Facilitators and barriers to community-led monitoring of health programs: Qualitative evidence from the global implementation landscape.

Achieving the global HIV, tuberculosis, and malaria targets will require innovative strategies to deliver high quality and person-centered health services. Community-led monitoring (CLM) is a rapidly proliferating health systems strengthening intervention for improving healthcare services and documenting human rights violations, through social empowerment and political accountability. Driven in part by increasing financial support from donors, a growing number of countries are implementing CLM programs. This study aimed to identify early challenges and lessons learned from CLM implementation, with the aim of informing and improving the implementation of CLM programs and ultimately achieving greater impact on the delivery of services. Twenty-five CLM implementors representing 21 countries participated in an interview. Early generation of buy-in from diverse stakeholders was noted as critical for CLM success. Leveraging existing networks of service users and community organizations to implement CLM also helped to maximize program reach and resources. Uncertainty around CLM's purpose and roles among CLM stakeholders resulted in challenges to community leadership and ownership of programs. Respondents also described challenges with underfunded programs, especially advocacy components, and inflexible donor funding mechanisms. Critical capacity gaps remain around advocacy and electronic data collection and use. With the rapid expansion of CLM, this study serves as an important first step in characterizing challenges and successes in the CLM landscape. Successful implementation of CLM requires prioritizing community ownership and leadership, donor commitment to sustainable and reliable funding, and strengthened support of programs across the data collection and advocacy lifecycle.

Intellectual Property and the Politics of Public Good during COVID-19: Framing Law, Institutions, and Ideas during TRIPS Waiver Negotiations at the WTO.

CONTEXT: To facilitate the manufacturing of COVID-19 medical products, in October 2020 India and South Africa proposed a waiver of certain intellectual property (IP) provisions of a World Trade Organization (WTO) agreement. After nearly two years, a narrow waiver agreement that did little for vaccine access passed the ministerial despite the pandemic's impact on global trade, which the WTO is mandated to safeguard. METHODS: The authors conducted a content analysis of WTO legal texts, key-actor statements, media reporting, and the WTO's procedural framework to explore legal, institutional, and ideational explanations for the delay. FINDINGS: IP waivers are neither legally complex nor unprecedented within WTO law, yet these waiver negotiations exceeded their mandated 90-day negotiation period by approximately 18 months. Waiver opponents and supporters engaged in escalating strategic framing that justified and eventually secured political attention at head-of-state level, sidelining other pandemic solutions. The frames deployed discouraged consensus on a meaningful waiver, which ultimately favored the status quo that opponents preferred. WTO institutional design encouraged drawn-out negotiation while limiting legitimate players in the debate to trade ministers, empowering narrow interest group politics. CONCLUSIONS: Despite global political attention, the WTO process contributed little to emergency vaccine production, suggesting a pressing need for reforms aimed at more efficient and equitable multilateral processes.

Drivers of HIV treatment interruption: Early findings from community-led monitoring program in Haiti.

BACKGROUND: Failure to retain people living with HIV (PLHIV) in care remains a significant barrier to achieving epidemic control in Haiti, with as many as 30% lost from care within one year of starting treatment. Community-led monitoring (CLM) is an emerging approach of improving healthcare and accountability to service users, through a cycle of monitoring and advocacy. In 2020, a CLM program was launched in Haiti to identify barriers to retention and advocating for better health services. METHODS: Data from the community-led monitoring program in Haiti were analyzed, from a sample of 65 healthcare facilities in the Nord, Artibonite, and Ouest departments collected from April 2021 to February 2022. Qualitative data from six community-based focus groups and 45 semi-structured individual interviews were analyzed. RESULTS: Confidentiality and stigmatization emerged as barriers to care, particularly due to the separation of PLHIV from other patients in view of community members. To avoid identification, patients described traveling long distances, with the reimbursement of transportation costs described as being insufficient or unavailable. Costs of non-HIV clinical services were a frequent concern and respondents described a need for clinics to provide food during all patient visits. Stock-outs were a regular challenge; by contrast, treatment literacy did not emerge as a major barrier to retention. CONCLUSIONS: These findings represent the first instance, to our knowledge, of original data from a community-led monitoring program being published in any country. These findings suggest that improving treatment retention for PLHIV is dependent on improving the acceptability and affordability of healthcare services. Ensuring confidentiality is critical, particularly where stigma is high. Retention could be improved by systematically strengthening patient confidentiality protections throughout the healthcare system, providing patients with sufficient travel compensation and other incentives, and delivering wraparound services provided for free. Addressing these challenges will require ongoing advocacy for community-developed recommendations and solutions.

The health inequity and socioeconomic inequality faced by adolescent girls and women on the move living with or at high risk of HIV infection, during the COVID-19 pandemic in Nigeria.

BACKGROUND: We assessed if women and girls on the move living with or at high risk of HIV faced increased health inequity and socioeconomic inequalities during the COVID-19 pandemic compared with other vulnerable women and girls. METHODS: We used data collected through a survey conducted in Nigeria between June and October 2021. Women and girls living with or at risk of HIV were recruited voluntarily, using a combination of venue-based and snowball sampling. We performed multivariable logistic regression models per mobility and HIV status to determine associations between health inequity, socioeconomic inequalities and macrosocial characteristics. FINDINGS: There were 3442 participants, of which 700 were on the move. We found no statistical difference between HIV-negative women and girls on the move and those not on the move. On the opposite, we found substantial differences in health inequity and socioeconomic inequalities between women and girls on the move living with HIV and those not on the move living with HIV. There are very strong associations between being a woman or girl on the move living with HIV and facing economic precarity (aOR 6.08, 95% CI 1.94 to 19.03), food insecurity (aOR 5.96, 95% CI 2.16 to 16.50) and experiencing more gender-based violence since COVID-19 started (aOR 5.61, 95% CI 3.01 to 10.47). INTERPRETATION: Being a woman or girl on the move and living with HIV compound increased health and socioeconomic vulnerabilities. The COVID-19 crisis seems to have exacerbated inequalities and gender-based violence. These findings call for more feminist interventions to protect women on the move living with HIV during health crises.

Increasing compliance with international pandemic law: international relations and new global health agreements.

Across multiple pandemics, global health governance institutions have struggled to secure the compliance of states with international legal and political commitments, ranging from data sharing to observing WHO guidance to sharing vaccines. In response, governments are negotiating a new pandemic treaty and revising the International Health Regulations. Achieving compliance remains challenging, but international relations and international law research in areas outside of health offers insights. This Health Policy analyses international relations research on the reasons why states comply with international law, even in the absence of sanctions. Drawing on human rights, trade, finance, tobacco, and environmental law, we categorise compliance mechanisms as police patrol, fire alarm, or community organiser models. We show that, to date, current and proposed global health law incorporates only a few of the mechanisms that have shown to be effective in other areas. We offer six specific, politically feasible mechanisms for new international agreements that, together, could create compliance pressures to shift state behaviour.

Income inequality and pandemics: insights from HIV/AIDS and COVID-19-a multicountry observational study.

OBJECTIVES: Assess the relationship between income inequality and HIV incidence, AIDS mortality and COVID-19 mortality. DESIGN: Multicountry observational study. SETTING: 217 countries for HIV/AIDS analysis, 151 countries for COVID-19 analysis. PARTICIPANTS: Used three samples of national-level data: a sample of all countries with available data (global sample), a subsample of African countries (African sample) and a subsample excluding African countries (excluding African sample). MAIN OUTCOME MEASURES: HIV incidence rate per 1000 people, AIDS mortality rate per 100 000 people and COVID-19 excess mortality rate per 100 000 people. The Gini index of income inequality was the primary explanatory variable. RESULTS: A positive and significant relationship exists between the Gini index of income inequality and HIV incidence across all three samples (p<0.01), with the effect of income inequality on HIV incidence being higher in the African sample than in the rest of the world. Also, a statistically positive association exists for all samples between income inequality and the AIDS mortality rate, as higher income inequality increases AIDS mortality (p<0.01). For COVID-19 excess mortality rate, a positive and statistically significant relationship exists with the Gini index for the entire sample and the excluding African sample (p<0.05), but the African sample alone did not deliver significant results (p<0.1). CONCLUSION: COVID-19 excess deaths, HIV incidence and AIDS mortality are significantly associated with income inequality globally-more unequal countries have a higher HIV incidence, AIDS mortality and COVID-19 excess deaths than their more equal counterparts. Income inequality undercuts effective pandemic response. There is an urgent need for concerted efforts to tackle income inequality and to build pandemic preparedness and responses that are adapted and responsive to highly unequal societies, prioritising income inequality among other social determinants of health.

Health Economics Research on Non-surgical Biomedical HIV Prevention: Identifying Gaps and Proposing a Way Forward.

BACKGROUND AND OBJECTIVE: Although HIV prevention science has advanced over the last four decades, evidence suggests that prevention technologies do not always reach their full potential. Critical health economics evidence at appropriate decision-making junctures, particularly early in the development process, could help identify and address potential barriers to the eventual uptake of future HIV prevention products. This paper aims to identify key evidence gaps and propose health economics research priorities for the field of HIV non-surgical biomedical prevention. METHODS: We used a mixed-methods approach with three distinct components: (i) three systematic literature reviews (costs and cost effectiveness, HIV transmission modelling and quantitative preference elicitation) to understand health economics evidence and gaps in the peer-reviewed literature; (ii) an online survey with researchers working in this field to capture gaps in yet-to-be published research (recently completed, ongoing and future); and (iii) a stakeholder meeting with key global and national players in HIV prevention, including experts in product development, health economics research and policy uptake, to uncover further gaps, as well as to elicit views on priorities and recommendations based on (i) and (ii). RESULTS: Gaps in the scope of available health economics evidence were identified. Little research has been carried out on certain key populations (e.g. transgender people and people who inject drugs) and other vulnerable groups (e.g. pregnant people and people who breastfeed). Research is also lacking on preferences of community actors who often influence or enable access to health services among priority populations. Oral pre-exposure prophylaxis, which has been rolled out in many settings, has been studied in depth. However, research on newer promising technologies, such as long-acting pre-exposure prophylaxis formulations, broadly neutralising antibodies and multipurpose prevention technologies, is lacking. Interventions focussing on reducing intravenous and vertical transmission are also understudied. A disproportionate amount of evidence on low- and middle-income countries comes from two countries (South Africa and Kenya); evidence from other countries in sub-Saharan Africa as well as other low- and middle-income countries is needed. Further, data are needed on non-facility-based service delivery modalities, integrated service delivery and ancillary services. Key methodological gaps were also identified. An emphasis on equity and representation of heterogeneous populations was lacking. Research rarely acknowledged the complex and dynamic use of prevention technologies over time. Greater efforts are needed to collect primary data, quantify uncertainty, systematically compare the full range of prevention options available, and validate pilot and modelling data once interventions are scaled up. Clarity on appropriate cost-effectiveness outcome measures and thresholds is also lacking. Lastly, research often fails to reflect policy-relevant questions and approaches. CONCLUSIONS: Despite a large body of health economics evidence on non-surgical biomedical HIV prevention technologies, important gaps in the scope of evidence and methodology remain. To ensure that high-quality research influences key decision-making junctures and facilitates the delivery of prevention products in a way that maximises impact, we make five broad recommendations related to: improved study design, an increased focus on service delivery, greater community and stakeholder engagement, the fostering of an active network of partners across sectors and an enhanced application of research.

Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey.

BACKGROUND: Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments. METHODS: This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs. FINDINGS: Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings. INTERPRETATION: Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV. FUNDING: National Institutes of Health. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Single-center experience in implementation of endoscopic surveillance protocol after esophagectomy.

Esophageal cancer has a notably high recurrence rate with a paucity of robust evidence in defining the optimal surveillance strategy. The surveillance protocol at our institution comprises of annual esophagogastroduodenoscopy (OGD) from years 1 to 5 postoperatively. This study aims to evaluate the implementation of the endoscopic surveillance at our center and ascertain the value of endoscopy in detecting local recurrence after esophagectomy. A retrospective cohort review of all patients (320 patients) who underwent esophagectomy between 2013 and 2018 was conducted. The local esophageal cancer database and corresponding OGD reports were accessed to obtain data on demographics, operation details, local recurrence, and endoscopy performed. 1086 OGDs were performed between 2014 and 2020, broadly categorized to surveillance and symptomatic OGDs; 555 and 531, respectively. Surveillance OGDs detected four asymptomatic local recurrences, of which only one was treated with curative intent. Symptomatic OGDs resulted in a higher yield for the detection of local recurrence compared with surveillance endoscopy; 5% versus 0.7%, with overall median time-to-recurrence of 11.5 months (95% confidence interval 9-17). Of local recurrences, 85.7% occurred within the first 2 years postoperatively. The proportion of endoscopic findings differed between intensive and ad hoc surveillance cohorts for strictures, esophagitis, Barrett's esophagus, and sloughing. Thirteen patients were diagnosed with histologically confirmed Barrett's with no subsequent local recurrences. Surveillance endoscopy had a low positive yield rate with subsequent minimal survival benefits. Therefore, it is prudent to consider an alternative protocol that focuses on the period with the highest risk of recurrence and symptom presentation.

[Planning for health equity in the Americas: an analysis of national health plansPlanejamento para equidade em saúde nas Américas: uma análise dos planos nacionais de saúde]. / Planificación para la equidad en la salud en la Región de las Américas: análisis de los planes nacionales de salud.

There is growing recognition that health and well-being improvements have not been shared across populations in the Americas. This article analyzes 32 national health sector policies, strategies, and plans across 10 different areas of health equity to understand, from one perspective, how equity is being addressed in the region. It finds significant variation in the substance and structure of how the health plans handle the issue. Nearly all countries explicitly include health equity as a clear goal, and most address the social determinants of health. Participatory processes documented in the development of these plans range from none to extensive and robust. Substantive equity-focused policies, such as those to improve physical accessibility of health care and increase affordable access to medicines, are included in many plans, though no country includes all aspects examined. Countries identify marginalized populations in their plans, though only a quarter specifically identify Afro-descendants and more than half do not address Indigenous people, including countries with large Indigenous populations. Four include attention to migrants. Despite health equity goals and data on baseline inequities, fewer than half of countries include time-bound targets on reducing absolute or relative health inequalities. Clear accountability mechanisms such as education, reporting, or rights-enforcement mechanisms in plans are rare. The nearly unanimous commitment across countries of the Americas to equity in health provides an important opportunity. Learning from the most robust equity-focused plans could provide a road map for efforts to translate broad goals into time-bound targets and eventually to increasing equity.

É cada vez mais aceito que os avanços em saúde e bem-estar não são partilhados por todas as populações nas Américas. Neste artigo são analisadas 32 políticas, estratégias e planos nacionais de saúde em 10 áreas distintas de equidade em saúde com o objetivo de entender, de uma única perspectiva, como a equidade está sendo contemplada na região. Existem diferenças consideráveis na forma e conteúdo do enfoque dado a esta questão nos planos de saúde. Quase todos os países estabelecem explicitamente a equidade em saúde como uma meta clara e a maioria aborda os determinantes sociais da saúde. O processo participativo documentado na elaboração dos planos também é variável, desde inexistente a amplo e decidido. Muitos planos contêm políticas concretas com foco central em equidade, por exemplo, políticas para melhorar a acessibilidade física à assistência de saúde e o acesso a medicamentos a preços razoáveis, mas nenhum país inclui todos os aspectos aqui examinados. Os países identificam as populações marginalizadas nos seus planos, porém, apenas um quarto distingue especificamente os afrodescendentes e mais da metade não contempla os povos indígenas, mesmo onde as populações indígenas são em grande número. Quatro países consideram a atenção aos migrantes. Embora existam metas de equidade em saúde e dados relativos a iniquidades de base, menos da metade dos países incorpora em seus planos metas com prazos definidos para reduzir as desigualdades absolutas ou relativas em saúde. Instrumentos claros de responsabilidade como educação, prestação de contas ou respeito aos direitos são raramente vistos. O compromisso praticamente unânime dos países das Américas com a equidade em saúde oferece uma oportunidade importante. Os planos mais bem fundados com enfoque em equidade poderiam servir de exemplo para guiar os esforços de converter metas gerais em metas com prazos definidos e, em última instância, aumentar a equidade.

Planificación para la equidad en la salud en la Región de las Américas: análisis de los planes nacionales de salud

[RESUMEN]. Cada vez más se reconoce que las mejoras en la salud y el bienestar no se han registrado por igual en las poblaciones de la Región de las Américas. En este artículo se analizan 32 políticas, estrategias y planes nacionales del sector de la salud en diez áreas diferentes de la equidad en la salud para comprender, desde una perspectiva, cómo se está abordando el tema de la equidad en la Región. Se encontraron variaciones significativas en la sustancia y estructura de la manera en que los planes de salud manejan el problema. Casi todos los países incluyen explícitamente la equidad en la salud como un objetivo claro y la mayoría de los países abordan los determinantes sociales de la salud. Los procesos participativos documentados seguidos en la formulación de estos planes abarcan desde inexistentes hasta extensos y bien concebidos. Muchos planes incluyen políticas sólidas centradas en la equidad, como las destinadas a mejorar la accesibilidad física de la atención de salud y aumentar el acceso asequible a los medicamentos, pero ningún país incluye todos los aspectos examinados. Los países consideran a las poblaciones marginadas en sus planes, aunque solo una cuarta parte incluye específicamente a los afrodescendientes y más de la mitad no abordan a los pueblos indígenas, incluso algunos con grandes poblaciones indígenas. Cuatro incluyen atención a los migrantes. A pesar de que incluyen objetivos sobre la equidad en la salud y datos sobre las inequidades como parámetros de referencia, menos de la mitad de los países se fijan objetivos con plazos específicos para reducir las desigualdades absolutas o relativas en el ámbito de la salud. Rara vez se encuentran en los planes mecanismos claros de rendición de cuentas, como la educación, la presentación de informes o mecanismos para hacer respetar los derechos. El compromiso casi unánime entre los países de la Región de las Américas con la equidad en la salud ofrece una oportunidad importante. Aprender de los planes más sólidos centrados en la equidad podría proporcionar una hoja de ruta para los esfuerzos tendientes a traducir las metas amplias en objetivos con plazos definidos y, finalmente, aumentar la equidad.

[ABSTRACT]. There is growing recognition that health and well-being improvements have not been shared across populations in the Americas. This article analyzes 32 national health sector policies, strategies, and plans across 10 different areas of health equity to understand, from one perspective, how equity is being addressed in the region. It finds significant variation in the substance and structure of how the health plans handle the issue. Nearly all countries explicitly include health equity as a clear goal, and most address the social determinants of health. Participatory processes documented in the development of these plans range from none to extensive and robust. Substantive equity-focused policies, such as those to improve physical accessibility of health care and increase affordable access to medicines, are included in many plans, though no country includes all aspects examined. Countries identify marginalized populations in their plans, though only a quarter specifically identify Afro-descendants and more than half do not address Indigenous people, including countries with large Indigenous populations. Four include attention to migrants. Despite health equity goals and data on baseline inequities, fewer than half of countries include time-bound targets on reducing absolute or relative health inequalities. Clear accountability mechanisms such as education, reporting, or rights-enforcement mechanisms in plans are rare. The nearly unanimous commitment across countries of the Americas to equity in health provides an important opportunity. Learning from the most robust equity-focused plans could provide a road map for efforts to translate broad goals into time-bound targets and eventually to increasing equity.

[RESUMO]. É cada vez mais aceito que os avanços em saúde e bem-estar não são partilhados por todas as populações nas Américas. Neste artigo são analisadas 32 políticas, estratégias e planos nacionais de saúde em 10 áreas distintas de equidade em saúde com o objetivo de entender, de uma única perspectiva, como a equidade está sendo contemplada na região. Existem diferenças consideráveis na forma e conteúdo do enfoque dado a esta questão nos planos de saúde. Quase todos os países estabelecem explicitamente a equidade em saúde como uma meta clara e a maioria aborda os determinantes sociais da saúde. O processo participativo documentado na elaboração dos planos também é variável, desde inexistente a amplo e decidido. Muitos planos contêm políticas concretas com foco central em equidade, por exemplo, políticas para melhorar a acessibilidade física à assistência de saúde e o acesso a medicamentos a preços razoáveis, mas nenhum país inclui todos os aspectos aqui examinados. Os países identificam as populações marginalizadas nos seus planos, porém, apenas um quarto distingue especificamente os afrodescendentes e mais da metade não contempla os povos indígenas, mesmo onde as populações indígenas são em grande número. Quatro países consideram a atenção aos migrantes. Embora existam metas de equidade em saúde e dados relativos a iniquidades de base, menos da metade dos países incorpora em seus planos metas com prazos definidos para reduzir as desigualdades absolutas ou relativas em saúde. Instrumentos claros de responsabilidade como educação, prestação de contas ou respeito aos direitos são raramente vistos. O compromisso praticamente unânime dos países das Américas com a equidade em saúde oferece uma oportunidade importante. Os planos mais bem fundados com enfoque em equidade poderiam servir de exemplo para guiar os esforços de converter metas gerais em metas com prazos definidos e, em última instância, aumentar a equidade.

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.

Mobility restrictions were associated with reductions in COVID-19 incidence early in the pandemic: evidence from a real-time evaluation in 34 countries.

Most countries have implemented restrictions on mobility to prevent the spread of Coronavirus disease-19 (COVID-19), entailing considerable societal costs but, at least initially, based on limited evidence of effectiveness. We asked whether mobility restrictions were associated with changes in the occurrence of COVID-19 in 34 OECD countries plus Singapore and Taiwan. Our data sources were the Google Global Mobility Data Source, which reports different types of mobility, and COVID-19 cases retrieved from the dataset curated by Our World in Data. Beginning at each country's 100th case, and incorporating a 14-day lag to account for the delay between exposure and illness, we examined the association between changes in mobility (with January 3 to February 6, 2020 as baseline) and the ratio of the number of newly confirmed cases on a given day to the total number of cases over the past 14 days from the index day (the potentially infective 'pool' in that population), per million population, using LOESS regression and logit regression. In two-thirds of examined countries, reductions of up to 40% in commuting mobility (to workplaces, transit stations, retailers, and recreation) were associated with decreased cases, especially early in the pandemic. Once both mobility and incidence had been brought down, further restrictions provided little additional benefit. These findings point to the importance of acting early and decisively in a pandemic.