IAPAC Response to Draft HIV Action Plan for Wales
The Fast-Track Cities initiative started as a global partnership between the Joint United Nations Programme on HIV/AIDS (UNAIDS), International Association of Providers of AIDS Care (IAPAC), United Nations Human Settlements Programme (UN-Habitat), and the City of Paris. Since its launch on World AIDS Day 2014 in Paris, more than 400 cities and municipalities from every region of the world have joined the initiative by signing the Paris Declaration on Fast-Track Cities, pledging to end urban HIV epidemics by getting to zero new HIV infections, zero AIDS-related deaths, and zero HIV-related stigma. The partnership also advances efforts to end tuberculosis (TB) epidemics, eliminate viral hepatitis (HBV and HCV) and other sexual transmitted infections (STIs) in urban settings by 2030.
Joining the Fast-Track City network simply requires a city or municipality leader to sign the Paris Declaration on Fast-Track Cities. However, being a Fast-Track City requires actioning the goals, objectives, and targets to which all Fast-Track Cities commit, including:
- Ending urban HIV, viral hepatitis, TB, and other STIs epidemics by 2030
- Putting people at the center of the HIV, TB, viral hepatitis, and other STIs responses
- Addressing the causes of HIV, TB, viral hepatitis, and other STIs risk, vulnerability, and transmission
- Using the HIV, TB, viral hepatitis, and other STIs response for positive social transformation
- Building and accelerating HIV, TB, viral hepatitis, and other STIs responses that reflect local needs
- Mobilizing resources for integrated public health and sustainable development
- Uniting as leaders by committing to an accountability framework
Currently, there are 8 Fast-Track Cities in the United Kingdom, including Aberdeen, Brighton and Hove, Bristol, Cardiff and Vale, Glasgow, Liverpool, London, and Manchester. More UK cities are set to join before the end of 2022. Fast-Track Cardiff and Vale together with partners in Cardiff and across Wales have pioneered the Fast-Track Cities initiative in Wales with a strong focus on engaging and empowering communities and collecting and understanding data to drive innovation and improvements in services as demonstrated by innovative interventions such as the Texting 4 Testing project.
The International Association of AIDS Care Providers (IAPAC) welcomes the draft HIV Action Plan for Wales that was released for public comment and awaits a final revision. We applaud the plan for its overarching action to establish Wales as a Fast-Track Country through the co-creation of an all-Wales coalition, Fast Track Cymru. In this, HIV Action Plan both fosters alignment between the national HIV agenda and urban HIV responses and demonstrates a clear understanding that moving from to the commitments in the Paris Declaration on Fast-Track Cities to actioning them requires consistent political buy-in, public health leadership, data-informed interventions, and community leadership. The forthcoming launch of a national HIV action plan with a clear integration of the Fast-Track Cities initiative and a national coordinating body is unprecedented in the initiative’s history and sets an important example and precedence for other Fast-Track Cities in the United Kingdom and globally.
With this integration of the Fast-Track Cities initiative into the proposed Welsh HIV Action Plan, the Welsh government honors several of the seven core commitments in the Paris Declaration on Fast-Track Cities, including using the HIV, TB, viral hepatitis, and other STI responses for positive social transformation by building on the highly successful interventions advanced by Fast-Track Cities Cardiff and Vale; mobilizing resources for integrated public health and sustainable development, and uniting as leaders by committing to an accountability framework. Nevertheless, IAPAC puts forward four recommendations for further refining the HIV Action Plan’s core commitments on stigma, involvement of people living with HIV, and monitoring and evaluation of the plan.
1. Measuring HIV-Related Stigma
HIV-related stigma can negatively impact on prevention, testing and treatment efforts and lead to adverse health outcomes. IAPAC is thus pleased to see that ‘tackling HIV-related stigma’ is one of the five priority areas for action in the plan in alignment with the Paris Declaration on Fast-Track Cities’ stated goal of achieving zero HIV-related stigma; Goal 3.3. of the Sustainable Development Goals; and the UNAIDS Global AIDS Strategy, 2021-2026. However, the draft Welsh HIV Action Plan’s outlined steps for to achieve the goal of zero tolerance towards HIV-related stigma does not include a clear monitoring framework to track progress. Without a monitoring framework, it will be difficult to understand how best to intervene and address individual and institutional drivers of stigma, and to assess whether the implanted interventions work as intended.
Stigma is a complex social phenomenon that is operationalized across several domains at the micro-, meso- and macro- level, and survey instruments that aim to meaningfully describe and assess how and in which contexts stigma unfolds thus necessarily need to capture this complexity. IAPAC therefore recommends the steps of actioning on the priority to ‘tackling HIV-related stigma’ to include the development of standardized and validated HIV-related stigma indicators that capture individual level drivers in and outside of healthcare setting such as fear of infection, prejudice, blame and social judgement and organizational level drivers such as social/cultural norms, policies, and practices.
2. Including People Living with or affected by HIV in all Five Priority Areas
One of the core commitments in the Paris Declaration on Fast-Track Cities is to ‘put people at the center of everything we do.’ This commitment includes not only focusing efforts on all people who are vulnerable to HIV, TB, viral hepatitis, and other diseases but also to meaningfully include people living with HIV in decision-making around policies and programs that affect their lives. Following through on this commitment is to realize the rights and responsibilities of people living with HIV, including their right to self-determination, and to let personal lived experiences shape the HIV and AIDS response.
While IAPAC acknowledges the clearly stated involvement of voluntary and community groups and people living with HIV in the Action Plan Oversight Group, the five priority areas – Prevention, Testing, Clinical Care, Living Well with HIV, and Tackling HIV-Related stigma – mainly position people living with HIV as the (passive) beneficiaries of the action HIV Action Plan’s steps and interventions outlined to action on the priority areas rather than the decision-makers and drivers of these steps and interventions.
The benefits of meaningfully involving people living with and affected by HIV are multi-levelled. For the individual, involvement can improve self-esteem, decrease isolation, and improve health through access to better information about prevention, treatment, and care initiatives. For organizations, involvement of people living with HIV can change perceptions, and provide valuable experiences and knowledge. For communities and societies, public involvement of people living with HIV can break down fear and prejudice by showing the faces of people living with HIV and demonstrating that they are productive members of, and contributors to, society.
IAPAC therefore encourages the intentional and active inclusion of people living with to ensure that representation of people living with and affected by HIV are present in the planning, implementation, and monitoring stages of all aspects of the five priority areas, and furthermore to use strategies to guarantee diverse representation within the group of people living with and affected by HIV in all their diversity. In other words, IAPAC encourages the formulation of clear steps to ensure that the attainment of the five priority areas is by people living with and affected by HIV and not primarily for or about them.
3. Facilitating Community-Led Monitoring
IAPAC commends that one of the draft HIV Action Plan’s three core principles is to have ‘All new initiatives and services be subject to ongoing monitoring and evaluation to make sure they meet the actions and principles laid out in the plan.’
IAPAC encourages these monitoring and evaluation initiatives to be community-led, ensuring that the collection, analysis, and utilization of data involves the community itself with support from our public health institutions – even if this necessitate making changes to policies within the authority at the city or health board level. This will in turn facilitate a data-driven, equity-based accountability mechanism for the Welsh Government’s communities inherent in the HIV Action Plan.
4. Developing an Accountability Framework for the Actions in the HIV Action Plan
While it is commendable that each of the five priority areas is operationalized through various concrete actions, amounting to 26 concrete actions within the draft HIV Action Plan, IAPAC notes that each of the actions are not matched with corresponding KPIs, timeline, or metrics for monitoring and evaluating on the progress towards attaining them.
IAPAC recommends the development of a clear accountability framework for each of the actions set within the HIV Action Plan. Pivotal to a comprehensive accountability framework is not simply setting quantifiable metrics and tangible milestones but furthermore a clear communication’s strategy for the action plan and for the achievements.
An accountability framework combining clear indicators to monitor progress and a corresponding communication strategy would arguably enable all stakeholders to stay informed on the progress of the actions set within the plan, facilitate stakeholder coordination, improve accountability, identify gaps, inform priorities, mobilize resources, allow for action course corrections, and enable political and community stakeholders to use the HIV Action Plan as an advocacy tool towards our shared vision of a world with zero new HIV infections, zero AIDS-related deaths, and zero HIV-related stigma.