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After being diagnosed in April in his home city of Edinburgh , Rowe met men on gay dating app Grindr and had sex with eight of them in Brighton , East Sussex , between October that year and February His six-week trial heard he embarked on a cynical and deliberate campaign to infect men with HIV, refusing treatment and ignoring advice from doctors. When they refused he tampered with condoms, tricking them into thinking he was practising safe sex.
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He told jurors he believed he had been cured of the virus by the time he moved to Brighton, having adopted the practice of drinking his own urine as a treatment, supplemented with natural remedies, including oregano, coconut and olive leaf oils. Many told how they had considered suicide, having suffered physical and psychological damage, needing to take daily medication. I would rather he had murdered me than left me to live my life like this. This was a deliberate campaign to infect multiple men with a serious life-threatening and life-changing disease such that it falls outside the sentences envisaged by the [sentencing] guidelines.
Those who live with HIV have good and high life expectancies. In a study by Ribakare et al. Furthermore, The primary focus was to scale up HIV services by setting specific goals with measurable outcomes [ 15 ]. Other low-income countries can have similar successes so long as they focus resources to the appropriate targets and outcomes they see fit for their situation. This could mean first setting short-term goals to achieve eventual long-term goals. Another Rwandan study evaluated the impact community-based health insurance and performance-based financing programs had on health centers in Rwanda that provide key HIV services.
Furthermore, centers that were incentivized by performance-based financing were also able to improve upon PMTCT [ 18 ].
Both Rwanda and Malawi are thus great models for other countries of similar economic status. Overall, since all above-described studies were observational in nature, biases exist namely confounding, selection and information. Two studies [ 13 , 18 ] had a small sample size raising a potential for selection bias. However, partner notification programs that reported successes with ART initiation or linkages to care were not highlighted, suggesting that additional attention is required to showcase successful programs in these areas.
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Implementation of a policy also requires infrastructural changes. For instance, part of the success of the US national strategy is attributed to the Affordable Care Act. This Act requires that insurance coverage includes HIV testing and direct linkages to care. Furthermore, HIV positive men who have sex with men are eligible for further coverage to cover costs of treatment.
The studies in our review from high income countries did not capture policies or national programs targeting viral suppression or retention in care. Three countries that have met these goals each have a publicly funded universal health care system, which potentially plays a major role in achieving the targets. Sweden, in particular, also implemented an education program to educate people who were diagnosed with HIV.
Furthermore, HIV-positive individuals are required to disclose their HIV status to any sexual partners or they risk imprisonment. In countries with a comparable cultural belief system, perhaps similar policies would be promising. In all these countries, advocacy has been a significant component of their policy implementations.
Specifically, in Kazakhstan, policies that focus on collaborations with providers to minimize consequences associated with disclosure of sero-status are in place [ 20 ]. It aims to conduct information campaigns and provide condoms to all illegal sex workers; rather than stigmatize them, the program sought to provide them with avenues to practice safe sex [ 21 ]. Furthermore, these three middle-income countries Romania, Kazakhstan, Thailand all have a universal healthcare system.
It might be significant to consider the successes while keeping this context in mind. Effective MIC initiatives are similar to the efforts the U. These efforts have shown great potential and findings from studies such as these further strengthen the positive direction we are heading towards achieving the targets by LICs require concerted efforts regarding all three aspects, namely, HIV testing, linkage and retention in care.
Although testing rates have increased, successes in linkages to care remain a distant dream. Malawi and Rwanda have demonstrated successes in testing rates through implementation of a policy for decentralized testing [ 18 ]. This allows for small but densely populated countries to have better access to testing and care. This approach shows tremendous promise and should be implemented in neighbouring countries.
The Rwandan National Program employed a multi-sectoral response where they looked at specific issues within their care cascade and created targets accordingly. Their primary focus was to scale up HIV services by establishing specific goals with measurable outcomes [ 15 ]. Similarly, other LICs can experience successes comparable to Rwanda and Malawi, but they should be able to target their resources to achieve outcomes and targets as they see fit to their situation. This could mean setting short-term goals to achieve eventual long-term goals.
Interestingly, the number of papers that reported country-level programs and policies were few. Although only eight interventions have come to light during our review of the literature, it is imperative to learn from these since they highlight innovative ways to engage people living with HIV into the cascade of care in its entirety. While there are indeed many policies in place, there remains a lack in procuring data in published peer reviewed literature.
Despite our exhaustive search, we could only find a few studies with good data on policies. This review offers a snapshot of successful programs and we plan to follow up on an extensive analyses of UNAIDS database alone, as a second step. There are a number of factors that determine the success of policy and the mere existence of policies does not guarantee success.
Hence reporting is sometimes misleading and ineffectual. The basic premise of this review is that in the identified countries under review, critical policies were created, implemented and enforced, and this lead to successful programs. There are some caveats to consider while interpreting these findings. Across income levels, the literature has made it evident that a multipronged approach connecting programs and stakeholders via expanded testing, linkage, and retention in care services, is necessary.
These programs have to be nested within the social or private health care systems in place in any country. Funded programs that are well supported by local governments have shown greater success and sustainability and have led to control of HIV. Although it seems clear that policies that enforce same-day diagnosis help improve linkage to care, it is essential to temper all these findings with caution.
For linkage and retention metrics are two separate entities, and for control and elimination we need to have data on both to understand the reality of the HIV epidemic in the country. A common theme of success across countries of all income levels was implementation of policies. In high-income countries, policies were enforced and followed, demonstrating in all the studies we evaluated, the UNAIDS targets were met.
In order to meet the targets, it was key for their policies to be well documented, have the required infrastructure, and be innovative at each step of the cascade of care. In particular, the successful policy interventions of Rwanda and Malawi should be exemplified and could serve as a model for a successful implementation across similar low-income settings.