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

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

Law, criminalisation and HIV in the world: have countries that criminalise achieved more or less successful pandemic response?

How do choices in criminal law and rights protections affect disease-fighting efforts? This long-standing question facing governments around the world is acute in the context of pandemics like HIV and COVID-19. The Global AIDS Strategy of the last 5 years sought to prevent mortality and HIV transmission in part through ensuring people living with HIV (PLHIV) knew their HIV status and could suppress the HIV virus through antiretroviral treatment. This article presents a cross-national ecological analysis of the relative success of national AIDS responses under this strategy, where laws were characterised by more or less criminalisation and with varying rights protections. In countries where same-sex sexual acts were criminalised, the portion of PLHIV who knew their HIV status was 11% lower and viral suppression levels 8% lower. Sex work criminalisation was associated with 10% lower knowledge of status and 6% lower viral suppression. Drug use criminalisation was associated with 14% lower levels of both. Criminalising all three of these areas was associated with approximately 18%-24% worse outcomes. Meanwhile, national laws on non-discrimination, independent human rights institutions and gender-based violence were associated with significantly higher knowledge of HIV status and higher viral suppression among PLHIV. Since most countries did not achieve 2020 HIV goals, this ecological evidence suggests that law reform may be an important tool in speeding momentum to halt the pandemic.

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

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

Social Media Monitoring of Discrimination and HIV Testing in Brazil, 2014-2015.

Big data can be used to assess perceptions about public health issues. This study assessed social media data from Twitter to inform communication campaigns to promote HIV testing and reduce discrimination related to HIV/AIDS or towards key populations to the HIV epidemic, and its potential utility to evaluate such campaigns through HIV testing uptake. Tweets from Brazil were collected from January 2014 to March 2015 and filtered by four categories of keywords including discrimination, HIV prevention, HIV testing, and HIV campaigns. In total over 100,000 geo-located tweets were extracted and analyzed. A dynamic online dashboard updated daily allowed mapping trends, anomalies and influencers, and enabled its use for feedback to campaigns, including correcting misconceptions. These results encourage the use of social networking data for improved messaging in campaigns. Clinical HIV test data was collected monthly from the city of Curitiba and compared to the number of tweets mapped to the city showing a moderate positive correlation (r = 0.39). Results are limited due to the availability of the HIV testing data. The potential of social media as a proxy for HIV testing uptake needs further validation, which can only be done with higher frequency and higher spatial granularity of service delivery data, enabling comparisons with the social media data. Such timely information could empower early response immediate media messaging to support programmatic efforts, such as HIV prevention, testing, and treatment scale up.

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

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

Global Trends of Monitoring and Data Collection on the HIV Response among Key Populations Since the 2001 UN Declaration of Commitment on HIV/AIDS.

Monitoring and evaluation indicators for HIV programs' response to the epidemic among key populations (sex workers, people who inject drugs, men who have sex with men, transgender people) are critical for reviewing the global response. From the beginning of global reporting, insufficiency of data has been a challenge for monitoring the epidemic response among key populations. However, key populations were only indirectly referenced in the 2001 Declaration of Commitment. By the 2006 Political Declaration on HIV/AIDS, data from key populations were still not required from every country, and were sparsely reported compared to other indicators. The 2011 Political Declaration on HIV/AIDS referenced key populations by name for the first time. In 2006, fewer than twenty countries (10%) reported HIV prevalence among key populations, whereas in 2012 the number of countries surpassed sixty (30%).

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

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