HIV Policy Alignment with International Standards in PEPFAR Countries

Key Findings

• Adoption of evidence-based guidelines, laws, and policies is important for improving HIV-related health outcomes. While PEPFAR’s primary focus is on HIV service delivery, it also aims to create conditions within countries that can contribute to successful implementation of HIV programs, which includes helping to foster policy environments through both operational guidance and diplomacy.
• We examined the policy environments in PEPFAR countries to assess alignment with international HIV-related standards, looking at four main categories (clinical care and treatment, testing and prevention, structural, and health systems). We also compared PEPFAR countries to other low- and middle-income countries (LMICs).
• Overall, we find that PEPFAR countries have stronger policy alignment than other LMICs – PEPFAR countries as a group have adopted 60% of recommended policies, compared with 48% among other LMICs, and PEPFAR countries have higher alignment scores than other LMICs in three of the four categories.
• Policy alignment was particularly strong, including relative to other LMICs, in areas in which PEPFAR directly focuses and supports. PEPFAR countries scored highest (81%) in the area of clinical care and treatment, which includes policies related to early treatment initiation, treatment regimens, and viral load testing, and scored 20 percentage points higher than other LMICs. While the overall score on testing and prevention was lower than that of clinical care and treatment, there was still a large differential compared to other LMICs (57% compared to 37%). Scores were lowest and similar for both groups on policies and laws related to structural factors, such as HIV-related non-criminalization policies.
• Policy alignment across PEPFAR countries varies substantially – overall policy adoption scores range from 33% in Trinidad & Tobago to 82% in South Africa and there is also variation 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.
• While PEPFAR countries scored higher than other LMICs overall, a significant share of recommended policies have yet to be adopted in PEPFAR countries, particularly in the area of structural barriers, 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. Going forward, these findings 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.

Introduction

The U.S. government’s President’s Emergency Plan for AIDS Relief (PEPFAR), the world’s largest commitment by any nation to address a single disease, has played a significant role in addressing HIV/AIDS in the hardest-hit countries around the world and is credited with helping to shift the trajectory of the epidemic.¹ While most of PEPFAR’s efforts are focused on providing services to those with and at risk for HIV, PEPFAR also aims to create conditions that can contribute to the successful implementation of HIV programs. ^2,3,4 This includes working to foster the adoption of normative, evidence-based guidance and policies developed by international bodies aimed at improving HIV-related health outcomes.^5,6,7

Through its operational guidance and direct diplomatic engagement,⁸ PEPFAR has worked to encourage and in some cases require that country programs adopt certain policies, such as new antiretroviral treatment guidelines; differentiated service delivery⁹ – including multi-month dispensing of antiretrovirals (ARVs) to reduce the need for frequent refills, which has become particularly important to ensure continuity of treatment during COVID-19; and the removal of user fees that can serve as obstacles to HIV service access; as well as increase domestic budgets for HIV.^{10,11,12,13,14} PEPFAR also has emphasized the importance of addressing stigma and a human rights approach, particularly for reaching key populations that some societies have historically shunned.^15,16,17,18 As a result, the program has been found to have played an important role in helping to shape the HIV policy environments in the countries in which it operates.^{19,20,21,22,23,24}

We sought to assess policy alignment with international HIV standards in PEPFAR countries. We included PEPFAR countries that were required to develop Country or Regional Operating Plans (COPs or ROPs), which are used for approval of funding and serve as annual strategic plans for U.S. HIV/AIDS efforts in host countries in 2020.^25,26,27 In addition to assessing how PEPFAR COP/ROP countries align with international standards, we also compared this group to other LMICs.^28,29

Because we looked only at a point-in-time snapshot, findings cannot necessarily be attributed to PEPFAR. Rather, they 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. It is possible that policies may have changed in PEPFAR countries since we completed the analysis. For instance, according to a presentation by PEPFAR headquarters staff to stakeholders on August 2, 2021, numerous PEPFAR countries have been making modifications to their polices or guidelines related to multi-month dispensing of antiretrovirals during the COVID-19 pandemic.³⁰

Methods^31,32

We analyzed data from the HIV Policy Lab, a joint project of Georgetown University’s O’Neill Institute and other academic, civil society, and multilateral partners, with the support of PEPFAR, which compiles and measures the HIV-related policies of the 194 World Health Organization (WHO) member states against international normative guidance. The policies that the HIV Policy Lab uses as benchmarks are those recommended by internationally-recognized authorities, including the WHO, UNAIDS, the U.N. Development Programme, the Global Commission on HIV and the Law, and others based on current science and evidence and aimed at improving HIV-related outcomes. The HIV Policy Lab database uses information reported by governments through the National Commitments and Policy Instrument (NCPI) housed on UNAIDS’ Laws and Policies Analytics platform,³³ and collects additional data from official countries sources, reports from U.N. member states, and other partner organizations.

We used the most recent year of data available (through 2020) on policies by country to assess their status in 53 PEPFAR countries required to submit a COP and ROP in 2020, and 85 other LMICs that either did not receive PEPFAR support (82 countries) or received some U.S. HIV support, but were not required to submit a COP or ROP in 2020 (3 countries).^34,35,36 We included the full set of 33 indicators – along with more than 30 sub-indicators – across the four categories that the HIV Policy Lab tracks: clinical care and treatment; testing and prevention; health systems; and structural barriers (see Table 1 and the Appendix; more detailed explanations of each indicator can be found in the HIV Policy Lab’s Codebook).

For each indicator where data are available, the HIV Policy Lab assigns points based on adoption status – “Adopted” (1 point), “Partially Adopted” (0.5), and “Not Adopted” (0). For indicators with sub-indicators, the HIV Policy Lab assigns a full point if all sub-indicators are adopted, a half point (0.5) if some are adopted, and 0 if none are adopted. The points for all indicators are added to obtain a raw score for each country. Adoption percentages are calculated by dividing the raw scores by the total possible scores; indicators for which there are no data available are excluded. Scores for groups (e.g., PEPFAR countries, regions) were calculated by averaging country scores at the overall- and category-level. Scores presented in the text are for the main indicators unless otherwise noted. Countries without data were excluded.

Our analysis is based on data downloaded on December 7, 2021.

Table 1: Policy Indicators Included in Analysis, by Category
Clinical Care and Treatment	Testing and Prevention	Health Systems	Structural
Treatment Initiation	Self-testing	Task Shifting	Same-sex Sex Non-Criminalization
Same-day Treatment Start	Partner Notification/Index Testing	Healthcare Financing	Sex Work Non-Criminalization
Treatment Regimen	Compulsory Testing	Universal Health Coverage	Drug Use Non-Criminalization
Differentiated Service Delivery	Age Restrictions on Testing & Treatment	User Fees	HIV Exposure Non-Criminalization
Viral Load Testing	PrEP	Access to Medicines (TRIPS)	Non-discrimination Protections
Pediatric Diagnosis & Treatment	Harm Reduction	Unique Identifiers with Data Protections	National Human Rights Institutions
Migrant Access to Healthcare	Comprehensive Sexuality Education	Data Sharing	Constitutional Right to Health
Tuberculosis Diagnosis	Prisoners Prevention		Girls Education
			Gender-based Violence
			Civil Society