Mobilizing civil society for the HIV treatment cascade: a global analysis on democracy and its association with people living with HIV who know their status

INTRODUCTION: Civil society organizations (CSOs) play an essential role in the global HIV/AIDS response. Past studies have described the beneficial role of CSOs in meeting the United Nations Programme on HIV/AIDS (UNAIDS) 90‐90‐90 target, but have not explored how political conditions, which influence the ability of CSOs to organize, have an impact on the cascade. This study explores the relationship between measures of democracy and its association with diagnosis rates among people living with HIV (PLHIV). METHODS: This study analyses 2016 data derived from the Economist Intelligence Unit's Democracy Index (EIUDI), UNAIDS country estimates for PLHIV and PLHIV who knew their status in 2016, World Bank's 2016 data on nominal gross domestic product (GDP) per capita and country population, HIV Justice Network's 2016 data on HIV criminalization, and country‐level estimates for PLHIV, PLHIV who know their status, and expenditure on HIV prevention from other independent sources. An estimated HIV prevalence variable was constructed by dividing the estimated PLHIV population with the total population of a country. Analyses were limited to countries with available data on PLHIV who know their status (n = 111). RESULTS: Of the 111 countries in the analytic sample, the mean democracy index score was 5.93 (of the 10), median estimated HIV prevalence was 0.20% (IQR 0.10‐0.65), median GDP per capita (in thousands, US dollar) was 4.88 (IQR 2.11‐13.79), and mean PLHIV who know their status is 67.12%. Preliminary analysis on the five component measures of the EIUDI revealed multicollinearity, and thus the composite democracy index score was used as the measure for democracy. Multivariate linear regression analyses revealed that democracy index scores (β = 2.10, SE = 1.02, p = 0.04) and GDP per capita (in thousands; β = 0.34. SE = 0.11, p < 0.01) were positively associated with diagnosis rates among PLHIV, controlling for country‐level expenditure on HIV prevention, HIV criminalization laws and estimated HIV prevalence. CONCLUSIONS: Results indicate that higher levels of democracy were positively associated with rates of diagnosis among PLHIV. Further analyses following wider implementation of universal testing and treatment is warranted, as well as the need for further research on the mechanisms through which political cultures specifically influence rates of diagnosis among PLHIV.