title: Direct and indirect effects of enablers on HIV testing, initiation and retention in antiretroviral treatment and AIDS related mortality.
abstract: BACKGROUND
  An enabling environment is believed to have significant and critical effects on HIV and AIDS program implementation and desired outcomes. This paper estimates the paths, directionality, and direct and indirect associations between critical enablers with antiretroviral treatment (ART) coverage and to AIDS-related mortality.
  
  
  METHODS
  Frameworks that consider the role of enablers in HIV and AIDS programs were systematically reviewed to develop a conceptual model of interaction. Measurements for constructs of the model were pooled from the latest publicly available data. A hypothetical model, including latent/unobserved factors and interaction of enablers, program activities and outcomes, was analyzed cross-sectionally with structural equation modeling. Coefficients of the model were used to estimate the indirect associations of enablers to treatment coverage and the subsequent associated impact on AIDS related mortality.
  
  
  RESULTS
  The model's fit was adequate (RMSEA = 0·084, 90% CI [0·062, 0·104]) and the indirect effects of enablers on outcomes were measured. Enablers having significant associations with increased ART coverage were social/financial protection, governance, anti-discrimination, gender equality, domestic AIDS spending, testing service delivery, and logistics.
  
  
  CONCLUSIONS
  Critical enablers are significantly correlated to outcomes like ART coverage and AIDS related mortality. Even while this model does not allow inference on causality, it provides directionality and magnitude of the significant associations.
authors.affiliation: Evaluation team, Evaluation and Economics Division, Strategic Information and Evaluation Department, United Nations Programme on AIDS (UNAIDS), Geneva, Switzerland.
authors.forename: Ali
authors.initials: A
authors.lastname: Safarnejad
authors.affiliation: Chief of the Evaluation and Economics Division, Strategic Information and Evaluation Department, Programme Branch, United Nations Programme on AIDS (UNAIDS), Geneva, Switzerland.
authors.forename: Jose-Antonio
authors.identifier: http://orcid.org/0000-0002-3658-2570
authors.initials: JA
authors.lastname: Izazola-Licea
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D006679:HIV Seropositivity / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008403:Mass Screening; D008962:Models, Theoretical; D011287:Prejudice; D012931:Social Environment; D012946:Social Welfare
chemical_list: D019380:Anti-HIV Agents