Laura Ferguson

The clinical logics of TasP shaped PEPFAR’s latest strategic initiative to achieve ‘epidemic control’ including the organisation’s use of metrics for evaluating performance, and decisions for allocating funds to specific programs and countries. TasP was conceptualised as an ‘evidence-based’ solution for effectively treating and preventing HIV, which could be consistently measured and reported on, however its ability to produce the right kinds of evidence remained abstract and hypothetical. The effects of TasP have also been evident in the budget since PEPFAR launched the strategy to achieve ‘epidemic control’. Whereas under previous initiatives to ‘lead to the global response’ to the epidemic, PEPFAR supported a wider variety of program areas, including by strengthening health systems, under the strategy of epidemic control PEPFAR has prioritised treatment programs over and above all others. TasP also justified disproportionate spending on a subset of countries. By adopting the clin...

What little data on transgender healthcare is available often focuses on transgender people's negative experiences in accessing healthcare. However, no research has been conducted that illustrates where gender-affirming hormone therapy, one part of transgender-specific medical care, is available. Without these data, large scale research to discern patterns of availability of and access to gender-affirming medical care is nearly impossible. Community-based organizations, and even trans individuals themselves have constructed repositories and databases of healthcare providers to inform other care seekers where they can access transition-related care providers, but their data are often incomplete, and usually formatted to be user-facing rather than streamlined for research purposes. To fill this gap, this article outlines the methodology for the construction of a spatial database of providers of gender-affirming hormone therapy for transgender people in the US, which is available on GitHub, created from existing community-based resources and the accompanying verification process. The completeness of the database is tested via comparison to data from the US Transgender Survey in which respondents reported travel distance to access transgender-specific care providers. The database accounted for all but 7.5% of respondents who may have accessed unknown facilities based on self-reported travel distance. Results indicate that existing methodologies for database construction regarding healthcare providers are difficult to apply when working with transgender-specific medical care and that tests for replicability and validation often take for granted the wide availability of relevant data and information. While the database unto itself can only demonstrate where care is available, it will enable future research into why these geographic patterns in care availability exist. Finally, the methodology can be replicated to produce databases for other kinds of specialized or politicized medical care such as abortion, gender-affirming surgery, or HIV treatment.

Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers ’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initi...

Background All around the world, the paralegal program prepares members of marginalized communities to face the legal system. Having a common background with their clients and being capable of conducting flexible work, paralegals’ role moves beyond enlarging the beneficiaries of legal aid to addressing intersectional issues around health-related rights. This study assesses the health and other impacts of paralegals recruited by Lembaga Bantuan Hukum Masyarakat (LBHM), a human rights organization which provides legal assistance and operates in Jakarta, Indonesia. The positive results these paralegals can bring in the specific context can contribute to the development of community-based paralegals elsewhere. Methods This mixed methods research was carried out in 2016-2018. In 2016, a quantitative survey was administered to LBHM-trained paralegals and a sub-set of paralegals who completed the survey were then also interviewed. Quantitative data were analysed using SPSS, and, for the qu...

IntroductionThere is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.Methods and analysisBuilding on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types...

The government of The Gambia is implementing the Maternal and Child Nutrition and Health Results Project (MCNHRP) to increase the use of community nutrition and primary maternal and child health services. In collaboration with the government, the World Bank is conducting an impact evaluation to assess the project’s impact on key aspects of maternal and child nutrition and health. The MCNHRP baseline evaluation was conducted between November 2014 and February 2015. Quantitative and qualitative data were collected on three regions: Central River Region (CRR), North Bank Region-West (NBR-W), and Upper River Region (URR). Its purpose was to establish a baseline against which project performance will be assessed in the future. This technical brief summarizes the baseline report findings related to maternal health and nutrition.

IntroductionThe COVID-19 pandemic and its control measures have impacted health and healthcare provision in various levels. Physical distancing measures, for instance, may affect sexual health, impacting access to HIV prevention supplies and changing sexual behaviour, as well as mental health, increasing feelings of unsafety and weakening community support ties. These effects can be worsened among socially marginalised groups, such as men who have sex with men (MSM) and transgender women (TGW). Brazil is among the countries most affected by COVID-19 in the world, where control measures have been inconsistently implemented. We aim to investigate the effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult MSM and TGW in Brazil.MethodsConvergent mixed-method prospective cohort study, nested in two ongoing HIV pre-exposure prophylaxis (PrEP) cohorts in Brazil, named PrEP1519 and Combina. Participants will be invited to answer, at baseline and after 6 mon...

This paper offers a critical overview of social science research presented at the 2014 International AIDS Conference in Melbourne, Australia. In an era of major biomedical advance, the political nature of HIV remains of fundamental importance. No new development can be rolled out successfully without taking into account its social and political context, and consequences. Four main themes ran throughout the conference track on social and political research, law, policy and human rights: first, the importance of work with socially vulnerable groups, now increasingly referred to as "key populations"; second, continued recognition that actions and programs need to be tailored locally and contextually; third, the need for an urgent response to a rapidly growing epidemic of HIV among young people; and fourth, the negative effects of the growing criminalization of minority sexualities and people living with HIV. Lack of stress on human rights and community participation is result...

Background Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays. Methods A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear...

There is growing recognition in the health community that the legal environment-including laws, policies, and related procedures-impacts vulnerability to HIV and access to HIV-related services both positively and negatively. Assessing changes in the legal environment and how these affect HIV-related outcomes, however, is challenging, and understanding of appropriate methodologies nascent. We conducted an evaluation of a UNDP project designed to strengthen legal environments to support the human rights of key populations, in particular LGBT populations, women and girls, affected by HIV in sub-Saharan Africa. We analyzed data on activities designed to improve legal environments through a systematic document review and 53 qualitative interviews. The project made substantial strides towards legal change in many places, and examples provide broader lessons for work in this area. Two core pillars appear fundamental: a government-led participatory assessment of the legal environment, and b...

HIV represents not only an unprecedented pandemic but also a site of civil society innovation. In the midst of devastation, activists in sub-Saharan Africa are progressing from traditional forms of health advocacy to strategies that engage human rights principles, techniques, and language. Employing a comparative case-study approach, Resilience and Contagion considers the efforts of nine local civil society organizations in Ghana, Uganda, South Africa, and Botswana. Kristi Heather Kenyon examines who adopts rights-based discourse and why, arguing that leadership, individual beliefs, and structure all play a critical role in framing advocacy. Beyond changing laws or policies, the most important impact of promoting the rights of people living with HIV, she attests, is that it enables individuals to interact with health services from a position of resilience, strength, and empowerment. This book delves into discourse at the juncture of human rights, social theory, and global health, prompting significant and relevant discussion on advocacy’s evolution in the region of the world hit hardest by the HIV pandemic. Drawing on 145 interviews, extensive participant observation, and fascinating document analysis, Resilience and Contagion foregrounds the voices of civil society actors who have conducted the most vocal, widespread, and innovative health advocacy to date.

Legal empowerment is increasingly recognized as a key approach for addressing socio-structural determinants of health and promoting the well-being and human rights of vulnerable populations. Legal empowerment seeks to increase people's capacity to understand and use the law. However, limited consensus remains on the effectiveness of legal empowerment interventions in optimizing health outcomes. Leveraging a meta-narrative approach, we synthesized literature describing how legal empowerment interventions have been operationalized and empirically studied with respect to health determinants. The studies included here document diverse legal empowerment approaches and highlight how interventions changed the context surrounding the health of vulnerable populations. The absence of robust conceptualization, operationalization, and measurement of the risk contexts in which legal empowerment approaches operate limits the clarity with which interventions' impact on health can be ascert...

Adolescents living with HIV experience worse HIV care outcomes compared to adults, especially during transition from pediatric to adult care. However, data regarding adolescents are limited. This paper describes and compares characteristics of male and female adolescents living with HIV preparing for transition from pediatric to adult care in Cambodia. This cross-sectional study was conducted in August 2016 among 328 adolescents aged 15-17, randomly selected from 11 antiretroviral therapy (ART) clinics. Data were collected using a structured questionnaire, and descriptive analyses were conducted to compare characteristics of male and female adolescents. Of total, 55.2% were male, and 40.8% were living with parents. Majority (82.6%) got HIV infection from their mothers. Overall, adolescents had received ART for an average of 8.4 years, and HIV care for 9.5 years. Additionally, 82.4% were on first line ART regimen. Mean CD4 count from the most recent test was 672 cells/mm, and viral l...

Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility,...

This roundtable discussion is the result of a research symposium entitled In Transition: Gender [Identity], Law & Global Health where participants took up the challenge to engage with the question: What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across the globe? The barriers to overcome are fierce, and include not only lack of access to health services and insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn. Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and political contexts in which people are situated, with social, psychological, medical, and legal gender affirmation as a key priority shap...

The last few years have seen a rise in the number of global and national initiatives that seek to incorporate human rights into public health practice. Nonetheless, a lack of clarity persists regarding the most appropriate indicators to monitor rights concerns in these efforts. The objective of this work was to develop a systematic methodology for use in determining the extent to which indicators commonly used in public health capture human rights concerns, using contraceptive services and programmes as a case study. The approach used to identify, evaluate, select and review indicators for their human rights sensitivity built on processes undertaken in previous work led by the World Health Organization (WHO). With advice from an expert advisory group, an analytic framework was developed to identify and evaluate quantitative, qualitative, and policy indicators in relation to contraception for their sensitivity to human rights. To test the framework's validity, indicators were rev...

Global health education has been expanding rapidly and several universities have created an undergraduate major degree (bachelor's degree) in global heath or global health studies. Because there are currently no national guidelines for undergraduate degrees in global health, each of these programs was developed along individual lines. To guide the development of future global health majors, we conducted a systematic review of undergraduate majors in global health. We identified eight programs and invited program directors or representatives to a symposium at the Consortium of Universities for Global Health 2016 conference to review their existing undergraduate major in global health and to discuss lessons learned and recommendations for other colleges and universities seeking to develop undergraduate degrees in global health. We noted significant diversity among the existing programs in terms of required courses, international field experiences, and thesis research projects. In ...

Over the last four decades, international health and global health, terms often used interchangeably, have been gradually acquiring distinct meanings. Specifically, international and global health initiatives can increasingly be understood to be grounded in different motivations, to employ different mechanisms, and to be subjected to different modes of governance.

The incorporation of human rights in health policy and programmes is known to strengthen responses to health problems and help address disparities created or exacerbated by illness yet this remains underexplored in relation to non-communicable diseases (NCDs). Aiming to understand existing synergies and how they might be further strengthened, we assessed the extent to which human rights are considered in global NCD policies and strategies and the degree of attention given to NCDs by select United Nations human rights mechanisms. Across global NCD policies and strategies, rhetorical assertions regarding human rights appear more often than actionable statements, thus limiting their implementation and impact. Although no human rights treaty explicitly mentions NCDs, some human rights monitoring mechanisms have been paying increasing attention to NCDs. This provides important avenues for promoting the incorporation of human rights norms and standards into NCD responses as well as for accountability. Linking NCDs and human rights at the global level is critical for encouraging national-level action to promote better outcomes relating to both health and human rights. The post-2015 development agenda constitutes a key entry point for highlighting these synergies and strengthening opportunities for health and rights action at global, national and local levels.

This roundtable discussion is the result of a research symposium entitled In Transition: Gender
[Identity], Law & Global Health where participants took up the challenge to engage with the question: What
will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across
the globe? The barriers to overcome are fierce, and include not only lack of access to health services and
insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn.
Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are
needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The
SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and
political contexts in which people are situated, with social, psychological, medical, and legal gender
affirmation as a key priority shaping any intervention. Bringing together nine diverse yet complementary
perspectives, our intent is to jumpstart a global and multigenerational conversation among transgender
activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians and all
other stakeholders to help think through priority areas of focus that will support the needs, rights, and health
of transgender populations. Making the changes envisioned here is possible but it will require not only the
advocacy, policy, programmatic and research directions presented here but also struggle and action locally,
nationally, and globally.

This report demonstrates plausible evidence that a human rights-based approach contributes to health improvements for women and children. It shows that the constitutional and international right to health can be translated into improved health services and health status through laws, policies and programmes that are explicitly shaped by health rights principles, such as accessibility, quality, participation and accountability. Applying human rights to women’s and children’s health policies and other interventions not only helps governments comply with their binding national and international obligations but also contributes to improving the health of women and children

To explore the accuracy of routinely collected prevention of mother-to-child transmission of HIV (PMTCT) coverage data in Kenya. In case studies at two government hospitals, the authors reviewed national reporting guidelines, interviewed nurses and undertook a retrospective analysis of routine hospital data from antenatal care, maternity and HIV services from January 2009 to June 2010. Each woman attending these services was given a unique study number to enable analysis of her recorded use of PMTCT services across different hospital visits. These data were compared with the hospitals' monthly PMTCT reports to the district. Where a woman made more than one visit, PMTCT drug provision could be reported multiple times for the same woman, and women known to be HIV positive prior to pregnancy were omitted from the denominator of PMTCT coverage calculations. Practices for reporting data on maternal PMTCT prophylaxis provision varied in the two hospitals. According to the study data, ...

To quantify attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services in low- or middle-income countries and to explore the reasons underlying client drop-out by synthesising current literature on this topic. A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000-2010. Only studies meeting pre-defined quality criteria were included. Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub-Saharan Africa. The pathway between testing HIV-positive in pregnancy-related services and accessing long-term HIV-related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38-88% of known-eligible women. Providing 'family-focused care', and integrating CD4 testing and HAART provision into prevention of mother-to-child HIV transmission services appear promising for increasing women's uptake of HIV-related services. Individual-level factors that need to be addressed include financial constraints and fear of stigma. Too few women negotiate the many steps between testing HIV-positive in pregnancy-related services and accessing HIV-related services for themselves. Recent efforts to stem patient drop-out, such as the MTCT-Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services.