Introduction
In recent years, the science of ending AIDS has advanced rapidly—demonstrating effective biomedical and structural interventions. Evidence on treatment as prevention, pre-exposure prophylaxis (PrEP), newer antiretroviral medicines and many other examples have rapidly changed what constitutes the best practices.1–4 Research has also shown how best to deliver interventions—differentiating service delivery, making self-testing available, eliminating criminalisation of key populations.5–8 Despite the progress of science, however, the global AIDS response is not on track to reach globally agreed targets.9 This can be understood, in part, through the gap between science and policy, which remains significant in many contexts.
Governments bring their understanding of best practices to scale through law and policy-making. Scholars have described the ‘legal determinants’ of health and the ‘triangle of rules’ that define health systems.10 11 In the global AIDS response, a wide range of mechanisms have been created to disseminate scientific information and support translation into laws and policies, including technical guidance from UNAIDS and the WHO and funding for implementation through mechanisms like the Global Fund to Fight AIDS, tuberculosis (TB) and Malaria. Nonetheless, data described below show substantial policy differences persist between countries. A small but growing literature in legal epidemiology shows an empirical link between laws and policies and health outcomes.12 For example, eliminating parental consent policies has been linked to increased rates of HIV testing.13 Countries where sex work is not criminalised have significantly lower HIV prevalence among sex workers.14 Medical, mining and criminal policies have been linked to TB rates.15 And countries with a constitutional right to health have better health outcomes than those without.16 Studies have also explored the drivers of HIV policy choice. The degree of ethnic cleavages and time leaders expect to be in power have both been shown to drive policy choice in countries.17 18 Existing research on the impact of policy represent only a small fraction of HIV-related policies for which we might expect variation to matter—from which antiretrovirals are used and whether PrEP is available to people facing HIV risk to rights protections and policies around human resources for health. Despite the centrality of policy environments to HIV outcomes, there is no global, longitudinal dataset that comprehensively measures variations in HIV laws/policies across countries.
The ability to monitor state behaviour has become a critical tool in international governance.19 Understanding policy choices in other countries reveals private information that can help governments make better informed decisions.20 Indicators that provide for comparison between states also constitutes an exercise of ‘social power’, with the potential to change important policies and increase the ability of domestic actors to hold leaders accountable to international standards.21 22
We describe a new dataset, index and research/advocacy platform which fills this information gap by rigorously tracking HIV policies adopted at the country level longitudinally. A public dataset and visualisation tool, the HIV Policy Lab, are available online at www.hivpolicylab.org and track 33 key indicators of HIV-related law and policy across 194 countries over multiple years. Policies are benchmarked against global norms and classified by alignment to these norms. Here, we describe the tool and initial findings about the substantial degree of variation in HIV-related policies between countries, surprising after decades of policy dissemination efforts. Researchers, civil society, policy-makers, funders and national and international officials can use this dataset to better understand the policy environment and as a tool for law and policy reform. There are also important unanswered questions about the impact of policies and how policies work differently in different contexts. What works in a randomised controlled trial often cannot be simply translated into national-level policy.23