HIV Policy Alignment with International Standards in PEPFAR Countries

PEPFAR countries, as a group, have greater policy alignment, than other LMICs.

• Overall, PEPFAR countries have an average adoption score of 60% for the recommended policies, compared to 48% for other LMICs. Policy adoption scores in PEPFAR countries range from 33% in Trinidad & Tobago to a high of 82% in South Africa (see Figure 1).

• PEPFAR countries score higher on three of the four policy categories tracked, with an average score 22 percentage points greater than that of other LMICs for clinical care and treatment indicators; 16 percentage points higher for testing and prevention indicators; and 10 points higher for health systems indicators. The score for the fourth category — structural indicators – was similar to that of other LMICs (see Figure 2).

PEPFAR countries have the strongest policy alignment in the area of clinical care and treatment and the weakest on structural indicators.

• On average, PEPFAR countries have an adoption score of 83% for policies related to clinical care and treatment (see Figure 2), ranging from a low of 31% (Nicaragua) to a high of 100% in eight countries (Eswatini, Ethiopia, Haiti, Malawi, Papua New Guinea, South Sudan, Uganda, and Zimbabwe).
• For testing and prevention indicators, PEPFAR countries have an average adoption score of 53%, ranging from 0% (Trinidad and Tobago) to 94% (Nigeria).
• PEPFAR countries scored an average of 60% for health systems indicators, ranging from 14% (Laos) to 93% in three countries (Eswatini, South Africa, and Thailand).
• PEPFAR countries have the weakest alignment for policies related to structural indicators (47%), with Lesotho scoring the lowest in this category at 11%, and Rwanda and South Africa scoring the highest at 70%.

There is also significant variation in policy alignment within each main category– for instance, while no PEPFAR country has adopted policies related to drug use non-criminalization (structural), all 53 PEPFAR countries have fully aligned viral load testing policies (clinical care and treatment) with international standards.

Clinical Care and Treatment

• All PEPFAR countries in this analysis (53) have fully adopted viral load testing policies aligned with international standards (whether a national policy is in place to monitor viral load in people with HIV at least once a year). This was the only indicator among the 33 for which 100% of countries have fully aligned policies. Treatment initiation policies (whether a national policy is in place that states that people with HIV, regardless of CD4 count, are eligible to start treatment) followed closely with 52 of the 53 PEPFAR countries fully adopting.
• Differentiated service delivery (DSD) policies (whether national policy allows for differentiated HIV treatment services such as multi-month dispensing and community antiretroviral therapy) had the smallest share of PEPFAR countries fully adopting – 15 of the 53 PEPFAR countries, although an additional 36 had adopted some DSD policies.

Testing and Prevention

• Adoption of prevention policies is greatest for comprehensive sexuality education (whether national policies require curriculum that meets international standards be taught in primary and secondary schools), with 42 PEPFAR countries fully adopting (out of 52 with available data).
• Policies related to HIV prevention among prisoners (whether national policy stipulates that prevention tools, such as condoms, lubricants, and syringe access/exchange programs available to prisoners) were the least likely to be aligned, with just two countries (Kyrgyzstan and Tajikistan) fully adopting policies aligned with international standards (out of 52 with available data), although an additional 13 had adopted some policies in this area.

Health Systems

• Within this category, PEPFAR countries are most aligned on policies related to unique identifiers with data protections (whether the country utilizes unique identifiers for continuity of care across multiple facilities and has legally-enforceable data privacy protections) – 33 of 53 PEPFAR countries have policies fully aligned with international standards and an additional 17 countries had some national policy related to patient data protection.
• More than half of PEPFAR countries (27 of 52 with available data) have fully aligned policies related to user fees (whether national policy stipulates that public primary care and HIV services are available without user fees) and an additional 20 have adopted some policies in this area.
• PEPFAR countries are least likely to be aligned on policies related to universal health coverage of HIV treatment and PrEP (whether national health coverage includes medications for HIV treatment and PrEP) – 11 PEPFAR countries (out of 51 with available data) have fully aligned policies with international standards, with an additional 22 having adopted some policies related to universal health coverage of HIV treatment and PrEP.

Structural

• PEPFAR countries have the strongest alignment on policies related to gender-based violence – an indicator that assesses whether or not countries have laws that explicitly address domestic violence with enforceable penalties (42 of 53 countries).
• On the other end of the spectrum, no PEPFAR country has adopted policies related to drug use non-criminalization (whether national policy avoids criminalizing personal possession of drugs). Additionally, only three of 53 PEPFAR countries have policies related to sex work non-criminalization (whether national policy avoids criminalizing the buying, selling, and organizing of sex work) that are fully aligned with international standards (Haiti, Honduras, and Panama).

Discussion

While no PEPFAR country has fully aligned its laws and policies with international standards, this analysis shows that they have, on average, greater alignment than other LMICs and this differential is greatest in areas in which PEPFAR focuses most of its direct support, such as treatment and testing policies. As noted above, PEPFAR has actively worked toward changing local policies in countries, principally with regard to the adoption of treatment guidelines, the removal of user fees for HIV services, and the implementation of differentiated service delivery strategies, such as the multi-month dispensing of antiretrovirals – which has become critically important during the COVID-19 pandemic – and increasing domestic budgets for HIV. Further, PEPFAR has played a role in spotlighting the need for countries to address HIV among some of the most vulnerable populations, which have been historically shunned by some countries. At the same time, as this analysis demonstrates, there is still a significant share of recommended policies that have yet to be adopted in PEPFAR countries, particularly in the area of structural barriers, such as policies related to non-discrimination of marginalized groups and decriminalization of activities including sex work and drug use, which may be the most difficult to affect at the country level given that they often require national legal changes and/or reach beyond HIV.

While the data included in this analysis do not measure the extent or quality of implementation, policy adoption can be viewed as a step in the direction of evidence-based practices and indicate a country’s commitment to addressing HIV and creating a foundation that can facilitate and optimize HIV/AIDS efforts. This is especially important in PEPFAR countries, which include those that have been hardest hit by the HIV/AIDS epidemic. Indeed, PEPFAR’s most recent draft guidance to COP and ROP countries for 2022 places an even greater premium on policy change, including requiring country programs to either ensure change in some areas as a condition of receiving funding, or submit a detailed description of existing barriers and proposed plan to be able to meet these requirements.

Looking ahead, there are important questions surrounding PEPFAR’s role, beyond service delivery, in countries, especially as the program awaits the confirmation of a new coordinator, is expected to release a new five-year strategy, and is due for reauthorization in two years, all of which could provide openings for strengthening PEPFAR even further. The findings presented here, while not necessarily attributable to PEPFAR, may serve as a baseline for targeting and assessing future PEPFAR efforts, as the program seeks to further improve HIV outcomes in the countries within which it works and policymakers consider PEPFAR’s next phase.