No abstract

High levels of medication adherence are central to HIV treatment success. Barriers to medication adherence may differ by cultural setting. We aimed to determine risk factors for medication non-adherence in HIV infected individuals in the Dominican Republic. Adherence was measured in 300 individuals using a visual analog scale assessing the prior month and dichotomized at 95%. High levels of adherence were reported by 228 (76%). Risk factors for non-adherence included heavy alcohol use: 2.5 times odds (95% CI: 1.4-4.5), having children: 2.2 times higher odds (95% CI: 1.1-4.9) and perceptions of less social support related to adherence: 2 times higher odds (95% CI: 1.1-3.6). Culturally appropriate interventions are needed to address alcohol use, which is common in this setting. Parenting may represent a competing demand on time and resources and be an adherence barrier. Self-reported perceived lack of adherence support may be a useful marker for need for adherence interventions.

Law and policy differences help explain why, as HIV-related science has advanced swiftly, some countries have realised remarkable progress on AIDS while others see expanding epidemics. We describe the structure and findings of a new dataset and research platform, the HIV Policy Lab, which fills an important knowledge gap by measuring the HIV-related policy environment across 33 indicators and 194 countries over time, with online access and visualisation. Cross-national indicators can be critical tools in international governance—building social power to monitor state behaviour with the potential to change policy and improve domestic accountability. This new and evolving effort collects data about policy through review of legal documents, official government reports and systematic review of secondary sources. Alignment between national policy environments and global norms is demonstrated through comparison with international public health guidance and agreements. We demonstrate substantial variation in the content of law and policies between countries, regions and policy areas. Given progress in basic and implementation science, it would be tempting to believe most countries have adopted policies aligned with global norms, with a few outliers. Data show this is not the case. Globally, alignment is higher on clinical and treatment policies than on prevention, testing and structural policies. Policy-makers, researchers, civil society, finance agencies and others can use these data to better understand the policy environment within and across countries and support reform. Longitudinal analysis enables evaluation of the impact of laws and policies on HIV outcomes and research about the political drivers of policy choice.

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.

The legalization of world politics is often celebrated for reducing impunity for those who contribute to humanitarian crises. This may sometimes be true but the opposite is also true. In 2010, United Nations peacekeepers unwittingly brought cholera to Haiti and sparked an epidemic. Nearly a million people were made sick and 8,500 died. Legal activists have sought to hold the UN responsible for the harms it caused and win compensation for the cholera victims. However, these efforts have been stymied by the structures of public international law—particularly UN immunity—which effectively insulate the organization from accountability. In short, the UN is empowered, and the cholera victims disempowered, by legalization. The Haiti case powerfully illustrates the dangers of legalism, which have been largely overlooked in discussions of international law, and suggests that law alone is an inadequate arbiter of responsibility in international politics.