswersforeachspecific policyquestion,thesecanprovidearoadmapforpublic healthofficials,governments,civilsociety,andfundersto prioritizelawandpolicychangestoimprovetheAIDS response.Ratherthansomeunattainablyhighstandard, these33indicatorsrepresentminimumpoliciesthathave beenrecommendedbyinternationallyrecognized normativeauthoritiesincludingWHO,UNAIDS,UNDP, theGlobalCommissiononHIVandtheLaw,andothers basedoncurrentscienceandevidence.Itwouldbe reasonable,therefore,tohopethatgovernmentswould alignonall33oftheseindicators,atminimum—evenas theseindicatorsareonlyastartingpointanddonot captureeverypolicythatwouldideallybeneededforan optimalresponse.

AchievinganendtoAIDSasapublichealththreat,the globalgoalsetfor2030bytheUNGeneralAssembly,will requiremorethangoodscienceandscaledupprograms. Itwillrequirelawsandpolicyalignedwiththatscience.In 2021,theclearmessagefromtheHIVPolicyLabdatais thattherecontinuestobemuchworktodotoputuson thispath.

AbouttheHIVPolicyLab

1.IntroductiontotheHIVPolicyLab

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FeaturesandResources onthe HIVPolicyLab.org platform

•NEWdatafor2021,addedto datafor2017-2020. •Countrypages foreachcountry featureadashboardsummarizing thecountry’spolicyprogress,a scorecardshowingtheadoption statusofeachpolicyindicator overtime,andinformationon sources.

•“ChooseYourOwn Comparison” toolsallowusers generatetheirowngraphicsand tablescomparingindividual countries’policyadoptionstatus orpolicyadoptionratesforthe countriesandpoliciesoftheir choice.

•Indextables rankcountriesby policyprogressoverallandin eachpolicycategory.Userscan choosetofiltercountriesby regionandPEPFARstatus.

•Activitiespage featuresreports, policybriefs,analyses,and advocacymaterialsproducedby theHIVPolicyLabteamandour partners.

•Datadownload allowsusersto downloadthecompleteHIV PolicyLabdatasetforfreeusein theirownanalyses.

•Policydocumentlibrary where userscandownloadpolicy documentsforallcountries.

•Sourcesandadditional resources pageprovideslinksto themainsecondarysourcesused bytheHIVPolicyLab,aswellas linkstoourpartners’pages whereuserscanfindin-depth informationonspecificpolicy issues.

ViewthefullHIVPolicyLab platformat HIVPolicyLab.org

•Globalprogressdashboard allowsuserstocompareratesof policyadoptionforeachregion andcountry,overallandineach policycategory.

•Methodsandcodebook pages provideadetaileddescriptionof themethodologybehindtheHIV PolicyLab,includingadetailed definitionandexplanationof codingforeachindicator.

•Policypages foreachpolicy indicatorshowtheratesofpolicy adoptionglobally,acrossregions andcountries,andovertime.

•Maps provideaglobalviewof policyprogressoverall,ineach policycategory,andforeach policyindicator.

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Migrantaccesstohealthcare

Harmreduction Nationalhumanrights institutions Uniqueidentifierswithdata protections

ARVtreatmentinitiation Self-testing Same-sexsexnoncriminalization Taskshifting

Viralloadtesting PrEP Non-discrimination protections Accesstomedicines(TRIPS)

Testing&Prevention

Pediatricdiagnosisand treatment

Table1.1-PolicyIndicatorsTrackedbytheHIVPolicyLabbyPolicyCategory

Compulsorytesting Drugusenon-criminalization Universalhealthcoverage

heHIVPolicyLabincludesadataset,index,and referencelibrary,andisaresearchand accountabilityplatformthatrigorouslytracksHIV-related lawandpolicyacrossthe194countriesthataremembers oftheWHO.Thedatasetquantitativelyrepresentsthe HIV-relatedlawandpolicyenvironmentinagiven countryformultipleyears,enablinggovernments,civil society,globalhealthactorsandresearcherstocompare countries. TheHIVPolicyLabdrawsonmethodsfrompolicy surveillance(thesystematic,scientificcollectionand analysisoflawsofpublichealthsignificanceovertime), politicalscience,andsocialscience.15,16 Thefull methodologyisdescribedonlineat www.hivpolicylab.org/methodsandinanarticlein BMJ GlobalHealth. 17

TheHIVPolicyLabtrackstheadoptionof33keyHIVrelatedlawsandpolicyindicators.Seventeenofthese policiescomprisetwoormoresub-policies,foratotalof 52policiestracked.Theseindicatorsaregroupedinto fourcategories:clinicalcareandtreatment,testingand prevention,structuralbarriers,andhealthsystems factors.

Clinical&Treatment Structural HealthSystems

Comprehensivesexuality education Constitutionalrighttohealth Datasharing

Indicators

Same-daytreatmentstart Partnernotification/index testing Sexworknon-criminalization Healthcarefinancing

POLICYINDICATORS

Tuberculosisdiagnosis Prisonersprevention Girlseducation Gender-basedviolence Civilsociety

POLICYCATEGORIES

ARVtreatmentregimen

Differentiatedservice delivery Agerestrictionsontesting andtreatment HIVexposurenoncriminalization Userfees

Methodology

DataCollection

Informationaboutpoliciesisreported

Foreachindicator,theHIVPolicyLabteamidentifiesa benchmark,i.e.,anevidence-basedpolicy recommendationissuedbyaninternationalauthorityor containedinaninternationalnormativeinstrument.Each country’snationallawsandpoliciesarethenanalyzedto assesswhetherthecountryhas“adopted,”“partially adopted,”or“notadopted”eachoftheinternationally recommendedpolicies.Thesebenchmarksinclude guidancefromUNAIDS,theWorldHealthOrganization, andinternationalrightsagreements.Afullsetof benchmarksisavailableinthefullPDFdownloadofthe onlinecodebook.Foreachpolicyareaandoverall,each countryreceivesanHIVPolicyLabsummaryscore.For allindicatorsforwhichtherearedata,thetotalofadopted (1)andpartiallyadopted(0.5)isdividedbythetotal numberofindicatorsscored.Wheredataaremissingfor agivenindicator,thenumeratorisreducedsothatthe HIVPolicyLabisonlyscoringacountrybasedon existingdata. Thisscoringmetricassignsacategoricallabelbasedon thequantitativescoretoconveythedegreetowhich countries’policiesarealignedwithglobalnorms,overall andineachofthefourpolicycategories.TheHIVPolicy Labrepresentsthedegreeofpolicyadoptionusingafivelevelscale:VeryFewindicatesthatlessthan20%of recommendedpolicieshavebeenadopted;Fewindicates that20-39%ofrecommendedpolicieshavebeenadopted; Someindicatesthat40-59%ofrecommendedpolicies havebeenadopted;Manyindicatesthat60-79%of recommendedpolicieshavebeenadopted;andMost indicatesthat80%ormoreofrecommendedpolicieshave beenadopted.Thissamescaleisusedforregionalpolicy adoptionscores,whichrepresenttheaverageofthepolicy adoptionscoresforcountriesinthatregion.

Eachobservation(i.e.,datapoint)intheHIVPolicyLab databaseconveysinformationaboutagivencountry’s policyonagivenindicatorinagivenyear.Thesourcesfor everyobservationarepubliclyavailableandcitedinthe onlinedatabase.Thisdataonnationalpoliciesfromthree maintypesofsources.First,theHIVPolicyLabcollectsa largenumberofprimarysources(i.e.,nationallawsand policydocuments)whichareavailableinthereference library.Second,dataalsocomefromformalreportingby governmentstoUNAIDSandtheWorldHealth OrganizationthroughtheGlobalAIDSMonitoring framework.18

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HIVPolicyLabindicatorswerechosenafteranextensive year-longglobalprocessin2019-2020thatincludedreview ofinternationalnormativeguidanceandagreements alongwithaseriesofsubject-specific,cross-sectoralfocus groupsandconsultationswithnationalpolicymakers, clinicians,researchersinsocialandbiomedicalscience, internationalorganizationsandotherglobalhealthactors, communitiesofpeoplelivingwithHIV,andothercivil societygroups.TheHIVpolicyenvironmentismadeupof hundredsofspecificpolicies.ThoseincludedintheHIV PolicyLabareintendedasindicatorsrepresentingthis broaderpolicycontext.Foreachoftheindicators,a codingschemawasdevelopedtotranslateinformation aboutthecontentofthelawsandpoliciesintodata.Afull listofscoringcriteriaforeachindicatorisavailablefrom theHIVPolicyLabcodebookat hivpolicylab.org/ codebook.

TheHIVPolicyLabisabletotriangulateinformationfrom thesethreesetsofsources,includethemostup-to-date dataavailable,andallowforabroaderscopeofanalysis.

CodingandScoring

Fig1.1-HIVPolicyLabAdoptionScoringSystem Score %ofrecommendedpoliciesadopted Veryfew 0–19% Few 20–39% Some 40–59% Many 60–79% Most 80–100%

throughtheNationalCommitmentsandPolicy Instrument(NCPI)andvalidatedbyUNAIDSandWHO. Third,thePolicyLabconductsmeta-analysesofother publishedsourcesofinformationaboutpoliciesinthe publicsphereincludingUnitedNations,nongovernmentalorganizations(NGOs),andacademic sources.Awiderangeofpartnersprovideddataforthis report.AfullsetofsourcesfromNGO,government,and UNpartnersisat https://www.hivpolicylab.org/sources

MappingHIVlawsandpolicies showsuswho,where,andinwhat wayspeoplearebeingleftbehind intheglobalAIDSresponse.

appingthestatusofHIVlawsandpoliciesaround theworldpaintsapictureofprotectionand vulnerability.Simplyput,adoptingthescience-basedlaws andpoliciesrecommendedbyUNAIDSandWHO protectspeople,directlyandindirectly.Incountries wherePrEPisreadilyavailable,comprehensivesexuality educationistaughtinschools,andcondomsareavailable inprisons,peoplecanmoreeasilyprotectthemselves fromHIVinfection.Incountriesthatallowself-testing, PLHIVcanmoreeasilylearntheirstatusandprotecttheir partnersandchildren.Incountriesthatpromotetimely testingandtreatmentwithoptimalregimens,aswellas viralloadmonitoring,PLHIVhaveabetterchanceof reachingandsustainingundetectableviralloads,which stavesoffdiseaseprogressionandpreventstransmission. Suchmeasuresaredoublyimportantinthetimeof COVID-19,sincepeoplewithweakenedimmunesystems areatsignificantlyhigherriskofsevereillnessanddeath fromCOVID-19.Incountrieswithdifferentiatedservice delivery(DSD),itiseasierforPLHIVtoremainon treatment,protectingtheirlong-termhealth;andwhen COVID-19hit,DSDmodelslikecommunityART distributionandmulti-monthdispensingallowedPLHIV tocontinuereceivingtheirmedicationswithreduced COVID-19exposure.

19 Incountriesthathavenot adoptedthebestavailablefirst-lineARVregimens,itmay bemoredifficultforPLHIVtoreachandmaintainan undetectableviralload.Incountriesthatcriminalize same-sexsex,sexwork,anddruguse,peopleareunable toaccessHIVservicesforfearofarrestandpersecution. Lawsandpoliciesthatmakeitmoredifficultformigrants, oradolescents,orthepoortoaccessservicespushthese individualsevenfurthertothemargins.Lawsagainst discriminationandgender-basedviolencedonotmake suchthreatsdisappearbuttheydoofferpeopleanadded levelofprotectionandrecourse.

Ontheotherhand,badlawsandpoliciesmakepeople morevulnerabletoinfection,illness,death,stigma,and violence.Incountrieswithoutpoint-of-careearlyinfant diagnosis,longwaittimesfortestresultsmeanthat infantsbornwithHIVarelesslikelytobelinkedto treatment,withdevastatingconsequences(halfofHIVpositiveinfantswhodonotreceivetreatmentwilldie beforetheirsecondbirthday).

ProtectionVersusVulnerabilityinthe TimeofHIVandCOVID-19

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AnalysisoftheHIVPolicyLabdatashowssignificant variationinratesofpolicyadoptionacrosspolicy categories,UNAIDSregions,andevenwithincountries. Figure2.1showsasummaryoftheaverageratesofpolicy adoptionforcountriesineachregion,incomparisonto theglobalaverage,overall,andineachpolicycategory.As such,itgivesreadersasenseofthevariableprogress beingmadeondifferentsetsofpolicyissuesindifferent partsoftheworld.ThemapsinAppendixAallowreaders tocomparepolicyadoptionratesamongthecountriesin eachregion,overall,andineachpolicycategory.Forafull breakdownofpolicyadoptionineachcountry,see AppendixB.

2.MappingHIVPolicies:TheTopTakeaways

TheFightAIDSCoalition(FAC)workstobringaboutspecificpolicychange toaddressthemaindriversofdeathamongPLHIV(tuberculosisand cryptococcalmeningitis)andensuretheclinicalandtreatmentpolicies reflectedintheHIVPolicyLabareimplemented.

M E N A A P E E C A GLOBAL AVERAGE L A C W C A E S A W C E N A A P E E C A M E N A W C E N A L A C W C A E S A M E N A W C A E S A A P L A C E E C A W C E N A M E N A A P E E C A E S A W C A L A C W C E N A Overall Clinical&treatment M E N A A P L A C E E C A W C A E S A W C E N A Testing&prevention Structural Healthsystems AP -AsiaandthePacific LAC -LatinAmericaandtheCaribbean MENA -MiddleEastandNorthAfrica WCA -WesternandCentralAfrica EECA -EasternEuropeandCentralAsia WCENA -WesternandCentralEuropeandNorthAmerica ESA -EasternandSouthernAfrica ← Veryfew Portionofpoliciesalignedwithinternationalstandards Most → Fig2.1-ComparingtheHIVPolicyEnvironmentsAcrossPolicyCategories&UNAIDSRegions:RegionalAverage PolicyAdoptionScores

“Ibelievepolicychangewillcomefrombelow,”saysVuyisekaDubula,apostdoctoralfellowattheCentreforCivilSocietyandFACmember,“whenactivists organizeandconnectwiththeircollectiveactionstopressuretheirrespective countriestocommittoendingAIDS,aswellasapplyingglobalpressure throughsolidarityactions...”

Advocatingforpreventing,detecting,andtreatingAIDS

W hileAdvancedHIVDisease(AHD)/AIDSisatopicthathasreceived greaterattentioninrecentyears,aglaringgapremainsinthe translationofdiscussionsandbroadambitionsintoconsequentialoutcomes forPLHIV.Thetoolstodetect,prevent,andtreatAIDSexist,butdeaths continue.Policygaps,lackofaccesstolife-savingtoolsandservices,andthe invisibilityaroundAIDSdeathsallneedtobeconfronted.

8 GlobalHIVPolicyReport PROFILE OF POLICY CHANGERS

FightAIDSCoalition(FAC)

Antiguaand LaoPeople's Austria Albania Austria Netherlands Barbuda Democratic Eritrea Chile Belgium Portugal Argentina Republic Finland Croatia Brazil SouthAfrica Australia Lebanon Lesotho Netherlands CapeVerde Belgium Lesotho Luxembourg Uruguay CentralAfrican Benin Malawi Netherlands Republic Brazil Mali Nigeria Croatia BurkinaFaso Mozambique Norway Cyprus Cambodia Namibia Portugal Denmark Cameroon Nepal Romania Estonia CentralAfrican Netherlands SouthAfrica Eswatini Republic Nigeria Switzerland Finland Chad Norway Uganda France Congo Panama Germany Croatia Paraguay Hungary Côted'Ivoire Poland Italy Democratic Portugal Kenya Republicofthe Rwanda Korea(Republicof) Congo Senegal Madagascar Dominican SierraLeone Malawi Republic Somalia Mauritania Egypt SouthSudan Norway EquatorialGuinea Sweden Poland Eswatini Switzerland Portugal Ethiopia Tajikistan Samoa France Tanzania Slovakia Gambia Thailand Slovenia Greece Togo SouthAfrica Guatemala Uganda Togo Guinea Venezuela UnitedKingdom Guyana VietNam Haiti Zambia Iran Zimbabwe Italy Kyrgyzstan

Nocountryintheworldhasadoptedall33internationally recommendedlawsandpolicies.WesternandCentralEuropeand NorthAmericaandEasternandSouthernAfrica(thetworegionsthatmade thegreatestprogresstowardsachievingthe90-90-90targets)alsoleadthe worldinpolicyadoption.Butevenamongthesecountries,thereareserious policygaps.6,21

Table2.1-CountriesThatHaveAdopted“Most”RecommendedPoliciesinEachPolicyCategory

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•Onlythreecountries(theNetherlands,Portugal,andSouthAfrica) haveadopted“Most”(≥80%)oftheinternationallyrecommended lawsandpolicies(seeTable2.1).Acrossall194countriestracked, themediancountryintheworldhasalignedjustoverhalf(56%)its policieswithinternationalstandards.

Clinical& Treatment (n=61) Testing& Prevention (n=13) Structural (n=2) Health Systems (n=29) Overall (n=3)

Policygapsexisteverywherein theworld,ineverypolicy category.

MappingHIVLaws&Policies:5KeyTakeaways

10 GlobalHIVPolicyReport Fig2.2-Differentiatedservicedelivery(CT4):Adoptionstatusbyregion %ofcountries Global 70 35 0 Adopted Notadopted Partial Datanotavailable Easternand SouthernAfrica Westernand CentralEuropeand NorthAmerica Westernand CentralAfrica

Nationalhumanrightsinstitutions(S6) Isthereanindependentnationalhumanrights institutiontowhichviolationscanbereported? 44% Constitutionalrighttohealth(S7) Isthereanenforceablerighttohealthinthe nationalconstitution? 40% First-lineregimens(CT3) Areup-to-datefirst-lineARVregimensaligned withinternationalrecommendationsincludedin nationalHIVpolicy? 38% PrEP(TP5) Aremedicinesforpre-exposureprophylaxis (PrEP)approvedandareallpeople/populationsat substantialriskofHIVinfectioneligibleforPrEP undernationalpolicy? 38%

Civilsocietyspace(S10) AreNGOs/CSOsabletoregister,seekfunding andoperatefreelyundernationallawandisthere asocialcontractingpolicyforfinancingNGOs/ CSO-providedservices?

TopPolicyAdoptionFailures

TopPolicyAdoptionSuccesses

81%

recommendationsthathavebeenmostwidelyignored. Notably,bothlistsincludepoliciesfromacrossallfour categories.

Agerestrictionsontesting&treatment(TP4) CanadolescentsaccessHIVtestingandtreatment withoutparentalconsentundernationalpolicy? 58%

#2 Thereissignificantvariationinratesofpolicy adoptionacrossthe33individualpoliciestracked.

Table2.2-BiggestPolicyAdoptionSuccessesandGaps

%ofcountriesthathave NOTAdoptedeachpolicy Drugusenon-criminalization(S3)

Harmreduction(TP6)

Same-sexsexnon-criminalization(S1) Doesnationallawavoidcriminalizingsexwork (buying,selling,andorganizingofsexwork)? 80% Gender-basedviolencelaws(S9)

Doesthenationalbudgetandfiscalpolicyinclude sufficienthealthspendingandadequatetax revenuestomeetinternationaltargets? 78%

Sexworknon-criminalization(S2) Doesnationallawavoidcriminalizingsexwork (buying,selling,andorganizingofsexwork)? 77% Prisonersprevention(TP8) Arebothcondoms/lubricantsandsyringeaccess/ exchangeprogramsavailabletoprisonersasa matterofpolicy? 59%

Doesnationallawrefrainfromcriminalizing personaldruguse/possession? 88%

Uniqueidentifierswithdataprotections(HS6) Areuniqueidentifiersforcontinuityofcareacross multiplefacilitiesincludedinnationalpolicyalong withprotectionsforpatients'privacy?

AreallpeoplelivingwithHIV,regardlessofCD4 count,eligibletostartHIVtreatmentinnational policy?

83%

95%

Doesthelawexplicitlyaddressdomesticviolence withenforceablepenalties? 78%

Table2.2showsthetenpolicyrecommendationsthat havebeenmostwidelyadoptedandthetenpolicy

Viralloadtesting(CT5) Isviralloadmonitoringatleastonceperyear providedforinnationalpolicy? 74%

DoesnationallawandHIVpolicyincorporatekey harmreductionstrategies,includingavoidanceof criminalizingsyringepossession?

Differentiatedservicedelivery(CT4) DonationalHIVtreatmentpoliciesinclude multipleoptionsfordifferentiatedHIVtreatment services? 74%

Non-discriminationprotections(S5) Donationallaws/policiesincludeprotectionsfrom discriminationonthebasisofsexualorientation, genderidentity,andHIVstatus? 77%

82%

Taskshifting(HS1) Arenursesorothernon-physiciansallowedto initiateHIVtreatmentundernationalpolicy? 53% Self-testing(TP1) Isself-testingapprovedinnationalpolicy? 51%

%ofcountriesthathave AdoptedorPartiallyAdoptedeachpolicy Treatmentinitiation("treatall")(CT1)

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Healthfinancing(HS2)

nalysiscarriedoutby KaiserFamilyFoundation utilizingdatafromthe HIVPolicyLabexaminespolicyalignmentwithinternationalHIV-related standardsin53PEPFAR-supportedcountries(thoserequiredtosubmita countryoperationalplan(COP)orregionaloperationalplan(ROP)in2020in ordertoreceivefinancialandprogrammaticsupport.Italsoassessespolicy alignmentinPEPFARcountriescomparedtootherlow-andmiddle-income countries(LMICs).

WhilePEPFAR’sprimaryfocusisonHIVservicedelivery,italsoaimsto createconditionswithincountriesthatcancontributetosuccessful implementationofHIVprograms.Assuch,thesefindingsmayserveasa baselinefortargetingandassessingfuturePEPFAReffortsastheprogram seekstofurtherimproveHIVoutcomesinthecountrieswithinwhichitworks.

POLICY ANALYSIS

•ThereissignificantvariationamongPEPFAR-supportedcountriesin adoptionofindividualpolicyindicators.Forexample,whileallPEPFARsupportedcountrieshavefullyalignedviralloadtestingpolicieswith internationalstandards,onlythreehavealignedpoliciesrelatedtosex worknon-criminalization.

•PEPFAR-supportedcountriesscoredhighestintheareaofclinicalcareand treatmentandlowestonaddressingstructuralbarriers.

Readmoreat: https://www.kff.org/global-health-policy/issue-brief/hivpolicy-alignment-with-international-standards-in-pepfar-countries

HIVPolicyAlignmentinPEPFAR-supportedCountries

Findings: •Overall,PEPFARcountrieshavestrongerpolicyalignmentthanother LMICs,includinggreaterpolicyalignmentinthreeofthefourcategories trackedbythedatabase:clinicalcareandtreatment,testingandprevention, andhealthsystemsindicators.

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Fig2.3-PolicyCategoryAdoption:ClinicalandTreatment

Countrieshavemadetremendous progressinadopting internationallyrecommended clinicalcareandtreatment policies,withafewkeygaps.

DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST

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•126of194countrieshaveadopted“Many”or“Most”ofthe internationallyrecommendedclinicalandtreatmentpolicies. Clinicalcareandtreatmentpolicieshavethehighestratesofpolicy adoptionineveryregionbutWesternandCentralEuropeand NorthAmerica.

Globally,countrieshaveadopted,onaverage,68%ofthe internationallyrecommendedclinicalcareandtreatmentpolicies— thehighestadoptionrateofanyofthefourpolicycategories.

•185(95%)countrieshaveadopteda“TreatAll”policy,makingit themostwidelyadoptedpolicybyfar,butonly106haveadopteda “same-daystart”policy.

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Fig2.4-TreatmentInitiation(CT1):PolicyAdoption

Widespreadadoptionof“TreatAll”policy(whichstatesthatpeoplelivingwith HIVshouldstarttreatmentassoonastheyarediagnosed,irrespectiveofCD4 count)isapolicychangesuccessstory,showinghowresearchers,activists, andpolicymakerscanworktogethertopromoteevidence-basedpolicies.Five yearsafterWHOguidelinesrecommended“treatall”,thereareonlyfour countriesforwhichthereisdatathathavenotadoptedit.However,aclosely relatedpolicy,“same daystart”(whichallowspeopletoactuallyreceivetheir firstdoseofARVsonthedaytheytestpositive)hasamuchlowerrateof adoption.Andatleast31countrieshaveadopted“treatall”butnot“same day start”.

DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST

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EnsuringthatPLHIVhaveaccesstothemosteffectiveARVregimensisa centralpillarofcountries’HIVresponses.However,WesternandCentral EuropeanandNorthAmericancountriesarenottheonlyoneswhoseHIV treatmentguidelinesareoverdueforanupdate.Atleast73countrieshave guidelinesthatdonotalignwithcurrentWHOrecommendationsontheuseof dolutegravir(DTG)asapreferredfirst-lineregimenforalladultsand adolescents,includingpeoplewhoarepregnantormaybecomepregnant.

Fig2.5-Same-dayTreatmentStart(CT2):PolicyAdoption DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST

•OnlyhalfofcountrieshaveadoptedWHOguidelinesonpreferred first-lineregimens,makingthistheleastwidelyadoptedofall internationallyrecommendedclinicalcareandtreatmentpolicies trackedbytheHIVPolicyLab.

Testingandpreventionand structuralpolicies(including non-criminalizationpolicies) havethelowestratesofpolicy adoptionofthefourpolicy categories,makingitharderfor peopletoprotectthemselvesand theirpartnersandtosafelyaccess HIVservices.

Global Countrieshaveadoptedroughlyhalfofthe internationallyrecommendedtestingand preventionandstructuralpolicies.

EvenamongcountriesthatdomakePrEPavailableto populationssubstantiallyatrisk,overlyexclusive eligibilitycriteriameanitmaynotbeavailabletoall peopleatsubstantialrisk.TheHIVPolicyLabhas gathereddetaileddataoneligibilitycriteriain91 countriesthathaveadoptedPrEPandthereiswide variationineligibilityofkeypopulations(seeTable2.3).

Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica Adopted Notadopted Partial Datanotavailable %ofcountries 60 30 0 #4

•Globally,onaverage,countrieshaveadopted only49%oftheinternationallyrecommended testingandpreventionandstructuralpolicies, respectively,comparedto68%ofthe recommendedclinicalcareandtreatment policies,and60%ofrecommendedhealth systemspolicies(seeFig2.1).

•Lessthanhalfofcountrieshaveadoptedor partiallyadoptedPrEPpoliciesalignedwith WHOguidelines.

PrEPisacrucialtoolforHIVprevention,yet100 countriesdonotmakePrEPavailabletopopulationsat substantialriskundernationalpolicy,asrecommendedby WHO.Inaddition,46countrieshavenotgranted regulatoryapprovalforPrEPmedications.

insub-SaharanAfrica6,yetonly12ofthe34sub-Saharan countrieswhosepolicieswerereviewedinclude adolescentgirlsandyoungwomenontheirlistofPrEPeligiblegroups.InEasternEuropeandCentralAsia,43% ofnewinfectionsoccuramongpeoplewhoinjectdrugs6 , yetofthe10EECAcountriesreviewed,onlyhalf designatepeoplewhoinjectdrugsaseligibleforPrEP.

Thus,PrEPstandsoutasacriticalissueforpolicychange, notjusttoexpandthenumberofcountriesthatmake PrEPavailable,buttherangeofpeopletowhomitis available.

16 GlobalHIVPolicyReport Fig2.6-PrEP(TP5):Adoptionstatusbyregion

Thegapinadoptionratesbetweenclinicalcareand treatmentandtestingandpreventionpoliciesismirrored byagapinhealthoutcomes.Theworldhasmade remarkableprogressonHIVtestingandtreatment. AccordingtoUNAIDS,attheendof2020,84%ofPLHIV knewtheirstatus,87%ofthosewereonART,and90%of thosewerevirallysuppressed.AIDS-relatedmortalityhas declinedby47%inthepastdecade.

6 Therehasnotbeen similarsuccesswhenitcomestoprevention.Thenumber ofnewHIVinfectionshasdeclinedbyonly31%since2010, withnodeclineatallpastfouryears.

Whereasover80%ofcountriesmakePrEPavailableto menwhohavesexwithmenandtheHIV-negative partnersinserodiscordantcouples,lessthan15%of countriesmakeitavailabletoprisoners.Adolescentgirls andyoungwomenaccountfor85%ofnewHIVinfections

6 Thereasonforthis lackofprogressisthat“toomanycountrieshavefailedto putinplacethecombinationofstructural,behavioraland biomedicalapproachestoHIVprevention,”includinglaws andpolicies,“thatexperienceshowshasthemaximum impact.”6

•Over100countriesrequireadolescentstohave parentalconsentbeforetheycanaccessHIV testingand/ortreatment,andsomecountries allowsomeadolescentstoaccessonebutnotthe other.

LawsthatrequireparentalconsentforHIVtestingand treatmentareamajorbarriertoadolescentsseekingcare. Yetcloseto60%ofcountriesstillimposeage-of-consent restrictionsontestingand/ortreatment.Thisincludes over80%ofcountriesinbothWesternandCentralAfrica andEasternEuropeandCentralAsia,andover70%of countriesinLatinAmericaandtheCaribbean.Inatleast 33countries,adolescentsarelegallyabletoconsentto sex,butnottotestingand/ortreatment.Perhapsworse, thereareatleast26countrieswheretheageofconsent fortestingdoesnotmatchtheageofconsentfor treatment.Thiscreatesthepotentialforabominable situationsinwhichayoungpersonwhoknowstheyare livingwithHIVandwantstostarttreatmentislegally unabletodoso,orsomeonewhowouldbeallowedto receivetreatmentinnotabletolearntheirstatus.

6 Toclosethese gapsinHIVoutcomes,policymakersneedtorecognize andremovethepolicybarriersthanmakeitdifficultfor childrenandadolescentstoaccessprevention,testing, treatment.

Childrenandadolescentsare beingleftbehind,inpartbecause ofpolicygaps.Thetoolstoprevent HIVinfectionsandAIDS-related deathsinyoungpeopleexist,but theyarenotbeingused.

•Druguseandsexworknon-criminalizationare theleastwidelyadoptedpolicies:88%of countriesstillcriminalizedruguseand77%of countriesstillcriminalizesexwork.

Childrenandadolescentsarebeingleftbehind intheglobalAIDSresponse.Globally,less than60%ofchildren(aged0-14)livingwith HIVknowtheirstatus,comparedto84%ofadults.Only 54%ofchildrenlivingwithHIVareontreatment, comparedwith74%ofadults.Andonly40%ofchildren livingwithHIVhavesuppressedviralloads,comparedto 67%ofadults.Meanwhile,AIDS-relateddeathsare decliningmoreslowlyamongadolescents(aged10-19) thanamongchildrenunder10oradults.

DiagnosinginfantslivingwithHIVatbirthisessentialto reducingAIDS-relateddeathsinchildren,sincehalfof childrenwhogoundiagnosedwilldiebeforetheirsecond birthday.Longwaittimesforconventionaltestresults meanthattoomanyinfantslivingwithHIVarelostto follow-up.Theuseofpoint-of-caretestingremovesthis barrierbyenablingimmediatediagnosisandlinkageto treatment.19

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Countriespersistincriminalizationdespiteclearevidence thatsuchlawsandpoliciesarenotjustdegrading,butalso makepeoplevulnerabletoHIVinfectionandlesslikelyto receiveHIVservices.23 Researchshowsthat criminalizationofsexworkanddruguseareassociated withincreasedriskofHIVinfection.24,25 Onestudy estimatesthatdecriminalizationofsexworkwouldavert 33–46%ofnewHIVinfectionsoveradecade.26 #5

•Atleast134countrieshavenotadoptedoronly partiallyadoptedWHOrecommendationson pediatrictestingandtreatment,including64 countrieshavethatadoptedWHOtreatment guidelinesforadultsbutnotforchildren.

Similarly,UNAIDSnotesthatthelowratesofviral suppressionandotherpoorHIVoutcomesseenin childrenarepartlyduetosuboptimalpediatrictreatment regimens.6 However,evenasmoreeffectiveDTG-based regimenshavebecomeavailableforyoungerchildren, over100countrieshaveyettoupdatetheirHIVtreatment guidelines,includingatleast64countriesthathave adoptedWHO’streatmentrecommendationsforadults butnotforchildren.

Yetatleastone-thirdofcountries,including 55%ofcountriesinAsiaandthePacific,havenot incorporatedpoint-of-caretestingforearly infant diagnosisintheirHIVtestingguidelines.

•Lessthantwo-thirdsofcountriesrequirecomprehensivesexuality education(CSE)inschools.

Adopted Notadopted Datanotavailable

Adopted

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Preventinginfectionsstartswithgivingpeoplecompleteandaccurate information.Yetatleast60countriesdonotrequireaCSEcurriculummeeting internationalstandardsbetaughtinschools.Onthisissue,thereisa particularlysharpcontrastbetweensub-SaharanAfrica,whereover80%of countriesrequireCSE,andtherestoftheworld.

Fig2.8-Comprehensivesexualityeducation(TP7):Adoptionstatusbyregion %ofcountries 90 45 0 Notadopted Datanotavailable Global Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica

Fig2.7-Agerestrictionsontesting&treatment(TP4):Adoptionstatusbyregion %ofcountries 90 45 0 Global Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica

Atleast43%ofcountriesinEasternandSouthernAfrica havefullyadoptedtheDSDpoliciestrackedbytheHIV PolicyLab,morethantwicetheadoptionrateofanyother region.ButCOVID’sdisruptionofdailyroutinesand routinehealthcaredeliveryallovertheworld demonstratedwhymaximumflexibilityandconvenience arevaluableeverywhere,notjustinhigh-burden,lowresourcesettings.DuringtheCOVID-19pandemic,more countrieshavemovedtoadoptmoremodelsofDSD,in particular,expandingwhoiseligibleforDSD,the durationofARTrefills,andtheprovisionofvirtual services.28,29 Goingforward,advocacyisneededto ensurethatpolicygainsmadeduringCOVID-19arenot rolledback.

T heworldisinthemidstoftwopandemicsandthe circumstancesthataffectonealsoimpacttheother.

•EasternandSouthernAfricancountriesleadthe wayonadoptingDSD.Otherregionsarefar behind,althoughCOVID-19mightbechanging that.

3.TheCaseforTwoPoliciesforHIVandCOVID-19

DifferentiatedServiceDelivery

•Nearly60%ofcountrieshavepartiallyadopted theDSDpoliciestrackedbytheHIVPolicyLab, butonly13%havefullyadoptedallthree policies.

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Countriesshouldmakewideruse ofpolicyoptionstosupportHIV andCOVIDresponses. OnelessonfromtheCOVID-19 pandemic:differentiatedservice delivery(DSD)isneeded everywhere.

Globally,atleast49countries(25%)allowcommunityART distribution.Atleast76countries(39%)offerPLHIVwho arestablyontreatmenttheoptionofgoing6monthsor morebetweenclinicalvisits.Atleast38countries(20%) allowPLHIVtopickupa6-monthsupplyofARVsatone time,andanother77countries(40%)allowa3-month supply.Butonly13%ofcountriestrulymaximize convenienceandflexibilityofservicedeliveryforPLHIV withpoliciesthatallowcommunitydistribution,6-monthly clinicalvisit,and6-monthdispensing.

Thisisparticularlytrueoflawsandpoliciesthatinfluence theavailabilityandaccessibilityofcriticalhealth technologies,namelymedicinesandvaccines.Ontheone hand,lockdownsandothersocialdistancingmeasures usedtocombatCOVID-19,aswellastheoverwhelmed healthcaresystemsithascaused,threatenPLHIV’sability toobtaintheirARVs.Ontheotherhand,theintellectual propertylawsthatdelayedaccesstoARTforentire countriesintheGlobalSoutharenowdelayingaccessto COVID-19vaccines.27 Twosetsoflawsandpolicieshave thepotentialtomitigatethesetwoparticularburdens: differentiatedservicedelivery(DSD)anduseofTRIPS flexibilities.TheHIVPolicyLabdatashowthatwhile somecountriesaretakingadvantageofthesepolicytools, othersarenot.

DSDpoliciesmaketreatmentandotherHIVservices moreconvenientforpeopletoaccessonanongoingbasis. ThereisawiderangeofDSDmodelsbeingimplemented (moreinformationisavailablefromourpartnersat www.differentiatedservicedelivery.org).TheHIVPolicy Labspecificallytrackswhethercountrieshavepoliciesin placetoallowcommunitydistributionofART,reducethe numberofclinicalvisits,andprovidepeopleonARTwith amulti-monthsupplyoftheirmedicines.Suchpoliciesare imperativetoreducepressureonPLHIVandhealth systemsduring“normal”times;inthemidstofCOVID-19, theybecamedoublyso.

DifferentiatedServiceDeliveryRelatedFindings:

TheHIVPolicyLabincludesdataontheuseofTB-LAMandrapidmolecular diagnostictestsforTBin174countriesandcommunity-basedARVandmultimonthdispensingin16countries. LearnmoreaboutDNP+at www.dnpplusindia.com DataNotCollected

Fig3.1-Differentiatedservicedelivery(CT4):PolicyAdoption

20 GlobalHIVPolicyReport PROFILE OF POLICY CHANGERS

DelhiNetworkofPositivePeople(DNP+) DeliveringARVsandpushingforrapidTBtesting

NP+worksrangefromservicedeliveryandtreatmentliteracytohuman rightsadvocacy.BeforeIndiaentereditsnation-wideCOVID-19 lockdownin2020,DelhiNetworkofPositivePeople(DNP+)worriedabout travelrestrictionsinterferingwithPLHIV’sabilitytogettheirARVs.They wrotetotheNationalAIDSControlOrganization(NACO)askingthe governmenttoputarrangementsinplacetoensureuninterruptedaccessto ART.Butoncethelockdownswentintoeffect,theyrealizedthattheyneeded totakemattersintotheirownhands.Withindaysofthelockdown,the organizationbegandeliveringARTtocommunitymembersonpersonal motorbikes.Withinthefirst45days,theydeliveredmedicationstoaround700 people.30 In2022,DNP+willfocusitspolicychangeeffortsonexpanding accesstoTB-LAMtesting,advocatingwiththeIndiangovernmenttostart offeringTB-LAMtestinginallgovernmentARTclinicsforpeoplelivingwith HIV.TB-LAMisapoint-of-carediagnostictestthatusesurineratherthan sputum.BecauseHIVinfectioncanalterTBsymptomsandmakesputumbaseddiagnostictestsunreliable,WHOrecommendstheuseofTB-LAMtests forthediagnosisofactiveTBinPLHIV.

InsufficientData NOTADOPTED PARTIAL ADOPTED

Twodecadeslater,the tensionbetweenintellectualpropertyrightsandpublic healthhasagaincometoaheadatWTOascountries pressforaglobalTRIPSwaivertofacilitateaccessto COVID-19vaccinesandmedications.

Atleast69countries(36%)havebothincorporatedTRIPS flexibilitiesintolawandutilizedthem(orattemptedto utilizethem,foranymedications).Another67countries haveeitherincorporatedthemintolaworattempted utilization.Theremainingthird(includingsome countriescurrentlypressingforaTRIPSwaiveratWTO) haveneitherincorporatednorattemptedtoutilizethese flexibilities.Ontheotherhand,nearly70%ofcountriesin WesternandCentralEuropeandNorthAmerica (includinganumberofcountriescurrentlyopposingthe TRIPSwaiveratWTO)havebothincorporatedTRIPS flexibilitiesintolawandattemptedtoutilizethem. CountriesthathaveadoptedTRIPSflexibilitiesshould stoperectingbarriersthroughtradeagreements,punitive trademeasures,andothermeansthathinderother countriesfromdoingthesame.Butcountriesthatare seekingadditionalexceptionstotheTRIPSagreement canalsodomoretoavailthemselvesoftheflexibilities thatexist.

21 GlobalHIVPolicyReport Fig3.2-Accesstomedicines(TRIPS)(HS5):Adoptionstatusbyregion Global Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica Adopted Notadopted Partial Datanotavailable %ofcountries 70 35 0

Inadditiontosupportinga TRIPSwaiver,governments shouldutilizeexistingTRIPS flexibilities.

Theleastdevelopedcountriestransitionperiod referstoagraceperiodaffordedtoleastdeveloped countriesduringwhichtheyarenotrequiredtoapply mostprovisionsoftheTRIPSagreement.34

•Roughlyone-thirdofcountrieshavefullyadopted TRIPSflexibilitiesandanotherthirdhave partiallyadoptedthem.

TRIPSFlexibilities&AccesstoMedicines

Twentyyearsago,LMICsandactivistswagedahardfoughtbattletoallowthemanufactureofgeneric, affordableARVsinordertomakelife-savingtreatment available.Recognizingthatintellectualpropertyrightsdo notandshouldnotstandinthewayofprotectingpublic healthandpromotingaccesstomedicineforall,the2001 WorldTradeOrganization(WTO)DohaDeclaration reiteratedthatcountrieshavetherighttomakeuseof flexibilitieswrittenintotheAgreementonTrade-Related AspectsofIntellectualPropertyRights(TRIPS)thatallow forthemanufacturingandprocurementofgeneric medications(andvaccines).

Yetevenas countriesandactivistsfightforaTRIPSwaiver, governmentsretaintheoptiontoutilizetheTRIPS flexibilities.TheHIVPolicyLabtrackswhethercountries haveincorporatedthreeoftheTRIPSflexibilities (compulsorylicensing,parallelimportation,andtheleast developedcountriestransitionwhereapplicable)intolaw and/orwhethertheyhavemadeuseoftheseflexibilities. Compulsorylicensingisamechanismthatallows governmentstoauthorizethirdpartiestoproducea patentedmedication,vaccineorotherproductwithoutthe consentofthepatentholderorplanstousethepatentprotectedproductitself,whilepayingcompensationtothe patentholder.Parallelimportationreferstothe importationintoonecountryofmedicines,vaccines,or otherprotectsthataremanufacturedunderpatentin anothercountrywithoutthepermissionofthepatentholder.33

Responses Dr. JoshuaR.Moon, oftheUniversityofSussexusesapolicymixapproach toexaminethedifferentcombinationsofpoliciesthatexistacrosscountries andunderstandhowpoliciesinteractwithoneanothertoaffecthealth outcomes.Thisapproachvisualizesandanalyzespoliciesusingnetworkmaps likethisone.

O nthispolicymap,eachpolicyappearsasacircle.Thecircle’scolorshows howmanycountrieshaveadoptedthatpolicy(rangingfromredforthe mostfrequentlyadoptedpoliciestobluefortheleastfrequentlyadopted).The sizeofthecirclerepresentsapolicy’scentrality,whichtellshowfrequently thatpolicyoccursincombinationwithotherpoliciesthatdonotoccuralone together.Forexample,self-testing(TP1)canbeseenontheperipherywith mediumfrequencybutalargecircle,showingthatalthoughonlyabout50% countrieshaveadoptedself-testing,theonesthathaveadoptedithave combineditwithawiderangeofotherpolicies.Thelinesbetweenthecircles showhowfrequentlytwopoliciesoccurtogether.Forexample,thereisa strong,visiblelinebetweenroutineviralloadtesting(CT5)andindextesting/ partnernotificationstrategies(TP2i),indicatingthatmanycountrieshave adoptedbothpolicies.However,confidentialityprotectionsforindextesting (TP2ii)isontheoutskirtsofthenetwork.Thelackofastronglineconnecting indextesting/partnernotificationstrategiesandconfidentialityprotections showsthatmanycountrieshaveadoptedtheformerwithoutthelater, highlightingtheneedforpolicychange.

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POLICY ANALYSIS

Usingtoolslikepolicymapstovisualizeandunderstandhowpoliciesinteract witheachotherisvitalbecause,intherealworld,nopolicyexistsinisolation— theirimplementationandimpactisalwaysaffectedbyotherpolicies.

UsingPolicyMixAnalysistoUnderstandHIV

MatthewMKavanagh,SchadracCAgbla,MarissaJoy,KashishAneja,Mara Pillinger,AlainaCase,NgoziErondu,TaaviErkkola,&EllieGraeden.Law, criminalizationandHIVintheworld:havecountriesthatcriminalizeachieved moreorlesssuccessfulpandemicresponse?

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POLICY ANALYSIS

Law,CriminalizationandHIVintheworld

A nanalysisby theHIVPolicyLabteam publishedin BMJGlobalHealth examinedhowchoicesincriminallawandrightsprotectionsaffect disease-fightingefforts.Thislong-standingquestionfacinggovernments aroundtheworldisacuteinthecontextofpandemicslikeHIVandCOVID-19.

4.ProgressTowardsthe10-10-10Targets: CombatingStigma,PromotingRights E ndinginequalityandpromotinghumanrightsis essentialtoendingAIDS.Amajorreasontheworld hasnotachievedthe2020goalscanbefoundinthelaw andpolicyenvironment.Criminalization,stigma,and discriminationagainstPLHIV,keypopulations,women andgirls,andothermarginalizedpopulationscreatevery realbarrierstoachievingglobalAIDSgoals.Peoplewho aretargetsofpervasivesocialandlegaldiscrimination, stigma,andviolencearemorelikelytobeexposedtoHIV andlesslikelytobeabletoaccessprevention,testingand treatmentservices.

TheGlobalAIDSStrategyofthelast5yearssoughttopreventmortalityand HIVtransmissioninpartthroughensuringpeoplelivingwithHIV(PLHIV) knewtheirHIVstatusandcouldsuppresstheHIVvirusthroughantiretroviral treatment.Thisarticlepresentsacross-nationalecologicalanalysisofthe relativesuccessofnationalAIDSresponsesunderthisstrategy,wherelaws werecharacterizedbymoreorlesscriminalizationandwithvaryingrights protections.Incountrieswheresame-sexsexualactswerecriminalized,the portionofPLHIVwhoknewtheirHIVstatuswas11%lowerandviral suppressionlevels8%lower.Sexworkcriminalizationwasassociatedwith10% lowerknowledgeofstatusand6%lowerviralsuppression.Druguse criminalizationwasassociatedwith14%lowerlevelsofboth.Criminalizingall threeoftheseareaswasassociatedwithapproximately18%–24%worse outcomes.Meanwhile,nationallawsonnon-discrimination,independent humanrightsinstitutionsandgender-basedviolencewereassociatedwith significantlyhigherknowledgeofHIVstatusandhigherviralsuppression amongPLHIV.Sincemostcountriesdidnotachieve2020HIVgoals,this ecologicalevidencesuggeststhatlawreformmaybeanimportanttoolin speedingmomentumtohaltthepandemic.

HaveCountriesThatCriminalizeAchievedMoreorLessSuccessful PandemicResponse?

BMJGlobal Health2021;6:e006315. Availableat: https://gh.bmj.com/content/6/8/ e006315

EvidenceshowsthatinordertoendAIDSby2030,itis crucialthatcountriesremovepunitivelawsthat criminalizekeypopulationsandexpandrights-supportive lawsandpoliciesthatfightstigma,discrimination, gender-basedviolence,andgenderinequity.Ananalysis bytheHIVPolicyLab(seebox)showsthatincountries withlawsthatcriminalizesame-sexsex,sexwork,and druguse,PLHIVaresignificantlylesslikelytoknowtheir HIVstatusandtoachieveviralsuppression.Theconverse wasalsofound.incountrieswithlawsprotectingagainst discriminationandviolence,PLHIVaresignificantlymore likelytoknowtheirHIVstatusandtoachieveviral suppression.

ThoughcountriesinEasternandSouthernAfricastand outfortheirhighoverallscoresintheHIVPolicyLab index,non-criminalizationlawsareoneareawherethey lagbehindtherestoftheworld.Ofthe21countriesinthe region,8countries(38%)fullyorpartiallycriminalizeall fourbehaviorsandanother11countries(52%)fullyor partiallycriminalizethreeofthefour.OfalltheUNAIDS regions,onlytheMiddleEastandNorthAfricahaslower ratesofpolicyadoption.

•Ensuringthat<10%ofpeoplelivingwith,atriskof, andaffectedbyHIVexperiencestigmaand discriminationby2025;

Nocountryintheworldhasadoptedallsevenoftheselaws andpolicies. But181countrieshaveadoptedatleastone oftheselawsandpolicies,andeachoftheselawsand policieshasbeenadoptedbyatleastonecountry.On average,countrieshavefullyorpartiallyadoptedthreeof thesevenpolicies.TheNetherlandsleadstheworldin policyprogresstowardsthe10-10-10targets,having partiallydecriminalizedsexworkandadoptedtheother policies. The10-10-10targetscallforremovingpunitivelawsthat criminalizesame-sexrelationships,sexwork,druguse andHIVexposureortransmission.Thoughnocountry hasadoptedanon-criminalizingapproachforallfourof these,nearlyeverycountryhasadoptedanoncriminalizingapproachforatleastoneofthem,onlyseven countriesforwhichthereisdatafullycriminalizeallfour behaviors.But33countriescriminalizeone,96 criminalizetwo,and49criminalizethreeofthefour.

ThesetargetsarefurtherexpandeduponintheGlobal AIDSStrategy2021-2016,whereUNAIDSestimatesthat achievingthesetargetswillprevent2.5millionnewHIV infectionsand1.7millionAIDS-relateddeathsby2030.36

LatinAmericanandCaribbeancountriesstandoutfor theirstrongtrackrecordinadoptingrights-supporting lawsandpolicies,particularlylegalprotectionsagainst discrimination.

•Ceaseenforcingandrepeallawsandpoliciesthat criminalizesexwork(includingthebuying,selling, andorganizingofsexwork);

Atthe2021UNHigh-LevelMeetingonAIDS,Member Statesadoptedapoliticaldeclarationendorsingambitious newtargetstocombatstigmaanddiscriminationand promoterights:35

•Passlawsandpoliciesthatprotectpeoplefrom discriminationonthebasisofsexualorientation, genderidentity,andHIVstatus;

Toachievethe10-10-10targets,countriesmustadoptaset ofsevenlaws/policies:

•Ensuringthat<10%ofwomen,girls,andpeopleliving with,atriskof,andaffectedbyHIVexperience gender-basedinequalitiesandsexualandgenderbasedviolenceby2025.

•Passlawsandpoliciesthatprotectpeoplefrom gender-basedandintimatepartnerviolence.

GlobalHIVPolicyReport

Twenty-ninecountrieshaveincorporated nondiscriminationprotectionsthatcoversexual orientation,genderidentity,andHIVstatus,aswellas creatingindependenthumanrightsinstitutionsand enforceablegender-basedviolencelaws.165countries haveadoptedatleastoneofthesethreelawsandpolicies.

Toachievethe10-10-10targets,countriesshouldalso adoptlawsandpoliciesthatcombatdiscriminationand gender-basedviolenceandhumanrightsviolations.The HIVPolicyLabdatashowsthatcountrieshavemade moreprogressinadoptingthesethreerights-supporting lawsandpoliciesthaninrejectingcriminalization.

•Ensuringthat<10%ofcountrieshaverestrictivelegal andpolicyframeworksthatleadtothedenialor limitationofaccesstoservicesby2025;

ThePolicyBigPicture

•Ceaseenforcingandrepeallawsandpoliciesthat criminalizethepossessionofsmallamountsofdrugs (includingopiates)forpersonaluse;

•Ceaseenforcingandrepeallawsandpoliciesthat criminalizeHIVexposure,transmission,ornondisclosure;

•Ceaseenforcingandrepeallawsandpoliciesthat criminalizesame-sexsexualrelationships;

•Establishmechanisms,suchasNationalHuman RightsInstitutions,throughwhichPLHIVandkey andmarginalizedpopulationscanreportabuseand seekredress;

Status: 100%ofcountriesaremissingthistarget Everycountryintheworldpartiallyorfullycriminalizes atleastoneofthesefourcomponents.Butforsomeof thesecomponents,realprogressisbeingmade:56%of countriesdonotcriminalizesame-sexrelationshipsand 41%donotcriminalizeHIVexposure,transmission,and non-disclosure.

Fig4.1-Same-sexsexnon-criminalization(S1):Adoptionstatusbyregion Global Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica

Same-sexrelationshipsarenotcriminalizedinany countryinWesternandCentralEuropeandNorth America,norinthree-quartersofthecountriesinEastern EuropeandCentralAsia.Attheotherendofthe spectrum,80%ofcountriesintheMiddleEastandNorth Africacriminalizeinlawandactivelyarrestorprosecute peopleforsame-sexsexualbehavior.

ProgressTowardsEachTarget Target: <10%ofcountrieshavepunitiveandrestrictive legalandpolicyenvironmentsby2025

Onnon-criminalizationofHIVexposure,transmission, andnon-disclosure,countriesinWesternandCentral AfricaandAsiaandthePacificareleadingtheway:60% and55%ofcountriesintheseregions,respectively, neithercriminalizeinlawnoractivelyarrestorprosecute peoplefornon-maliciousHIVexposureortransmissionor non-disclosureofHIVstatus.Incontrast,EasternEurope andCentralAsialagsfarthestbehindtherestofthe world,ashalfofthecountriesintheregionstillfully criminalizeHIVexposure,transmission,non-disclosure.

Adopted Notadopted Partial Datanotavailable %ofcountries 110 55 0

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Sub-target: <10%ofcountriescriminalizesexwork, possessionofsmallamountsofdrugs,same-sexsexual behavior,andHIVtransmission,exposureor nondisclosureby2025

Sexworkanddrugusenon-criminalizationpolicieshavethelowestrateof adoptionofanypoliciestrackedintheHIVPolicyLab.Globally,88%of countriesstillfullycriminalizedruguseorpossessionand77%ofcountriesstill fullycriminalizesexwork.

Fig4.3-Drugusenon-criminalization(S3):Adoptionstatusbyregion

Global Easternand Southern Africa MiddleEast andNorth Africa Asiaandthe Pacific LatinAmerica andthe Caribbean Eastern Europeand CentralAsia Westernand CentralEurope andNorth America Westernand CentralAfrica Adopted Notadopted Partial Datanotavailable

%ofcountries 70 35 0

%ofcountries 110 55 0

Fig4.2-HIVexposurenon-criminalization(S4):Adoptionstatusbyregion

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Fig4.5-Nationalhumanrightsinstitutions(S6):Adoptionstatusbyregion

Adopted Notadopted Partial Datanotavailable

Status: 60%ofcountriesaremissingthistarget. Only40%ofcountrieshaveaccreditednationalhuman rightsinstitutions(NHRIs)thatarefullycompliantwith theParisPrinciples.Another16%haveaccreditedNHRIs thatarepartiallycompliantwiththeParisPrinciples.Sixty percentofcountriesinAsiaandthePacificand55%of countriesintheMiddleEastandNorthAfricalackany accreditedNHRI.

Adopted Notadopted Partial Datanotavailable 110 55 0

Nationallawsandpoliciesthatprotectpeoplefrom discriminationonthebasisofsexualorientation,gender identity,andHIVstatusarecrucialtosafeguardhuman rightsandsignalthatthereisnoplaceforstigmain society.

Status:75%ofcountrieshavelawsandpoliciesthat arenotalignedwiththistarget. Only49countrieshave lawsthatprotectpeoplefromallthreeformsof discrimination.

%ofcountries

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Sub-target: <10%ofcountrieslackmechanismsfor peoplelivingwithHIVandkeypopulationstoreport abuseanddiscriminationandseekredressby2025

%ofcountries 70 35 0

Fig4.4-Sexworknon-criminalization(S2):Adoptionstatusbyregion

Target: <10%ofPLHIVandkeypopulationsexperience stigmaanddiscrimination

Adopted Notadopted Partial Datanotavailable

Ofallthe10-10-10 targets,thisoneiswherethemostprogresshasbeen madeintermsoflawsandpolicies.Globally,atleast153 countrieshaveadoptedlawswithenforceablepenalties

%ofcountries 100 50 0

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%ofcountries 90 45 0

Adopted Notadopted Partial Datanotavailable

Status:17%ofcountrieshavelawsandpoliciesthat arenotalignedwiththistarget.

TheMiddleEastandNorthAfricanandWesternand CentralAfricahavethelowestratesofpolicyadoption: only45%and56%ofcountries,respectively,havelaws protectingagainstgender-basedviolence.Ineveryother region,over80%ofcountrieshaveadoptedprotective laws.

Lawsthatimposeenforceablepenaltiesforgender-based violencearekeytoprotectingthehealthandwellbeingof womenandgirls.

Fig4.6-Non-discriminationprotections(S5):Adoptionstatusbyregion

Target: <10%ofwomen,girls,PLHIVandkeypopulations

Fig4.7-Genderbasedviolence(S9):Adoptionstatusbyregion

experiencegenderinequalityandviolence

Takingeachoftheseprotectionsindividually,greater progressisvisible:atleast86(44%)countrieshavelaws thatprotectpeoplefromdiscriminationonthebasisof sexualorientation;atleast73(38%)countrieshavelaws thatprotectpeoplefromdiscriminationonthebasisof genderidentity;andatleast116(66%)countrieshavelaws thatprotectpeoplefromdiscriminationonthebasisof HIVstatus.

againstgender-basedviolence.Atleast9countrieshave newlyadoptedsuchlawssince2017:Armenia,Burkina Faso,Djibouti,Eswatini,Kuwait,Liberia,Madagascar, Morocco,andtheUnitedArabEmirates.

ThroughtheLoveAlliance,GNP+andAidsfondswillalsocollaboratewiththe HIVPolicyLabtodeveloptoolstohelpcommunitiesmakethecasefor 10-10-10goalsatthenationalandgloballevels.Thisincludesacompendiumof agreeduponlanguageatinternationalbodiesontheissuesofhumanrights, analysesandpolicytoolsregardingcommunity-ledHIVresponsesandother societalenablers,andproposalsforaccountabilitymechanismsthrough consultationswithstakeholders.

**FundedbytheDutchMinistryofForeignAffairs,theLoveAllianceisa€63millionmulticountryprogramimplementedbynationalthoughtleadersGALZ,SANPUDandSisonke,regional grantmakersUHAIEASHRI,AFEandISDAO,withGNP+andtheadministrativeleadAidsfonds. ItisactiveinBurkinaFaso,Burundi,Egypt,Kenya,Morocco,Mozambique,Nigeria,SouthAfrica, Uganda,andZimbabwe.

PROFILE OF POLICY CHANGERS

GNP+andAidsfonds

heGlobalNetworkofPeopleLivingwithHIV(GNP+)andAidsfonds jointlyworkedtosupportandcoordinateabroad,representativeand inclusiveparticipationofcommunitiesandcivilsocietyinthe2021United NationsHigh-LevelMeetingonHIV/AIDS(HLM).Theinvolvementof communities,civilsociety,andleadershipfromkeymemberstateshelped bringaboutthe2021PoliticalDeclarationonHIV/AIDScommitmentsto measurableglobaltargetsoncommunity-ledHIVresponses(the30-80-6035 communityleadershipgoals)andsocietalenablingpolicies(the10-10-10 goals)intheHIVresponse.

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Fightingfor10-10-10goalsandcommunity-ledresponsesatthe nationalandgloballevels

*Thecommunity30-80-60targetsadoptedbymemberstatesintheGlobalAIDSstrategyand2021 UNPoliticalDeclarationarethatby2025,communitieswilldeliver30%oftestingandtreatment services,80%ofHIVpreventionservices,and60%ofprogrammessupportingtheachievementof societalenablertargets.Africa,Uganda,andZimbabwe.

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3.MakofaneK,BeckJ,LubenskyM,AyalaG.Homophobiclegislationandits impactonhumansecurity.AfrSecurRev.2014;23(2):186-195. doi:10.1080/10246029.2014.913832

11.KavanaghMM.TheRighttoHealth:InstitutionalEffectsofConstitutional ProvisionsonHealthOutcomes.StudCompIntDev.2016;51(3):328-364. doi:10.1007/s12116-015-9189-z

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2.GrimsrudA,BygraveH,DohertyM,etal.ReimaginingHIVservice delivery:theroleofdifferentiatedcarefrompreventiontosuppression.JInt AIDSSoc.2016;19(1):21484.doi:10.7448/IAS.19.1.21484

4.NjauB,CovinC,LisasiE,etal.Asystematicreviewofqualitativeevidence onfactorsenablinganddeterringuptakeofHIVself-testinginAfrica.BMCPublic Health.2019;19(1):1289.doi:10.1186/s12889-019-7685-1

13.ReevesA,SteeleS,StucklerD,McKeeM,Amato-GauciA,SemenzaJC. NationalsexworkpolicyandHIVprevalenceamongsexworkers:anecological regressionanalysisof27Europeancountries.LancetHIV.2017;4(3):e134-e140. doi:10.1016/S2352-3018(16)30217-X

17.KavanaghMM,GraedenE,PillingerM,SinghR,EaneffS,BendaudV, GustavR,ErkkolaT.UnderstandingandcomparingHIV-relatedlawandpolicy environments:cross-nationaldataandaccountabilityfortheglobalAIDS response.BMJGlobalHealth.2020:e003695.AccessedFebruary14,2022. https:/ /gh.bmj.com/content/5/9/e003695

19.MilangaMandVolginaA.Opinion:PEPFARandtheGlobalFundmust improvecareforHIV-positivechildren.Devex.AccessedFebruary14,2022. https://www.devex.com/news/opinion-pepfar-and-the-global-fund-must-improvecare-for-hiv-positive-children-98860 20.TBEuropeCoalitionStrategy2021-2024.TBCoalitionEurope;2021:338-341. AccessedFebruary14,2022. https://www.tbcoalition.eu/wp-content/uploads/ 2021/10/TB-Europe-Coalition-Strategy-2021.pdf 21.UNAIDS2021HLMreportslides.AccessedFebruary14,2022. https:// www.unaids.org/en/resources/documents/2021/2021-HLM-report-slides 22.WHO.ConsolidatedguidelinesonHIVprevention,testing,treatment, servicedeliveryandmonitoring:recommendationsforapublichealthapproach. AccessedFebruary14,2022. https://www.who.int/publications-detail-redirect/ 9789240031593 23.UNAIDS.EvidenceReview:Implementationofthe2016-2021UNAIDS StrategyontheFast-TracktoEndAIDS:UNAIDSStrategyBeyond2021.2020. https://www.unaids.org/sites/default/files/media_asset/ PCB47_CRP3_Evidence_Review_EN.pdf 24.BakerP,BeletskyL,AvalosL,etal.PolicingPracticesandHIVRiskAmong PeopleWhoInjectDrugs-ASystematicLiteratureReview.SocialScience ResearchNetwork;2019.doi:10.2139/ssrn.3401985 25.LyonsCE,SchwartzSR,MurraySM,etal.Theroleofsexworklawsand stigmasinincreasingHIVrisksamongsexworkers.NatCommun. 2020;11(1):773.doi:10.1038/s41467-020-14593-6 26.ShannonK,StrathdeeSA,GoldenbergSM,etal.GlobalepidemiologyofHIV amongfemalesexworkers:influenceofstructuraldeterminants.TheLancet. 2015;385(9962):55-71.doi:10.1016/S0140-6736(14)60931-4

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AP -AsiaandthePacific LAC -LatinAmericaandtheCaribbean MENA -MiddleEastandNorthAfrica WCA -WesternandCentralAfrica EECA -EasternEuropeandCentralAsia WCENA -WesternandCentralEuropeandNorthAmerica ESA -EasternandSouthernAfrica 31 GlobalHIVPolicyReport AppendixA:RegionalMaps Fig5.1-Portionofpoliciesalignedwithinternationalstandards: Overall M E N A A P E E C A GLOBAL AVERAGE L A C W C A E S A W C E N A Most ←→ Veryfew Fig5.2-Portionofpoliciesalignedwithinternationalstandards: Clinical&treatment DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST A P E E C A M E N A W C E N A L A C W C A E S A GLOBAL AVERAGE Most ←→ Veryfew

Testing&prevention M E N A A P L A C E E C A W C A E S A W C E N A GLOBAL AVERAGE Most ←→ Veryfew

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Fig5.4-Portionofpoliciesalignedwithinternationalstandards:

Structural DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST M E N A W C A E S A A P L A C E E C A W C E N A GLOBAL AVERAGE Most ←→ Veryfew

Fig5.3-Portionofpoliciesalignedwithinternationalstandards:

33 GlobalHIVPolicyReport Fig5.5-Portionofpoliciesalignedwithinternationalstandards: Healthsystems DataNotCollected InsufficientData VERYFEW FEW SOME MANY MOST M E N A A P E E C A E S A W C A L A C W C E N A GLOBAL AVERAGE Most ←→ Veryfew

34 GlobalHIVPolicyReport AppendixB:CountryPolicyProgress Fig6.1-Clinical&treatment Adopted Notadopted Partial Datanotavailable Countries

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40 GlobalHIVPolicyReport Fig6.2-Testing&prevention Adopted Notadopted Partial Datanotavailable

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50 GlobalHIVPolicyReport Fig6.4-Healthsystems Adopted Notadopted Partial Datanotavailable

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Global HIV Policy Report 2022

Articles inside

3. The Case for Two Policies for HIV and COVID-19