In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.
We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS’ definition of ‘community-led’ and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.
Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.
Conclusions and recommendations
Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.
Citation: Ayala G, Sprague L, van der Merwe LL-A, Thomas RM, Chang J, Arreola S, et al. (2021) Peer- and community-led responses to HIV: A scoping review. PLoS ONE 16(12): e0260555. https://doi.org/10.1371/journal.pone.0260555
Editor: Petros Isaakidis, Médecins Sans Frontières (MSF), SOUTH AFRICA
Received: August 19, 2021; Accepted: October 18, 2021; Published: December 1, 2021
Copyright: © 2021 Ayala et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Communities affected by health emergencies have a long history of acting to promote and protect the wellness and rights of their members, a fact that has been generally accepted in the public health field [1–3]. Communities are recognized as a ‘critical catalyst’ to achieving the health-related targets in Sustainable Development Goal (SDG) 3 . Stakeholders at all levels in the HIV sector are also increasingly recognizing, with some resolve, that communities living with and disproportionately affected by HIV must now play an even more prominent role in the global response [5–8]. This recognition comes with the realization that the world is off-track to meet global HIV targets [9, 10] as evidenced by current epidemiologic trends in HIV incidence, prevalence, viral suppression, and AIDS deaths, especially among socially marginalized populations [11, 12]. Underlying these trends are persistent inequities in access to and funding for HIV prevention, care, and treatment, which are experienced by people living with HIV, young women and girls (especially in Sub-Saharan Africa), gay and bisexual men, people who use drugs, prisoners, sex workers, and transgender people (key and vulnerable populations) . Unabated stigmatization, discrimination, violence, and criminalization directed at key and vulnerable populations fuel inequities, undermining traction made towards achieving global targets [14–25]. Over 60% of all new HIV infections worldwide are among key populations, which reflect said inequalities .
The COVID-19 pandemic and its aftermath further threaten the gains made in a global HIV response that is already off-track [26, 27]. People living with HIV are more likely than the general population to become severely ill with COVID-19 and more likely to die if hospitalized . Investment in comprehensive HIV services, which is at present contracting , will likely shrink further as the world struggles to fund its response to the COVID-19 crisis. Moreover, key and vulnerable populations worldwide continue to be excluded from national social protection schemes, undermining critical and hard-fought gains in the fight against AIDS .
An international commitment to people-centred systems for health was enshrined in the United Nations (UN) 2021 Political Declaration on HIV and AIDS (“the Declaration”), building on strong commitments in the 2016 Political Declaration to ensure 30% of HIV service delivery would be community-led by 2030 . In the 2021 Declaration, UN member States committed, as appropriate in the context of national programmes, to increase the proportion of HIV services delivered by community-led organizations to reach 30% of HIV testing and treatment services, 80% of HIV prevention services for high-risk populations, and 60% of programmes to achieve societally enabling environments by the year 2025 [31–33]
However, commitments made in 2016 have not yet translated into scaled-up coverage of community-led responses to HIV, despite donor recognition of the integral role communities can and do play . The 2021 commitments are likely to see the same fate without concerted action. There are several reasons for this. First, the 2016 Declaration failed to clearly define what constitutes a ‘community-led’ programme, and until recently, the HIV sector had not come together to develop a shared definition of the term. As a result, activities led by people living with and disproportionately affected by HIV at the grassroots level have often been conflated with those led by national agencies or by international non-governmental organizations (INGOs), which may physically base themselves in communities, but that may not in fact have representatives from affected communities in senior management positions or on governance boards. This confusion over what legitimately constitutes a ‘community-led’ programme obfuscates responses at the local level, makes comparisons across studies challenging at best, and complicates monitoring, reporting, and analysis of progress towards commitments in the Declaration across regions.
Second, as previously mentioned, although there is recognition by governments, donors, and implementers of the need for community-led responses, the evidence to support them has lagged. This is because community-led organizations and networks, those with the greatest interest in documenting the effectiveness of their responses, seldom have the resources to conduct large-scale research . Further, community-led studies might be critiqued as biased or conflicted or dismissed if experimental study designs, e.g., randomized control trials, which may be more appropriate for biomedical research, were not used to test for efficacy [36–39]. And because the HIV sector has been operating without a generally accepted definition, quantitatively measuring the comparative advantages of community-led responses is difficult to achieve.
Third, the global HIV response continues to operate with a “democratic deficit”. In other words, despite the expressed commitment to the Greater Involvement of People Living with AIDS (“the GIPA Principle”), a commitment which was explicitly mentioned for the first time in the 2021 Declaration, people living with and most affected by HIV are often not meaningfully and equitably engaged in decision-making, planning, financing, or implementing service delivery [32, 40–43]. As a result, funding intended for community-led organizations has sometimes been captured by programmes that in practice fail to consult or meaningfully partner with the communities they serve. What some authors have called the biomedicalization of the HIV response has further complicated decision-making regarding the various roles communities can and should play, including in service delivery .
Clarifying terminology and examining the evidence for greater coverage of community-led responses are of urgent importance. This article presents a definition for community-led responses developed in 2019 during a 2-day expert consultation convened by the Joint UN Programme on HIV/AIDS (UNAIDS) and endorsed by a diverse group of government and civil society experts in late 2020. We then present the results of a scoping review that examined and synthesized research focused on community- and peer-led HIV responses published in the past 40 years. Our aim is to strengthen the case for expanded coverage of community-led HIV responses, supported by a clear definition, peer-reviewed evidence, and a set of recommendations for decision makers and funders.
Community experts’ meeting to define ‘community-led’
Recognizing the challenges in monitoring progress towards the commitments in the Declaration and the need for a clearer definition of “community-led”, the UNAIDS Secretariat (JAI, LS) convened a 2-day consultation with community experts in June 2019, to suggest an operational definition of community-led responses to HIV, at the request of its Programme Coordinating Board (PCB). A subsequent consultation was planned to define ‘woman-led’, building from the definitions developed during the 2019 Expert Consultation in Montreux, Switzerland. The meeting was postponed because of the COVID-19 pandemic.
Experts who participated in the June 2019 consultation included representatives from the leading global transnational networks of people living with HIV and key populations, who together represent hundreds of national and regional community-led organizations. They included: the International Community of Women Living with HIV (ICW), Global Network of People Living with HIV (GNP+), Global Network of Young People Living with HIV (Y+), International Treatment Preparedness Coalition (ITPC), Global Network of Sex Work Projects (NSWP), International Network of People Who Use Drugs (INPUD), Innovative Response Globally to Transgender Women and HIV (IRGT), MPact Global Action for Gay Men’s Health and Rights, TB People (the network of people living with tuberculosis), Gestos–HIV, Communication and Gender, representatives from the NGO delegation to the UNAIDS PCB, and members of the Communities Delegation to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (“the Global Fund”). Staff members from the Global Fund and the U.S. Centres for Disease Control and Prevention were also in attendance. The meeting participants recognised the priorities of people living with HIV, including women and young people living with HIV, gay men and bisexual men, people who use drugs, sex workers, and transgender people as an integral part of their consensus-building deliberations.
Experts began their meeting with a review of findings from a global survey undertaken by UNAIDS just prior to the consultation. The survey, offered in four languages (English, French, Spanish, and Russian), was designed to canvass diverse definitions for ‘community’ and to identify core elements of ‘community-led’ and ‘key population-led’ in the context of the HIV/TB response. There were 475 completed surveys from respondents, representing 97 countries. Experts also studied policy documents and discussed ways to use the definition to monitor support and funding for critical community-led programmes. The meeting resulted in working definitions for the terms “community-led organizations”, “community-led responses”, “key population-led organizations”, and “key populations-led responses”. Meeting participants defined community-led responses as:
…actions and strategies that seek to improve the health and human rights of their constituencies, that are specifically informed and implemented by and for communities themselves and the organizations, groups, and networks that represent them.
Community-led responses are determined by and respond to the needs and aspirations of their constituents. Community-led responses include advocacy, campaigning and holding decision-makers to account; monitoring of policies, practices, and service delivery; participatory research; education and information sharing; service delivery; capacity building, and funding of community-led organizations, groups, and networks. Community-led responses can take place at global, regional, national, subnational, and grassroots levels, and can be implemented virtually or in person.
Not all responses that take place in communities are community-led.
Subsequent to this expert consultation, the proposed definitions of community-led responses and community-led organizations were vetted with two multistakeholder working groups for further input, resulting in minor changes to wording [44, 45]. The careful distinctions made in the definitions, initially developed by community experts and further refined through the multistakeholder processes, are important and include a clear emphasis on the meaningful inclusion of people living with HIV, gay and bisexual men, people who use drugs, sex workers, and transgender people in designing, implementing, managing, and evaluating programmes. Similar distinctions have been made by other groups . All four definitions are presented in Table 1. The definition of community-led responses presented here informed the inclusion/exclusion criterion used in the scoping review, which focused on identifying evidence for the impact of community-led programmes on HIV outcomes.
The scoping review began as a discussion between co-authors (GA, LS, JAI) and principal stakeholders involved in a technical consultation on social enablers as part of the UNAIDS-led 2025 Target Setting process. Building on this work, we conducted a literature search focused on research published between January 1982 (six months after the first cases of HIV/AIDS were published in the United States of America) and February 2021 . The overall goals of this scoping study were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to immediately inform policy, practice, and research . We followed a five-step procedure that involved articulating a research question, identifying relevant studies, selecting studies, charting the data, and summarizing the findings [49–51]. Our study was guided by the question: What evidence is there about the comparative advantages of community-led HIV responses?
Data sources and search strategy
The search was conducted on February 20, 21, and 22, 2021 by the lead author (GA) using PubMed/MEDLINE, Embase, and Web of Science. The search included articles published between January 1982-and February 2021. Due to resource limitations, we restricted the search to articles published in English and focused on HIV. We used a Boolean search strategy , which combined search terms as follows: “community led HIV” OR “peer led HIV” OR”community led AIDS” OR “peer led AIDS”.
Only titles were reviewed for the first level of screening. Second-level screening involved review of abstracts to exclude articles not relevant to the search and to remove duplicates. Studies were eligible for inclusion if they described community-led responses to HIV and their outcomes. Understanding that a common definition for community-led was absent when many studies were published, we included the search term ‘peer-led’ and evaluated each article against the criteria described in the definition developed at the Montreux consultation. Our search strategy included randomized controlled trials, quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. We excluded study protocols, feasibility studies, case studies, case reports, editorials, behavioural surveillance studies, biomedical or pharmaceutical studies, and program reports. We also excluded articles that were not HIV-related, and/or that did not describe a program or intervention that was community- or peer-led.
After review and removal of non-relevant articles and duplicates, the two lead authors (GA, LS) cross-validated selected records, with inter-rater agreement reached for 86% of retrieved publications. Inclusion and exclusion discrepancies were discussed and resolved. Full text articles were then retrieved for review after consensus was reached. All co-authors were invited to identify additional peer-reviewed articles and grey literature, which were added if they appeared relevant to the review and conformed to the inclusion criteria. The study characteristics from full articles were extracted and compiled into a single spreadsheet for additional validation and coding. Authors communicated via email to resolve any additional outstanding questions or disagreements. Simple descriptive statistics were calculated to summarize the characteristics of research and data . Other than what we describe in the methods section of this paper, no formal review protocol exists.
Search and selection of evidence
Our search yielded 279 potentially relevant records. After screening titles for relevance, 102 studies were excluded. After reviewing all abstracts remaining records for relevance, lead authors (GA, LS) then excluded another 56 articles. Sixty-two duplicate abstracts were identified and removed, leaving a total of 59 records. And after cross-validation and full text screening, 36 articles were selected. An additional 12 articles identified by co-authors and not captured by this scoping review were then added. The flow of articles in the selection process is presented in Fig 1.
Our search strategy yielded a total of 48 articles that met the inclusion criteria. Study methods and summary of findings are displayed in Table 2.
While scarce, research on community-led responses and their outcomes appears to be gaining traction in recent years. Sixty-nine percent (n = 33) of articles included in this scoping review were published in the last 10 years between 2011 and early 2021. Fifty-six percent (n = 27) took place in the global south. South Africa (n = 4) and China (n = 3) were represented in the highest number of included studies from the global south [53–79]. The United States of America (n = 9) represented the highest number of studies that were implemented in the global north [80–94]. A diverse range of focus populations were represented in selected articles. Youth, gay and bisexual men, and people living with HIV were study populations in 27%, 23%, and 16% of articles included, respectively [56, 67, 69, 72, 75, 76, 78, 81, 84, 86, 88, 89, 94–99]. Research methods also varied. Twenty-seven percent of articles reported findings from quasi-experimental studies (n = 13) [54, 57, 58, 64, 67, 70, 72, 74, 77, 80, 81, 84, 86], 23% (n = 11) from systematic reviews [62, 63, 68, 69, 75, 83, 95, 96, 98–100], 19% (n = 9) from randomized control trials [55, 59, 61, 73, 76, 87–90], and 15% (n = 7) from prospective or longitudinal studies [56, 60, 65, 78, 79, 92, 93].
A range of community-led approaches were described in the 48 articles we reviewed. Nearly half (48%, n = 23) described peer-led education or prevention interventions [54, 55, 57–62, 64–66, 70, 74, 79, 80, 82, 83, 85–88, 91, 96], of these more than half (n = 12) were focused on students or youth. Approaches in reviewed articles also include community-led testing, care, and treatment (n = 8) [56, 63, 67, 69, 73, 94, 97, 98], community mobilization, advocacy, monitoring, and human rights programs (n = 5) [53, 75, 78, 93, 100], community support groups, clubs, and mentors (n = 4) [71, 76, 89, 95], adherence programs (n = 4) [72, 77, 90, 99], community empowerment (n = 3) [68, 81, 84], and drop-in centres (n = 1) . General characteristics of studies included in this scoping study are presented in Fig 2.
Outcomes studied also varied. At the individual level, more than half of studies (58%, n = 28) reported improved prevention outcomes, i.e., condom use, sexual risk, self-efficacy, attitudes, and intentions [53–55, 57–62, 64, 66, 70, 71, 74, 79–88, 91, 93, 96, 100]. There were 8 studies that reported improved HIV treatment adherence [89, 90, 95, 99] and viral load or viral suppression [56, 72, 76, 77]. Two studies report HIV incidence as an outcome [65, 68]. Findings that community-led responses led to improvements in HIV incidence were associative. At the service level, improvements were reported in 10 studies, including in the areas of access, quality, demand, linkage to care, utilization, community-provider relationships, and coordination [63, 67, 69, 73, 75, 78, 92, 94, 97, 98]. At the societal level, the beneficial effects of community-led HIV responses reported included: increases in community engagement, mobilization, social cohesion; and improvements in institutional norms and action planning [53, 75, 78, 93, 97, 100]. Community empowerment was reported as critically important for engaging sex workers and gay and bisexual men, although its benefit was implied for other populations as well.
There were 3 studies reporting the beneficial effects of community-led HIV responses at the structural level, 2 of which are systematic reviews. Outcomes reported in this category included broadened recognition of gay men and other men who have sex with men as a priority population, secured positive influence on policy, reduced stock outs of HIV-related commodities, increased adoption of viral load testing to monitor clinical outcomes, improved access to legal aid, increased awareness of rights on the part of both rights holders and duty bearers, and improved community-government relations [75, 78, 100]. A recent systematic review that examined human rights-related interventions, found improvements in HIV-related health outcomes in addition to positive changes at the structural-level. The same review also found a small number of interventions that had no or negative influence. These failures appeared to be related to incomplete initiatives, limited dissemination, or limited enforcement of study protocols (100).
Nine studies in our scoping review reported mixed results or no differences in main outcomes measured between intervention and comparison arms [60, 64, 69, 76, 86, 89, 90, 96, 99]. Efficacy seemed to vary by study design, with no improvements reported more often when analyses were restricted to randomized control trials. Reasons given by investigators for mixed efficacy results included risk of bias, misalignment between intervention design and intervention objectives, and failure to adequately assess both the contexts in which risk behaviours occur and intervention preferences among populations for which the studied intervention was intended.
Finally, two studies, each a systematic review, reported that community-led responses were cost effective or cost saving (i.e., per patient costs associated with HIV testing and counselling, health-services, adherence clubs, and costs associated with accessing services like transportation, childcare, lost work time) [63, 69]. Cost effectiveness is likely due to the adoption of community-led models with clinically stable patients, enabling communities to deliver care and treatment sustainably, cost-effectively, and equitably in resource-limited settings. Also contributing to cost effectiveness was the adoption of community-based or -led HIV testing and counselling approaches, which were found to be less expensive than facility-based strategies.
We found strong evidence to support expanded coverage of community-led HIV responses. Our scoping review revealed more than 40 beneficial outcomes linked to community-led HIV prevention, treatment, care, support, monitoring, and advocacy. More than half were prevention-related improvements. One prospective evaluation study of advocacy, conducted across 7 countries, documented, and verified 103 positive health and social inclusion outcomes over 24 months. Other investigators have similarly documented the critical importance of community engagement and the scale-up of peer-led prevention and treatment to fast-tracking the HIV response [2, 101–103].
We found study designs varied, with only 9 randomized control trials reported in the last 40 years. This finding makes sense given that randomized control trials may be exceedingly difficult to design and implement, given the multi-faceted and complementary nature of community-led HIV responses and the challenges inherent with meaningfully engaging key and vulnerable populations . The absence of a previously agreed to definition has added to the complexity of studying community-led HIV responses. Outcomes measured also varied greatly, making it exceedingly difficult to draw comparisons between community-led approaches.
Most studies in our review took place in the global south and focused on peer-led approaches for students or youth. Five of the 15 studies that took place in the global north focused on gay and bisexual men. Studies focused specifically on people who use drugs, and transgender women represented a very small proportion of studies we examined, despite the potential benefits of community-led responses for these groups. For example, using a differentiated service delivery approach to prevention, testing, care, and treatment, delivered by and designed in consultation with men who have sex with men and transgender women, in partnership with the public health sector, can improve service coverage, reach, utilization, and retention .
Sixty percent of studies (n = 29) described more than one beneficial outcome linked to community-led HIV responses. This finding suggests that comprehensive community-led responses, especially when combined with structural level interventions, may have synergistic and simultaneous effects at more than just the individual level. This could be because programs were designed to address more than one outcome, or because when programs are community-led, clients’ needs are addressed holistically . However, beneficial structural-level outcomes, e.g., changes in repressive laws and social attitudes, were rarely reported and were of mixed effectiveness . This is not surprising given that societal and structural or legal changes operate on a longer time horizon than do traditionally measured public health outcomes and have multiple inputs, making advocacy programs more difficult to evaluate [107, 108].
Community-led HIV responses reported in the literature that we reviewed had several common characteristics that build on and reinforce the definition we used to conduct our scoping review. For example, some studies highlight the importance of empowerment and mobilization as effective strategies for engaging communities to lead HIV responses [41, 68, 93]. Relatedly, some studies underscore social cohesion as both an outcome and mediator of effective community-led HIV responses [93, 109]. Social networks might be another engine driving success. For example, understanding community-led HIV responses through a social networking lens, may shed light on how criminalized or stigmatized groups build power to influence change at the local level. This may be linked with the experience of affiliation, support, feeling valued, and making meaningful contributions to one’s community, each fundamental to social action and well-being [110–112]. Other researchers point to the importance of understanding community-led HIV responses as an iterative process that feeds back onto itself, beginning with constituency engagement, followed by alignment of adopted approaches with needs, adaptation of adopted approaches, and application of evidence gathered from monitoring and evaluation activities to influence policy changes  Also key are the inclusion of community-led responses in national AIDS plans and their funded operationalization at the local level. Bringing accountability closer to the level of service provision through community-led monitoring can increase the uptake and quality of HIV and other health services [69, 75, 78, 92, 97]. Moreover, sustained community activism for improved and sustained political commitment is vital for meeting HIV-related targets at local, national, regional, and global levels .
Together, the 48 studies we reviewed suggest comparative advantages of community-led HIV responses over facility-based, standard-of-care. Quantitative studies with comparison arms reinforce the importance of community-led prevention (i.e., HIV testing and counselling, risk reduction education and other behaviour change programs). Likewise, community-led components in treatment programs (i.e., adherence support, decentralized medication delivery) yield better service utilization as well as clinical outcomes. Our review also suggests that communities living with and disproportionately affected by HIV can effectively deliver services and influence policy. The comparative advantage of community-led HIV responses is predicated on several factors, including credibility with community members, ability to adapt to changing contexts and policy priorities, maintaining influence both within the community and at the policy level, community ownership, and iterative interactions and alliances with authorities resulting in accountability gains [31, 68, 115]. Likewise, several studies reiterated the point that having interventions that are community-based is insufficient for producing improved outcomes–interventions must be peer-led, of high quality, and possess strengthened capacity through skills training to ensure stronger, community-endorsed outcomes [57, 94, 116]. Peer-led responses are not only feasible but are also effective in producing higher service-related yields .
Formidable structural barriers to enabling community-led HIV response were repeatedly named in studies we reviewed. They include regressive laws and policies, funding constraints, and intersecting social stigmatizations, discrimination, and violence [68, 100]. Differentiated approaches to the delivery of HIV services might be a good bridge to enable expanded coverage of community-led HIV responses, especially in contexts that are hostile to key and vulnerable populations. This is because differentiated care flexibly tailors the provision of antiretroviral treatment for patients based on their acuity, greatly expanding the range of alternatives for how care occurs and who delivers it [72, 118–121].
At a time when funding for HIV is becoming more difficult given COVID-19’s detrimental impact and other competing priorities, the global HIV response needs to become more strategic in the investments it makes. Although research focused on community-led structural interventions is rare, studies we reviewed suggest that targeting social determinants shown in research to be associated with improved HIV outcomes—such as the availability of syringe programmes and comprehensive sexuality education, or removing barriers to high quality HIV and health services—have long been recognized as effective [63, 69, 75, 78, 100, 122]. Community empowerment and mobilization are also highly effective at engaging key and vulnerable populations, increasing service utilization and improving HIV-related health outcomes. They should become standard components of demand generation initiatives as well as testing, prevention, and violence mitigation programs [41, 68, 93, 123–126]. Additionally, we can become more strategic in combining community-led biomedical, behavioural, and structural interventions, and in so doing, leverage their synergistic effects . Based on our scoping review and corroborated by other researchers, we should pursue better coverage of community-led, differentiated prevention, care, support, and treatment, socio-economic impact mitigation and other non-HIV support services [72, 118, 121]. Community-led services can be optimized when conducted in tactical and supportive partnerships with healthcare providers and government officials across health sectors [127–130]. Concurrently, some investment in high impact ‘disruptive innovations’ like HIV self-testing, multi-dose ARV dispensing for both prevention and treatment, adherence clubs, and drop-in centres may also be warranted. Disruptive innovations are interventions and program approaches that are inexpensive, rapid, consumer-controlled, and can be easily delivered in and by communities [73, 131].
Limitations and strengths
There are a few important limitations to note. We restricted our scoping review to articles and reports published in English. Research published in other languages may have added to and/or validated the findings reported in this paper or might have contradicted them. Also, we used only three search engines–PubMed, Embase, and Web of Science–to conduct the article search. Other search engines may have yielded studies not included here. Finally, the limited number of published works reviewed in this scoping study, as well as the heterogeneity of research designs and outcomes reported, make it difficult to draw conclusions in many areas where community-led HIV responses might be beneficial. There is a need for more research to strengthen the evidence base undergirding normative guidance on the expanded role communities can play towards more effective and cost-efficient HIV responses. There is also a need for more studies showing the impact of community-led advocacy strategies focused on different issues across diverse contexts. In addition, research tools and protocols should be developed and made available to support community-led research in these areas.
Limitations notwithstanding, our scoping review allowed us to examine a broad and diverse range of research designs and outcomes . This was especially important given the scarcity of research focused on community-led HIV responses. Our scoping review uncovered 9 probability-based randomized control trials, which is also worth noting. Although this study design is considered the gold standard for generalizability, such studies are costly and may be unethical to implement, especially in contexts that criminalize or stigmatize key and vulnerable populations. Creative study designs that are fit-for-purpose and can be community-led are warranted . Indeed, sampling experts have advocated for innovative nonprobability sampling methods that are useful and cost-efficient, such as Internet sampling, especially in research with marginalized communities .
Findings from this scoping review offer strong support for greater coverage of community-led HIV responses given their comparative advantages. To scale-up community-led HIV responses, we must first more meaningfully engage people living with HIV, key and vulnerable populations, and fund the organizations and networks they lead. In addition, we should:
- Promote broad adoption of the definition of community-led HIV response included here, which can be applied uniformly across research, practice, and policy spheres. A universally accepted definition would make it easier to track investments, monitor effectiveness, and report results.
- Implement prerequisite steps to establishing and supporting community-led HIV responses. They include strengthening technical and operational capacities of organizations led by people living with HIV, women, gay and bisexual men, people who use drugs, sex workers, transgender people, young people, and people with histories of incarceration. Special attention should be given to removing legal, policy, and funding barriers preventing community-led organizations from safely and efficiently operating [125, 130]. In addition, funding community empowerment and other processes that promote peer support and social cohesion among key and vulnerable populations may optimize the impact community-led responses can have [114, 135].
- Curate prevention portfolios that are predominantly community-led and include two or more of the following: outreach; HIV testing–including self-testing; STI testing and treatment; comprehensive sexuality education; condom and lubricants; pre- and post-exposure prophylaxis (PrEP and PEP); behavioural interventions; harm reduction, including needle and syringe programmes; peer support; risk reduction counselling; and drop-in centres [136, 137]. Community-led prevention programs are especially important for driving down incidence curves among key and vulnerable populations .
- Design treatment programs that have two or more well-funded, community-led components. Essential components include linkage to and coordination of care [67, 116]; decentralized dispensation of multi-dose ART that use differentiated care models to downstream treatment [72, 118, 121]; retention support [41, 69, 72]; adherence programs [56, 69, 72, 76, 95, 118]; home health [56, 138]; peer counselling and peer-led support groups [56, 139]; and treatment education . At present, 27% of all people living with HIV worldwide are without treatment . Our scoping review revealed evidence on the beneficial outcomes from community-led treatment, care, and support programmes, which when implemented with differentiated care models, can help to bridge the treatment gap .
- Support community-led organizations that deliver services to empower and mobilize their clients/service recipients, monitor local HIV responses, advocate, expand access, mitigate and address violence, and generate demand for quality services . Support for community-led monitoring and advocacy could also help ensure availability of medicines and diagnostics, while addressing service-related gaps and access barriers .
- Leverage the synergistic effects of multi-component community-led responses that can amplify beneficial changes at individual, service, societal, and structural levels.(13) Also, invest in interventions that target multiple outcomes that are proximally related to HIV .
- Conduct more research on community-led HIV responses, especially responses led by key and vulnerable populations. Research focused on programs led by people who use drugs and transgender people is especially needed. Studies are also needed on cost effectiveness of community-led HIV responses as well as on the long-term impact of structural-level interventions. Future research should adopt creative study designs and methods that are fit-for-purpose. For example, fractional factorial designs can identify independent and synergistic effects of intervention components and combination approaches [104, 142]. Communities of people living with HIV, key and vulnerable populations should be supported to lead research, including policy and evaluation studies [143–146]. Finally, the use of a consistent set of outcome measures focused on HIV and stronger integration of metrics used by health ministries, researchers, and program implementers should be encouraged. The need for more research should not preclude scaling of community-led responses.
The leadership of people living with and disproportionately affected by HIV is central to the global response. We must act rapidly to scale-up coverage of peer- and community-led programs and advocacy initiatives if we are to achieve the 2030 targets.
We would like to acknowledge the community experts convened by UNAIDS who worked tirelessly to develop the definitions for ‘community-led’ included in this paper. They are Timur Abdullaev, George Ayala, Victoria Bendaud, Judy Chang, Carlos Garcia de León, José Antonio Izazola-Licea, Renatta Langlais, Chad Martin, Dasha Ocheret Matyushina, Wame Mosime, Lillian Mworeko, Elani Nassif, Alessandra Nilo, Sharmeen Premjee, Gavin Reid, Laurel Sprague, Omar Syarif, Aditia Taslim, Ruth Morgan Thomas, and Leigh Ann van der Merwe. We also thank the civil society, academic, UN Member States, UNAIDS staff, and UN agency partners in the UNAIDS Multi-stakeholder Consultation on Social Enablers, June 2019, for their review and inputs to the definitions. Finally, we send appreciation to the 2020–2021 Multi-stakeholder Task Force on Community-led AIDS Responses, comprised equally of UN Member States and civil society members, which was co-convened by WHO, UNDP, and UNAIDS.
- 1. Declaration of Alma-Ata. International Conference on Primary Health Care; 1978; Geneva Switzerland: World Health Organization.
- 2. Loewenson R, Accoe K, Bajpai N, Buse K, Deivanayagam TA, London L, et al. Reclaiming comprehensive public health. BMJ Glob Health. 2020;5(9). pmid:32978214
- 3. Gillespie AM, Obregon R, El Asawi R, Richey C, Manoncourt E, Joshi K, et al. Social Mobilization and Community Engagement Central to the Ebola Response in West Africa: Lessons for Future Public Health Emergencies. Glob Health Sci Pract. 2016;4(4):626–46. pmid:28031301
- 4. Towards a global action plan for healthy lives and well-being for all: uniting to accelerate progress towards the health-related SDGs. Geneva: World Health Organization; 2018. Contract No.: WHO/DCO/2018.3.
- 5. Aggleton P, Parker R. Moving Beyond Biomedicalization in the HIV Response: Implications for Community Involvement and Community Leadership Among Men Who Have Sex with Men and Transgender People. Am J Public Health. 2015;105(8):1552–8. pmid:26066963
- 6. Collins CJ, Greenall MN, Mallouris C, Smith SL. Time for full inclusion of community actions in the response to AIDS. J Int AIDS Soc. 2016;19(1):20712. pmid:27083149
- 7. Rodriguez-García R, Bonnel R., Wilson D., N’Jie N. Investing in Communities Achieves Results: Findings from an Evaluation of Community Responses to HIV and AIDS. Washington D.C.: The World Bank; 2013.
- 8. Morolake O, Stephens D, Welbourn A. Greater involvement of people living with HIV in health care. J Int AIDS Soc. 2009; 12:4. pmid:19284672
- 9. UNAIDS. Seizing the moment: Tackling entrenched inequalities to end epidemics. Global AIDS Update. Geneva, Switzerland: UNAIDS; 2020.
- 10. Wolf RC, Bingham T, Millett G, Wilcher R. Building the evidence base to optimize the impact of key population programming across the HIV cascade. J Int AIDS Soc. 2018;21 Suppl 5(Suppl Suppl 5): e25146. pmid:30033673
- 11. Thomas-Slayter BP, Fisher WF. Social capital and AIDS-resilient communities: strengthening the AIDS response. Glob Public Health. 2011; 6 Suppl 3: S323–43. pmid:21943211
- 12. Rispel L, Popay J. Confronting social exclusion, HIV and gender inequalities in South Africa. Agenda. 2009;23(81):90–100.
- 13. Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations– 2016 Update. Geneva, Switzwerland: World Health Organization; 2016.
- 14. Laar A, DeBruin D. Key populations and human rights in the context of HIV services rendition in Ghana. BMC Int Health Hum Rights. 2017;17(1):20. pmid:28768541
- 15. King EJ, Maksymenko KM, Almodovar-Diaz Y, Johnson S. ’If she is a good woman …’ and ’to be a real man …’: gender, risk and access to HIV services among key populations in Tajikistan. Cult Health Sex. 2016;18(4):422–34. pmid:26902344
- 16. Wheeler T, Wolf RC, Kapesa L, Cheng Surdo A, Dallabetta G. Scaling-up HIV responses with key populations in West Africa. J Acquir Immune Defic Syndr. 2015;68 Suppl 2:S69–73. pmid:25723993
- 17. Ochonye B, Folayan MO, Fatusi AO, Emmanuel G, Adepoju O, Ajidagba B, et al. Satisfaction with use of public health and peer-led facilities for HIV prevention services by key populations in Nigeria. BMC Health Serv Res. 2019;19(1):856. pmid:31752853
- 18. Yi S, Sok S, Chhim S, Chhoun P, Chann N, Tuot S, et al. Access to community-based HIV services among transgender women in Cambodia: findings from a national survey. Int J Equity Health. 2019;18(1):72. pmid:31101106
- 19. Robert K, Maryline M, Jordan K, Lina D, Helgar M, Annrita I, et al. Factors influencing access of HIV and sexual and reproductive health services among adolescent key populations in Kenya. Int J Public Health. 2020;65(4):425–32. pmid:32337631
- 20. Nnko S, Kuringe E, Nyato D, Drake M, Casalini C, Shao A, et al. Determinants of access to HIV testing and counselling services among female sex workers in sub-Saharan Africa: a systematic review. BMC Public Health. 2019;19(1):15. pmid:30611219
- 21. Holland CE, Papworth E, Billong SC, Kassegne S, Petitbon F, Mondoleba V, et al. Access to HIV Services at Non-Governmental and Community-Based Organizations among Men Who Have Sex with Men (MSM) in Cameroon: An Integrated Biological and Behavioral Surveillance Analysis. PLoS One. 2015;10(4):e0122881. pmid:25906046
- 22. Scheim AI, Santos GM, Arreola S, Makofane K, Do TD, Hebert P, et al. Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men. J Int AIDS Soc. 2016;19(3 Suppl 2):20779. pmid:27431466
- 23. Santos GM, Makofane K, Arreola S, Do T, Ayala G. Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men. Sex Transm Infect. 2017;93(1):62–4. pmid:26944344
- 24. Arreola S, Santos GM, Beck J, Sundararaj M, Wilson PA, Hebert P, et al. Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide. AIDS Behav. 2015;19(2):227–34. pmid:25086670
- 25. Sidibé M, Goosby EP. Foreword: Global action to reduce HIV stigma and discrimination. J Int AIDS Soc. 2013; 16(3 Suppl 2):18893. pmid:24242270
- 26. Sanchez TH, Zlotorzynska M, Rai M, Baral SD. Characterizing the Impact of COVID-19 on Men Who Have Sex with Men Across the United States in April 2020. AIDS Behav. 2020;24(7):2024–32. pmid:32350773
- 27. AIDS and Rights Alliance for Southern Africa HEaHARDotUoKN. Impact of the COVID-19 national measures on community-led HIV responses in the SADC region: Summary Brief. Windhoek, Namibia: ARASA and HEARD; 2020.
- 28. Ambrosioni J, Blanco JL, Reyes-Urueña JM, Davies MA, Sued O, Marcos MA, et al. Overview of SARS-CoV-2 infection in adults living with HIV. Lancet HIV. 2021;8(5):e294–e305. pmid:33915101
- 29. van Ryneveld M, Whyle E, Brady L. What Is COVID-19 Teaching Us About Community Health Systems? A Reflection From a Rapid Community-Led Mutual Aid Response in Cape Town, South Africa. Int J Health Policy Manag. 2020. pmid:32892520
- 30. Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030. New York: United Nations; 2021. Contract No.: Agenda Item 10.
- 31. Kiragu M, Fonner VA, Munyuwiny S, Izulla P, Pantelic M, Restoy E, et al. Does Capacity Development Increase Demand for Health Services and Rights Among Key Populations Affected by HIV? A Systematic Review of Evidence from Low and Middle-Income Countries. AIDS Behav. 2020;24(8):2268–81. pmid:32696105
- 32. Peersman G, Ferguson L, Torres MA, Smith S, Gruskin S. Increasing civil society participation in the national HIV response: the role of UNGASS reporting. J Acquir Immune Defic Syndr. 2009;52 Suppl 2:S97–103. pmid:19901632
- 33. Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030. New York, New York: United Nations June 2016.
- 34. Sands P. HIV: from exceptionalism to endgame. Lancet. 2018;392(10144):261–2. pmid:30032979
- 35. Pantelic M, Stegling C, Shackleton S, Restoy E. Power to participants: a call for person-centred HIV prevention services and research. J Int AIDS Soc. 2018;21 Suppl 7(Suppl Suppl 7):e25167.
- 36. Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med. 2000;342(25):1878–86. pmid:10861324
- 37. Bigby M. Challenges to the hierarchy of evidence: does the emperor have no clothes? Arch Dermatol. 2001;137(3):345–6. pmid:11255336
- 38. Befani B. Models of causality and causal inference. London: Department for International Development; 2012.
- 39. Bickman L, Reich S. M. Random controlled trials a gold standard with feet of clay. In: Donaldson CAC S.I., editor. What counts as credible evidence in applied research and evaluation practice. Thousand Oaks, California: Sage Publications; 2009. p. 51–72.
- 40. Brown G, Crawford S, Perry GE, Byrne J, Dunne J, Reeders D, et al. Achieving meaningful participation of people who use drugs and their peer organizations in a strategic research partnership. Harm Reduct J. 2019;16(1):37. pmid:31182099
- 41. Cowan FM, Reza-Paul S, Ramaiah M, Kerrigan DL. Strategies to promote the meaningful involvement of sex workers in HIV prevention and care. Curr Opin HIV AIDS. 2019;14(5):401–8. pmid:31219886
- 42. Chang Pico TA, Kohler JC, Hoffmann J, Mungala L. No More Broken Promises: Challenges and Opportunities for Key Populations in Demanding More Transparency, Accountability, and Participation in the Global Response Against the HIV and AIDS Epidemic. Health Hum Rights. 2017;19(2):197–209. pmid:29302176
- 43. Glandon D, Paina L, Alonge O, Peters DH, Bennett S. 10 Best resources for community engagement in implementation research. Health Policy Plan. 2017;32(10):1457–65. pmid:29092039
- 44. UNAIDS. 2025 AIDS Targets: Target-setting, impact and resource needs for the global AIDS response—technical consultation on social enablers. Geneva, Switzerland: UNAIDS; 2019 June 2019.
- 45. UNAIDS. Progress Report of the Multistakeholder Task Team on Community-led AIDS Responses. Geneva, Switzerland: UNAIDS; 2020.
- 46. Brown G, Reeders D, Cogle A, Madden A, Kim J, O’Donnell D. A Systems Thinking Approach to Understanding and Demonstrating the Role of Peer-Led Programs and Leadership in the Response to HIV and Hepatitis C: Findings From the W3 Project. Front Public Health. 2018; 6:231. pmid:30234083
- 47. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. pmid:20854677
- 48. Daudt HM, van Mossel C, Scott SJ. Enhancing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework. BMC Med Res Methodol. 2013; 13:48. pmid:23522333
- 49. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19–32.
- 50. DiCenso A, Martin-Misener R, Bryant-Lukosius D, Bourgeault I, Kilpatrick K, Donald F, et al. Advanced practice nursing in Canada: overview of a decision support synthesis. Nurs Leadersh (Tor Ont). 2010;23 Spec No 2010:15–34. pmid:21478685
- 51. Brien SE, Lorenzetti DL, Lewis S, Kennedy J, Ghali WA. Overview of a formal scoping review on health system report cards. Implement Sci. 2010; 5:2. pmid:20205791
- 52. Karimi S, Pohl S, Scholer F, Cavedon L, Zobel J. Boolean versus ranked querying for biomedical systematic reviews. BMC Med Inform Decis Mak. 2010; 10:58. pmid:20937152
- 53. Reza-Paul S, Beattie T, Syed HU, Venukumar KT, Venugopal MS, Fathima MP, et al. Declines in risk behaviour and sexually transmitted infection prevalence following a community-led HIV preventive intervention among female sex workers in Mysore, India. Aids. 2008;22 Suppl 5:S91–100. pmid:19098483
- 54. Sifunda S, Reddy PS, Braithwaite R, Stephens T, Bhengu S, Ruiter RA, et al. The effectiveness of a peer-led HIV/AIDS and STI health education intervention for prison inmates in South Africa. Health Educ Behav. 2008;35(4):494–508. pmid:18591222
- 55. Hong H, Ji GP, Ye DQ. Long-term follow-up of a peer-led HIV/AIDS prevention program for married women in rural China. Int J Gynaecol Obstet. 2009;106(1):69–70. pmid:19345945
- 56. Nglazi MD, Lawn SD, Kaplan R, Kranzer K, Orrell C, Wood R, et al. Changes in programmatic outcomes during 7 years of scale-up at a community-based antiretroviral treatment service in South Africa. J Acquir Immune Defic Syndr. 2011;56(1):e1–8. pmid:21084996
- 57. Aramburú MG, Estripeaut D, Rowley S, Smoot S, Chamorro F, Bayard V. Educational impact of peer-intervention on the knowledge and attitudes about HIV/AIDS in adolescents in Panama. Int J Adolesc Med Health. 2012;24(2):135–41. pmid:22909922
- 58. Baghianimoghadam MH, Forghani H, Zolghadr R, Rahaei Z, Khani P. Peer-led versus teacher-led AIDS education for female high-school students in Yazd, Islamic Republic of Iran. East Mediterr Health J. 2012;18(4):353–7. pmid:22768697
- 59. Ibrahim N, Rampal L, Jamil Z, Zain AM. Effectiveness of peer-led education on knowledge, attitude and risk behavior practices related to HIV among students at a Malaysian public university—a randomized controlled trial. Prev Med. 2012;55(5):505–10. pmid:22982947
- 60. Michielsen K, Beauclair R, Delva W, Roelens K, Van Rossem R, Temmerman M. Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial. BMC Public Health. 2012;12:729. pmid:22938717
- 61. Saad A, Lekhraj R, Sabitu K, AbdulRahman H, Awaisu A, AbuSamah B, et al. An HIV-STI risk reduction program among undergraduate students at a northern Nigerian university: a randomized controlled field trial. Journal of Public Health. 2012;20(5):549–59.
- 62. Xiao Z, Li X, Mehrotra P. HIV/sexual risk reduction interventions in China: a meta-analysis. AIDS Patient Care STDS. 2012;26(10):597–613. pmid:22989271
- 63. Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, Saltzman AK, et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med. 2013;10(8):e1001496. pmid:23966838
- 64. Thato R, Penrose J. A brief, peer-led HIV prevention program for college students in Bangkok, Thailand. J Pediatr Adolesc Gynecol. 2013;26(1):58–65. pmid:23332197
- 65. Traore IT, Hema MN, Meda N, Konate I, Some F, Bazie W, et al. P3.402 Effect of a Tailored Intervention Package on HIV-1 Acquisition Among Young Female Sex Workers in Ouagadougou, Burkina Faso. Sexually Transmitted Infections. 2013;89(Suppl 1):A275–A.
- 66. Jain B, Krishnan S, Ramesh S, Sabarwal S, Garg V, Dhingra N. Effect of peer-led outreach activities on injecting risk behavior among male drug users in Haryana, India. Harm Reduct J. 2014; 11:3. pmid:24495379
- 67. Yan H, Zhang R, Wei C, Li J, Xu J, Yang H, et al. A peer-led, community-based rapid HIV testing intervention among untested men who have sex with men in China: an operational model for expansion of HIV testing and linkage to care. Sex Transm Infect. 2014;90(5):388–93. pmid:24926040
- 68. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015;385(9963):172–85. pmid:25059938
- 69. Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, et al. Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets. Curr HIV/AIDS Rep. 2016;13(5):241–55. pmid:27475643
- 70. Timol F, Vawda MY, Bhana A, Moolman B, Makoae M, Swartz S. Addressing adolescents’ risk and protective factors related to risky behaviours: Findings from a school-based peer-education evaluation in the Western Cape. Sahara j. 2016;13(1):197–207. pmid:27892820
- 71. Mantsios A, Galai N, Mbwambo J, Likindikoki S, Shembilu C, Mwampashi A, et al. Community Savings Groups, Financial Security, and HIV Risk Among Female Sex Workers in Iringa, Tanzania. AIDS Behav. 2018;22(11):3742–50. pmid:29478147
- 72. Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, et al. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med. 2019;16(7):e1002874. pmid:31335865
- 73. Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, et al. Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial. BMC Infect Dis. 2019;19(1):814. pmid:31533646
- 74. Naserirad M, Ayari F, Hamdini A, Hadiji K. Effectiveness of a peer-led HIV/AIDS education program on HIV-related health literacy of jailed adolescents in Tunis, Tunisia. Journal of Public Health. 2019;27(4):425–33.
- 75. Baptiste S, Manouan A, Garcia P, Etya’ale H, Swan T, Jallow W. Community-Led Monitoring: When Community Data Drives Implementation Strategies. Curr HIV/AIDS Rep. 2020;17(5):415–21. pmid:32734363
- 76. Denison JA, Burke VM, Miti S, Nonyane BAS, Frimpong C, Merrill KG, et al. Project YES! Youth Engaging for Success: A randomized controlled trial assessing the impact of a clinic-based peer mentoring program on viral suppression, adherence and internalized stigma among HIV-positive youth (15–24 years) in Ndola, Zambia. PLoS One. 2020;15(4):e0230703. pmid:32240186
- 77. Mavhu W, Willis N, Mufuka J, Bernays S, Tshuma M, Mangenah C, et al. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. Lancet Glob Health. 2020;8(2):e264–e75. pmid:31924539
- 78. Miller RL, Rutledge J, Ayala G. Breaking Down Barriers to HIV Care for Gay and Bisexual Men and Transgender Women: The Advocacy and Other Community Tactics (ACT) Project. AIDS Behav. 2021;25(8):2551–67. pmid:33730253
- 79. Leonard L, Ndiaye I, Kapadia A, Eisen G, Diop O, Mboup S, et al. HIV prevention among male clients of female sex workers in Kaolack, Senegal: results of a peer education program. AIDS Educ Prev. 2000;12(1):21–37. pmid:10749384
- 80. Shulkin JJ, Mayer JA, Wessel LG, de Moor C, Elder JP, Franzini LR. Effects of a peer-led AIDS intervention with university students. J Am Coll Health. 1991;40(2):75–9. pmid:1939937
- 81. Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. Am J Public Health. 1996;86(8):1129–36. pmid:8712273
- 82. O’Hara P, Messick BJ, Fichtner RR, Parris D. A peer-led AIDS prevention program for students in an alternative school. J Sch Health. 1996;66(5):176–82. pmid:8735582
- 83. Wingood GM, DiClemente RJ. HIV sexual risk reduction interventions for women: a review. Am J Prev Med. 1996;12(3):209–17. pmid:8743877
- 84. Kegeles SM, Hays RB, Pollack LM, Coates TJ. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. Aids. 1999;13(13):1753–62. pmid:10509578
- 85. Kocken P, Voorham T, Brandsma J, Swart W. Effects of peer-led AIDS education aimed at Turkish and Moroccan male immigrants in The Netherlands. A randomised controlled evaluation study. Eur J Public Health. 2001;11(2):153–9. pmid:11420801
- 86. Flowers P, Hart GJ, Williamson LM, Frankis JS, Der GJ. Does bar-based, peer-led sexual health promotion have a community-level effect amongst gay men in Scotland? Int J STD AIDS. 2002;13(2):102–8. pmid:11839164
- 87. Borgia P, Marinacci C, Schifano P, Perucci CA. Is peer education the best approach for HIV prevention in schools? Findings from a randomized controlled trial. J Adolesc Health. 2005;36(6):508–16. pmid:15901516
- 88. Wolitski RJ, Gómez CA, Parsons JT. Effects of a peer-led behavioral intervention to reduce HIV transmission and promote serostatus disclosure among HIV-seropositive gay and bisexual men. Aids. 2005;19 Suppl 1:S99–109. pmid:15838199
- 89. Simoni JM, Pantalone DW, Plummer MD, Huang B. A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women. Health Psychol. 2007;26(4):488–95. pmid:17605569
- 90. Webel AR. Testing a peer-based symptom management intervention for women living with HIV/AIDS. AIDS Care. 2010;22(9):1029–40. pmid:20146111
- 91. Calloway DS, Long-White DN, Corbin DE. Reducing the risk of HIV/AIDS in African American college students: an exploratory investigation of the efficacy of a peer educator approach. Health Promot Pract. 2014;15(2):181–8. pmid:24149215
- 92. Kim SR, Goldenberg SM, Duff P, Nguyen P, Gibson K, Shannon K. Uptake of a women-only, sex-work-specific drop-in center and links with sexual and reproductive health care for sex workers. Int J Gynaecol Obstet. 2015;128(3):201–5. pmid:25627707
- 93. Argento E, Duff P, Bingham B, Chapman J, Nguyen P, Strathdee SA, et al. Social Cohesion Among Sex Workers and Client Condom Refusal in a Canadian Setting: Implications for Structural and Community-Led Interventions. AIDS Behav. 2016;20(6):1275–83. pmid:26499335
- 94. Strömdahl S, Hoijer J, Eriksen J. Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey. Sex Transm Infect. 2019;95(8):575–9. pmid:31113905
- 95. CADTH Rapid Response Reports. Peer Support for Diabetes, Heart Disease and HIV/AIDS: A Review of the Clinical Effectiveness, Cost-effectiveness, and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013.
- 96. Ye S, Yin L, Amico R, Simoni J, Vermund S, Ruan Y, et al. Efficacy of peer-led interventions to reduce unprotected anal intercourse among men who have sex with men: a meta-analysis. PLoS One. 2014;9(3):e90788. pmid:24614809
- 97. Ayala G, Santos GM. Will the global HIV response fail gay and bisexual men and other men who have sex with men? J Int AIDS Soc. 2016;19(1):21098. pmid:27876454
- 98. Shangani S, Escudero D, Kirwa K, Harrison A, Marshall B, Operario D. Effectiveness of peer-led interventions to increase HIV testing among men who have sex with men: a systematic review and meta-analysis. AIDS Care. 2017;29(8):1003–13. pmid:28150501
- 99. Boucher LM, Liddy C, Mihan A, Kendall C. Peer-led Self-management Interventions and Adherence to Antiretroviral Therapy Among People Living with HIV: A Systematic Review. AIDS Behav. 2020;24(4):998–1022. pmid:31598801
- 100. Stangl AL, Singh D, Windle M, Sievwright K, Footer K, Iovita A, et al. A systematic review of selected human rights programs to improve HIV-related outcomes from 2003 to 2015: what do we know? BMC Infect Dis. 2019;19(1):209. pmid:30832599
- 101. Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, et al. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health. 2018;3(Suppl 3):e001384. pmid:31297243
- 102. Vannakit R, Andreeva V, Mills S, Cassell MM, Jones MA, Murphy E, et al. Fast-tracking the end of HIV in the Asia Pacific region: domestic funding of key population-led and civil society organisations. Lancet HIV. 2020;7(5):e366–e72. pmid:32386723
- 103. Trapence G, Collins C, Avrett S, Carr R, Sanchez H, Ayala G, et al. From personal survival to public health: community leadership by men who have sex with men in the response to HIV. Lancet. 2012;380(9839):400–10. pmid:22819662
- 104. West SG, Duan N, Pequegnat W, Gaist P, Des Jarlais DC, Holtgrave D, et al. Alternatives to the randomized controlled trial. Am J Public Health. 2008;98(8):1359–66. pmid:18556609
- 105. De Lind Van Wijingaarden JW LD. Differentiated HIV-service delivery along the cascade for men who have sex with men and transgender women in Thailand: Lessons learned from the LINKAGES Project. Thai Red Cross AIDS Research Center, FHI360; 2020.
- 106. Solar O IA. A conceptual framework for action on the social determinants of health. World Health Organization; 2010. Report No. 2.
- 107. Mannell J, Cornish F, Russell J. Evaluating social outcomes of HIV/AIDS interventions: a critical assessment of contemporary indicator frameworks. J Int AIDS Soc. 2014;17(1):19073. pmid:25160645
- 108. Miller RL, Reed SJ, Chiaramonte D, Strzyzykowski T, Spring H, Acevedo-Polakovich ID, et al. Structural and Community Change Outcomes of the Connect-to-Protect Coalitions: Trials and Triumphs Securing Adolescent Access to HIV Prevention, Testing, and Medical Care. Am J Community Psychol. 2017;60(1–2):199–214. pmid:28851064
- 109. Lippman SA, Maman S, MacPhail C, Twine R, Peacock D, Kahn K, et al. Conceptualizing community mobilization for HIV prevention: implications for HIV prevention programming in the African context. PLoS One. 2013;8(10):e78208. pmid:24147121
- 110. Miller RL, Forney JC, Hubbard P, Camacho LM. Reinventing Mpowerment for black men: long-term community implementation of an evidence-based program. Am J Community Psychol. 2012;49(1–2):199–214. pmid:21773862
- 111. Prilleltensky I. Mattering at the Intersection of Psychology, Philosophy, and Politics. Am J Community Psychol. 2020;65(1–2):16–34. pmid:31407358
- 112. Prilleltensky I. Understanding, resisting, and overcoming oppression: toward psychopolitical validity. Am J Community Psychol. 2003;31(1–2):195–201. pmid:12741700
- 113. Hernández A, Hurtig AK, Goicolea I, San Sebastián M, Jerez F, Hernández-Rodríguez F, et al. Building collective power in citizen-led initiatives for health accountability in Guatemala: the role of networks. BMC Health Serv Res. 2020;20(1):416. pmid:32404089
- 114. Ackerman Gulaid L, Kiragu K. Lessons learnt from promising practices in community engagement for the elimination of new HIV infections in children by 2015 and keeping their mothers alive: summary of a desk review. J Int AIDS Soc. 2012;15 Suppl 2(Suppl 2):17390. pmid:22789645
- 115. Biermann O, Eckhardt M, Carlfjord S, Falk M, Forsberg BC. Collaboration between non-governmental organizations and public services in health—a qualitative case study from rural Ecuador. Glob Health Action. 2016; 9:32237. pmid:27852423
- 116. Martinez O, Lopez N, Woodard T, Rodriguez-Madera S, Icard L. Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience. Health Soc Work. 2019;44(2):104–12. pmid:30855670
- 117. Busza J, Chiyaka T, Musemburi S, Fearon E, Davey C, Chabata S, et al. Enhancing national prevention and treatment services for sex workers in Zimbabwe: a process evaluation of the SAPPH-IRe trial. Health Policy Plan. 2019;34(5):337–45. pmid:31157368
- 118. Lazuardi E, Newman CE, Anintya I, Rowe E, Wirawan DN, Wisaksana R, et al. Increasing HIV treatment access, uptake and use among men who have sex with men in urban Indonesia: evidence from a qualitative study in three cities. Health Policy Plan. 2020;35(1):16–25. pmid:31625559
- 119. Hagey JM, Li X, Barr-Walker J, Penner J, Kadima J, Oyaro P, et al. Differentiated HIV care in sub-Saharan Africa: a scoping review to inform antiretroviral therapy provision for stable HIV-infected individuals in Kenya. AIDS Care. 2018;30(12):1477–87. pmid:30037312
- 120. Ssonko C, Gonzalez L, Mesic A, da Fonseca MS, Achar J, Safar N, et al. Delivering HIV care in challenging operating environments: the MSF experience towards differentiated models of care for settings with multiple basic health care needs. J Int AIDS Soc. 2017;20(Suppl 4):21654. pmid:28770590
- 121. Macdonald V, Verster A, Baggaley R. A call for differentiated approaches to delivering HIV services to key populations. J Int AIDS Soc. 2017;20(Suppl 4):21658. pmid:28770592
- 122. Adimora AA, Auerbach JD. Structural interventions for HIV prevention in the United States. J Acquir Immune Defic Syndr. 2010;55 Suppl 2(0 2):S132–5. pmid:21406983
- 123. Reza-Paul S, Lorway R, O’Brien N, Lazarus L, Jain J, Bhagya M, et al. Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore. Indian J Med Res. 2012;135(1):98–106. pmid:22382190
- 124. Nwakamma IJ, Erinmwinhe A, Ajogwu A, Udoh A, Ada-Ogoh A. Mitigating Gender and Maternal and Child Health Injustices through Faith Community-Led Initiatives. Int J MCH AIDS. 2019;8(2):146–55. pmid:31890346
- 125. Zhang T, Tian X, Ma F, Yang Y, Yu F, Zhao Y, et al. Community based promotion on VCT acceptance among rural migrants in Shanghai, China. PLoS One. 2013;8(4):e60106. pmid:23560071
- 126. Beyrer C, Crago AL, Bekker LG, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex workers. Lancet. 2015;385(9964):287–301. pmid:25059950
- 127. Gregson S, Nyamukapa C, Schumacher C, Magutshwa-Zitha S, Skovdal M, Yekeye R, et al. Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe? AIDS Care. 2013;25 Suppl 1(Suppl 1):S88–96. pmid:23745635
- 128. Wyatt GE, Hamilton AB, Myers HF, Ullman JB, Chin D, Sumner LA, et al. Violence prevention among HIV-positive women with histories of violence: healing women in their communities. Womens Health Issues. 2011;21(6 Suppl):S255–60. pmid:22055676
- 129. Augusto GF, Aldir I, Bettencourt J, Melo T, Dias SF, Abrantes A, et al. Preventing HIV under financial constraints: The 2011–12 reform of the Portuguese HIV/AIDS Programme. Health Policy. 2020;124(4):339–44. pmid:32115251
- 130. Aveling EL. The impact of aid chains: relations of dependence or supportive partnerships for community-led responses to HIV/AIDS? AIDS Care. 2010;22 Suppl 2:1588–97. pmid:21161763
- 131. Rotheram-Borus MJ, Swendeman D, Chovnick G. The past, present, and future of HIV prevention: integrating behavioral, biomedical, and structural intervention strategies for the next generation of HIV prevention. Annu Rev Clin Psychol. 2009;5:143–67. pmid:19327028
- 132. Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5(4):371–85. pmid:26052958
- 133. Sprague L, Afifi R, Ayala G, El-Nasoor ML. Participatory praxis as an imperative for health-related stigma research. BMC Med. 2019;17(1):32. pmid:30764812
- 134. Catania JA, Dolcini MM, Orellana R, Narayanan V. Nonprobability and probability-based sampling strategies in sexual science. J Sex Res. 2015;52(4):396–411. pmid:25897568
- 135. Jupp D, Ali SI. Measuring Empowerment? Ask Them—Quantifying Qualitative Outcomes from People’s Own Analysis. Swedish International Development Cooperation Agency, Sida; 2010 2010.
- 136. Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet. 2011;377(9782):2031–41. pmid:21641026
- 137. Lasry A, Sansom SL, Hicks KA, Uzunangelov V. Allocating HIV prevention funds in the United States: recommendations from an optimization model. PLoS One. 2012;7(6):e37545. pmid:22701571
- 138. Aantjes C, Quinlan T, Bunders J. Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment. Global Health. 2014;10:85. pmid:25499098
- 139. Ti L, Hayashi K, Kaplan K, Suwannawong P, Fu E, Wood E, et al. HIV testing and willingness to get HIV testing at a peer-run drop-in centre for people who inject drugs in Bangkok, Thailand. BMC Public Health. 2012; 12:189. pmid:22414406
- 140. Fact Sheet 2021. Joint United Nations Programme on HIV/AIDS; 2021 2021.
- 141. Blankenship KM, Friedman SR, Dworkin S, Mantell JE. Structural interventions: concepts, challenges and opportunities for research. J Urban Health. 2006;83(1):59–72. pmid:16736355
- 142. Nair V, Strecher V, Fagerlin A, Ubel P, Resnicow K, Murphy S, et al. Screening experiments and the use of fractional factorial designs in behavioral intervention research. Am J Public Health. 2008;98(8):1354–9. pmid:18556602
- 143. Sofolahan-Oladeinde Y, Mullins CD, Baquet CR. Using community-based participatory research in patient-centered outcomes research to address health disparities in under-represented communities. J Comp Eff Res. 2015;4(5):515–23. pmid:26436953
- 144. Patel DI, Winkler P, Botello J, Villarreal J, Puga F. The citizen scientist: Community-academic partnerships through Translational Advisory Boards. Patient Educ Couns. 2016;99(12):2087–90. pmid:27432015
- 145. Glassman M, Erdem G. Participatory Action Research and Its Meanings:Vivencia, Praxis, Conscientization. Adult Education Quarterly. 2014;64(3):206–21.
- 146. Wallerstein N DB. Theoretical, historical and practice roots of community-based participatory research. In: Minkler M WN, editor. Community-based participatory research for health. San Francisco: Wiley; 2017.