From Criminalization to Compassion: The Evolution of HIV Laws

First set in 2014, the 90-90-90 program from UNAIDS had 3 goals: diagnose 90% of people living with HIV, provide antiretroviral therapy (ART) for 90% of diagnosed patients, and achieve viral suppression for 90% of patients on treatment.¹ These goals were not achieved. In December 2020, an extension of this original programming was proposed, and on June 9, 2021, it was formally adopted by United Nations member states with a hoped-for end date of 2026: 95-95-95 hopes to see 95% of people living with HIV diagnosed, 95% of those who are diagnosed on treatment, and 95% of those on treatment virally suppressed.²

The session “Are Countries Allowing Communities to Lead? The Global Landscape of National Civil Society Laws and Their Association With HIV 95-95-95 Indicators” at AIDS 2024 explored the impact of legal limitations on the ability of civil society organizations (CSOs) to operate and continue their advocacy on behalf of those living with HIV and AIDS, who remain marginalized and stigmatized, and therefore vulnerable.³

Varsha Srivatsan, ScM, program manager, Center for Global Health Policy & Politics and the HIV Policy Lab, and the O’Neill Institute for National and Global Health Law, Georgetown Law, led this discussion. Together with her team at the O’Neill Institute—comprising lawyers, epidemiologists, and policy experts—they track laws and policies across 194 countries, focusing on areas such as HIV and health care workers. Among their primary responsibilities are “to codify information into quantitative metrics—'adopted,’ ‘not adopted,’ or ‘partially adopted’—to indicate how well countries align with international normative guidance,” and “to specifically measure 33 indicators (covering 52 laws and policies) crucial to the AIDS response, including aspects of clinical care, HIV prevention, criminal and consent laws, and health system policies.”

Varsha Srivatsan, ScM | Image Credit: © O’Neill Institute for National and Global Health Law

The interview has been edited for clarity and length.

The American Journal of Managed Care^® (AJMC^®): What are some of the most notable improvements in HIV-related laws and policies since the onset of the HIV/AIDS epidemic in the early 1980s?

Srivatsan: Since the 1980s, we have made substantial progress in HIV-related laws and policies. It’s remarkable to consider that ART, which was initially met with skepticism, now supports nearly 30 million people according to the latest UNAIDS estimates. Most countries have now implemented policies that facilitate treatment initiation regardless of CD4 count and enable same-day linkage to treatment upon diagnosis. Recently, more countries have begun adopting differentiated service policies, particularly in response to COVID-19–related movement restrictions and to alleviate the strain on health systems. We anticipate that more countries will follow this approach as we advance toward person-centered care.

Importantly, many countries have been working to abolish laws that criminalize lesbian, gay, bisexual, transgender, queer, plus (LGBTQ+) individuals. Currently, over two-thirds of countries have removed such laws, marking a significant victory for the global HIV community. Between 2017 and 2024, 15 countries repealed these criminal codes, with Namibia and Dominica recently joining this trend. This is remarkable progress. The HIV Policy Lab published an insightful report on this issue last year.⁴ The report includes case studies of countries that have recently decriminalized, data and analysis of laws, and compelling human rights and economic arguments for the decriminalization of LGBTQ+ individuals and same-sex relationships.

AJMC: Where do we currently stand with the United Nations’ 95-95-95 global initiative, and what are the potential reasons these targets—knowing HIV status, being on treatment, and viral suppression—remain elusive?

Srivatsan: Despite considerable progress since the 1980s, there is much work to do to achieve the 95-95-95 targets. There are many reasons for this. In some countries, the issue lies in the implementation or enforcement of good laws and policies, while in others, the problem is the laws and policies themselves, and bad or restrictive laws hinder progress toward national goals and international commitments. For example, criminalizing key populations exacerbates stigma and discourages them from seeking lifesaving health care, including preventive measures like pre-exposure prophylaxis (PrEP).

In fact, although many countries are repealing criminal laws on LGBTQ+ individuals and making progress, others are enacting more stringent measures, undermining their AIDS response. Moreover, criminalization may impact who may be eligible for or get access to essential services such as PrEP, because even where PrEP policies exist, the criteria for eligibility under national laws and policies can be complex, sometimes excluding high-risk populations. This is concerning given the significant scientific advancements made in the past few decades. And there is no progress if there is no progress for all—these advancements should benefit everyone.

Our recent analysis of the effects of criminal and protective laws on 95-95-95 outcomes revealed that countries with laws criminalizing key populations experienced lower levels of HIV status knowledge and viral suppression compared with those without such laws.⁵ Conversely, nations with protective laws on nondiscrimination, human rights, and gender-based violence showed significantly better outcomes in HIV status awareness and viral suppression.

AJMC: What would you like to see prioritized in this area under a new presidential administration?

Srivatsan: The incoming administration will build on the modest progress made over the past decade toward ending AIDS. Domestically, I hope to see a focus on expanding access to PrEP, including newer injectable formulations; combating stigma, discrimination, and violence faced by people living with HIV and key populations through effective messaging; and advancing equality and safety for transgender Americans.

Globally, US efforts to end AIDS have been significantly marked by The United States President's Emergency Plan for AIDS Relief (PEPFAR), which has saved over 25 million lives through its programmatic initiatives. It is crucial to continue US global leadership and build on the 20-year legacy of PEPFAR. Maintaining funding remains essential, particularly in the context of pandemics and climate change. Additionally, reimagining PEPFAR programs to emphasize sustainability in the AIDS response and strengthening the capacity of national governments and civil society to manage and lead their own HIV programs, I hope will be key priorities.

AJMC: Can you tell us about your presentation at AIDS 2024 and the roles and contributions of CSOs in the global response to HIV/AIDS?

Srivatsan: CSOs has played a crucial role in the global HIV response, and the progress we’ve achieved so far would simply not have been possible without their contributions. They are nonstate, not-for-profit entities that advocate for and represent the interests and needs of their communities. They vary in size, governance structures, and functions, and are typically regulated by established frameworks that govern their national registration. The scope of their operations is often influenced by national policies, which affect how freely and effectively they can pursue their objectives and address the needs of their communities.

CSOs engender trust within their communities and can reach marginalized groups where states and other actors cannot, and are therefore critical to reducing inequalities associated with the HIV/AIDS pandemic. Their active participation and engagement in the HIV response has been critical for (1) governance and decision-making, where they represent and voice the needs of the communities at the decision-making table; (2) driving service delivery; and (3) demanding accountability from their governments and policy actors.

In my presentation at AIDS 2024, we explored the effect of national laws that dictate whether CSOs have operational freedom and domestic funding on the HIV/AIDS response. More specifically, we measured 2 specific policies. First, we measured social contracting and if there was an existing social contracting policy for financing nongovernmental organizations (NGO)-/CSO-provided services. Then we measured civil society freedom and if NGOs/CSOs (including those that work with key populations) are able to register, seek funding, and operate freely under national law. Countries that had both in place were coded as adopted, countries that had only 1 were coded as having made partial progress or partially adopted, and countries that had neither in place were coded as not adopted.

Our analysis of legal trends and adoption rates from 2017 to 2023 revealed a significant increase in the number of countries implementing social contracting policies. However, despite some progress and setbacks in the adoption of civil society freedom policies, 50% of countries still do not grant operational freedom to civil society organizations, indicating there is much work left to be done.

Further, our correlation and regression analysis showed a strong positive relationship between civil society freedom policies and increased awareness of HIV status. Civil society groups and NGOs are instrumental in linking people with HIV services, and therefore we would expect to see an impact on HIV status awareness as reflected in our findings here. However, although there has been a rise in the adoption of social contracting laws over the past 8 years, these laws alone do not significantly enhance awareness of HIV status as our results indicate. To fully realize the benefits of community-led HIV services and improve HIV outcomes, it is critical to have laws that ensure both social contracting and civil society freedom, as they work together synergistically. Importantly, our analysis shows that it’s critical to recognize the fundamental role that law plays in achieving the 95-95-95 goals.

AJMC: This study focused on 194 countries from 2017 to 2023. Can you explain why you chose these countries and these years for your data analysis?

Srivatsan: Since 2017, the Policy Lab has monitored 33 indicators (covering 52 policies) across 194 countries annually, shortly after many of the normative guidelines related to our issues/indicators were established or updated. As these guidelines evolve, we revise our measures and coding to reflect what it means for countries to have "adopted" specific laws or policies.

For this analysis, we concentrated on countries (from the 194) where data on the specific legal and policy measures were available based on our research. Additionally, we used the most recent estimates from UNAIDS, which informed the timeframe for our regression analysis.

AJMC: Are there any next steps planned for this research in tracking policy adoption on national and global scales?

Srivatsan: At the HIV Policy Lab, we will be continuing to track civil society–related measures in the coming years. As for this specific research I presented on at AIDS2024, we are currently conducting some multivariate regressions, adjusting for variables such as Gini and HIV prevalence among others. We are excited with our findings so far, and very much look forward to be able to disseminate and publish the research this year.

References

1. 90-90-90: treatment for all. UNAIDS. Accessed September 30, 2024. https://www.unaids.org/en/resources/909090

2. Reaching the 95-95-95 targets: the importance of multi-stakeholder collaboration. International AIDS Society. Accessed September 30, 2024. https://www.iasociety.org/sites/default/files/CPP/IAS-CPP-Key-considerations.pdf

3. Mukherjee S, Srivatsan V, Lamontagne E, Kavanagh MK. Are countries allowing communities to lead? The global landscape of national civil society laws and their association with HIV 95-95-95 indicators. Presented at: AIDS 2024; July 22-26, 2024; Munich, Germany. Abstract 12437. https://programme.aids2024.org/Abstract/Abstract/?abstractid=12437

4. Global HIV policy lab report - progress and the peril: HIV and the global decriminalization of same-sex sex. HIV Policy Lab/O’Neill Institute. November 13, 2023. Accessed September 30, 2024. https://www.hivpolicylab.org/publications/global-hiv-policy-lab-report

5. Kavanagh MK, Agbla SC, Joy M, et al. Law, criminalisation and HIV in the world: have countries that criminalise achieved more or less successful pandemic response? BMJ Glob Health. 2021;6(8):e006315. doi:10.1136/bmjgh-2021-006315