Social Enablers

Objectives: Socially assistive humanoid robots are considered a promising technology to tackle the challenges in health and social care posed by the growth of the ageing population. The purpose of our study was to explore the current evidence on barriers and enablers for the implementation of humanoid robots in health and social care.

Primary outcomes: Identification of enablers and barriers to the implementation of socially assistive humanoid robots in health and social care, and consequent insights and impact. Future developments to inform further research.

Social Enablers

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Results: Twelve studies met the eligibility criteria and were included. None of the selected studies had an experimental design; hence overall quality was low, with high risks of biases. Several studies had no comparator, no baseline, small samples, and self-reported measures only. Within this limited evidence base, the enablers found were enjoyment, usability, personalisation and familiarisation. Barriers were related to technical problems, to the robots' limited capabilities and the negative preconceptions towards the use of robots in healthcare. Factors which produced mixed results were the robot's human-like attributes, previous experience with technology and views of formal and informal carers.

Conclusions: The available evidence related to implementation factors of socially assistive humanoid robots for older adults is limited, mainly focusing on aspects at individual level, and exploring acceptance of this technology. Investigation of elements linked to the environment, organisation, societal and cultural milieu, policy and legal framework is necessary.

Four years later, 2020 has arrived, and according to the Joint United Nations Programme on HIV and AIDS (UNAIDS), it appears unlikely that Fast-Track target of 6% of resources to be budgeted for social enablers has been met. UNAIDS states that key enablers of effective HIV responses remain neglected in dozens of countries across multiple regions, and this collective failure to invest sufficiently in comprehensive, rights-based HIV responses resulted in 3.5 million more HIV infections and 820 000 more AIDS-related between 2015 to 2020 than if the world was on track to meet its 2020 targets.

Although definitions vary, structural interventions can be broadly considered as interventions that alter the social, economic, legal and political environment that shapes health processes and outcomes. Social enablers tend to be defined more narrowly as social factors that affect uptake of health services. There is growing appreciation that structural interventions and interventions addressing social enablers may be critical to reducing HIV incidence, but evidence is weak and limited, as many structural interventions cannot be evaluated in individual-randomized experiments. There is also growing appreciation that in order for the HIV response to be sustained in the longer term, it needs to be more integrated into the current Sustainable Development Goals (SDG) framework, which emphasizes the structural factors that shape HIV risk. Funders are increasingly interested in quantifying the impact of these structural interventions.

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In the context of HIV, an enabling environment is one free of societal, political, legal and economic impediments to availability, access and uptake of HIV services [1]. Such impediments include: stigma and discrimination, gender-based violence, punitive or harmful laws and policies, limited access to justice for key (i.e. gay men and other men who have sex with men, sex workers, transgender people and people who inject drugs) and vulnerable (i.e. women, adolescent girls, migrants, refugees and incarcerated people) populations, and gender-based, racial, economic, and educational inequalities [2, 3]. Over the past decade, emphasis has been placed on incorporating social and structural interventions, which work by altering the societal, political, legal and economic contexts that influence individual, community and societal health outcomes [4], into combination HIV prevention [5] and care and treatment strategies to improve the quality of life of people living with HIV.

Since the publication of the HIV Investment Framework, other key guidance and initiatives have been launched that must be taken into consideration as we now refine our thinking around the enablers of the HIV response. Firstly, in 2012, UNAIDS recommended seven human rights programmes for investment to end punitive approaches to HIV: (i) reducing stigma and discrimination, (ii) increasing access to HIV-related legal services, (iii) monitoring and reforming laws, policies, and regulations, (iv) enhancing legal literacy, (v) sensitizing lawmakers and law enforcement agents, (vi) training health care providers on human rights and medical ethics related to HIV, and (vii) reducing discrimination against women in the context of HIV [7].

Over the past decade, significant progress has been made to develop and test interventions to address societal and legal impediments to HIV services [3, 10, 11]. This paper presents: a scoping review of the evidence on the impact of societal impediments and societal enabling approaches on HIV outcomes, a re-envisioned framework of the enablers of the HIV response, and evidence-based societal enabler targets and indicators for monitoring progress towards achieving an enabling environment for HIV services that were proposed and adopted at the UN high level meeting in June 2021.

Following the consultation, these eight areas were condensed further (by AS, TP and JAI-L) into overarching themes that we now consider to be the four societal enablers of the HIV response: (1) societies with supportive legal environments and access to justice, (2) gender equal societies, (3) societies free of stigma and discrimination, and (4) co-action across development sectors to reduce exclusion and poverty (Fig 1). While we recognize that other development sectors outside HIV have an impact on the HIV response, indicating the need for coordinated action at the country level, this paper focuses on the first three enablers, which fall under the purview of the HIV sector. It should be noted that the societal enablers are not mutually exclusive, and interventions are likely to focus on multiple enablers. Success in one societal enabler (e.g. supportive legal environments) is very likely to influence another (e.g. reduced HIV stigma and discrimination).

A scoping review was then performed on research published in English up to 16 June 2020. This type of review was chosen due to the diversity of evidence across the broad range of societal enablers that we were attempting to clarify [13]. The purpose of the review was to identify the best available evidence regarding the impact of societal impediments (e.g. criminalization, violence, stigma and discrimination, etc.) and societal enabling interventions (de-criminalization; violence reduction, etc.) on HIV outcomes to inform the re-envisioned framework. We searched available published literature across three databases: Pubmed, Scopus and Web of Science. The Population, Intervention, Comparison and Outcome (PICO) framework was used to develop the search strategy. We developed three blocks of search terms to capture the populations of interest, the societal impediments and/or societal enabling approaches and HIV outcomes. Specific search terms used are available in S1 Table. We included all study designs across all countries and population groups. For this paper, we include only peer-reviewed studies that explicitly examined the relationship between a societal enabler or impediment and an HIV outcome/s and demonstrated a significant impact using quantitative measures.

One author (TP) screened the title and abstract for all records and a second author (AS) examined a random selection of records. Expert advice from the Technical Expert Group on Social Enablers and HIV and UN co-sponsors added additional articles not captured in the literature search. We extracted information from articles related to the study author, the year of publication, the country, the study design, the study population and sample, the social impediment studied/addressed, the intervention description, duration and socio-ecological level of the intervention where appropriate, the HIV outcome/s, and impact estimates of the societal impediment or societal enabling approach on HIV outcomes. We examined HIV outcomes including HIV prevalence, HIV incidence, HIV testing, ART adherence, AIDS-related mortality, linkage to HIV care and viral suppression.

We limited our search strategy to the three enablers that fall within the HIV sector (S1 Fig). Development coaction areas (i.e. education, poverty reduction and economic development) that influence HIV outcomes have already been clearly described in the Sustainable Development Goals (SDGs) and existing evidence-based targets are available [14]. Evidence from 16 studies on the impact of key development co-action areas on HIV outcomes was recommended by technical experts and UN co-sponsors and is summarized in S2 Table.

Two studies assessed the impact of social enabling approaches to improve gender equality on HIV outcomes. Community mobilization interventions to reduce IPV led to increased HIV testing and condom use among heterosexual men in Uganda [24]. Likewise, heterosexual couples HIV counselling and testing in South Africa led to more partners testing for HIV and learning their HIV status [26]. 2351a5e196