This issue brief assesses how the HIV policy landscapes in PEPFAR countries compare to international standards and recommendations.

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.

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