Research into the effects of global health initiatives (GHIs) on health systems has largely left out the viewpoints and contributions of civil society. This study details civil society's perspective regarding the effects of two GHIs, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), on country health systems and the added value of civil society interacting with GHIs to strengthen health systems. The study employed qualitative data collection methods using semi-structured interviews administered during focus groups and key informant interviews. A range of health system stakeholders were interviewed in Kenya, Malawi, Uganda and Zambia. Data were coded and analysed for themes and sub-themes. In total, 2910 civil society participants provided information individually or in focus groups. Respondents reported that GHIs have contributed to dramatic health benefits within and outside of a disease-specific focus, including health systems strengthening efforts. However, opportunities for synergy between GHIs and health systems have been missed, and GHIs have not worked sufficiently to close capacity gaps of grassroots civil society organisations. Despite some governance innovations, civil society's opportunities to participate meaningfully in GHI priority setting efforts are limited. Recommendations are included on how to best use GHIs to strengthen health systems by partnering with civil society.

Recent years have seen significant advances in the science of using antiretroviral medicines (ARVs) to fight HIV. Where not long ago ARVs were used late in disease to prevent sick people from dying, today people living with HIV can use ARVs to achieve viral suppression early in the course of disease. This article reviews the mounting new scientific evidence of major clinical and prevention ARV benefits. This has changed the logic of the AIDS response, eliminating competition between "treatment" and "prevention" and encouraging early initiation of treatment for individual and public health benefit. These breakthroughs have implications for the health-related human rights duties of States. With medical advance, the "highest attainable standard" of health has taken a leap, and with it the rights obligations of States. We argue that access to early treatment for all is now a core State obligation and restricting access to, or failing to provide accurate information about, it violates both individual and collective rights. In a context of real political and technical challenges, however, in this article we review the policy implications of evolving human rights obligations given the new science. National and international legal standards require action on budget, health and intellectual property policy, which we outline.

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