We thank Harding et al for their attention to our supplement and for acknowledging the need to prioritize HIV care and support interventions for maximum impact. We appreciate the opportunity to address the issues raised regarding the methods used in the evidence reviews in the supplement and the overall conclusions. | The introductory article in the supplement1 explains the process used in performing these reviews. Selection of articles involved a 3-step process: (1) the total number of citations from the CDC Library (and other sources, if applicable), (2) the number of abstracts that were deemed eligible for review of the full-text articles (eligible studies), and (3) the number of studies that fulfilled the inclusion criteria upon review of the full-text articles (included studies). These steps are those specified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines.2 Details, including search terms used for the literature review and flow diagrams, are included in each of the intervention-specific articles in the supplement. The introductory article explains the rating systems used for the quality of evidence of individual studies, and for the overall quality of the body of evidence and expected impact, of each intervention for each of the specific outcomes of interest. The rating system of the overall quality of evidence was adapted from that used by the US Preventive Services Task Force, as indicated

Over the past decade, tremendous progress has been made in addressing the HIV epidemic in low- and middle-income countries, with expanded access to antiretroviral therapy (ART) in many countries, and advances in key areas, such as prevention of mother-to-child transmission and voluntary medical male circumcision.1 However, many gaps remain, with limited coverage for care and treatment in many countries1 and ongoing challenges for epidemic control. As countries and donors work to expand access to critical HIV prevention, care and treatment services in an era of declining funding and multiple competing needs, programs will need to determine strategic priorities, identifying and implementing interventions that demonstrate the greatest impact on key outcomes. | The US President's Emergency Plan for AIDS Relief (PEPFAR), which supports HIV programs in 36 countries and regions in Africa, Asia, Eastern Europe, Central America, and the Caribbean, is currently engaged in such a process, re-examining overall priorities with the goal of controlling the epidemic and achieving an AIDS-free generation. As outlined in PEPFAR 3.0: Controlling the epidemic: Delivering on the promise of an AIDS-free generation,2 PEPFAR is in the process of realigning geographic and programmatic focus, emphasizing strategic investments to scale up effective evidence-based interventions in high HIV prevalence areas and populations to maximize impact on the epidemic. As part of this focus on impact, efficiency, and sustainability, PEPFAR is reassessing programmatic priorities both within and across program areas. PEPFAR-supported programs are engaged in a similar prioritization process at the country/regional level.

As of December 2012, an estimated 35.3 million persons were living with HIV; approximately two thirds of these people were living in sub-Saharan Africa.1 The response to the HIV pandemic in Africa and in other low-and middle-income regions of the world has consisted of a variety of bilateral and multi-lateral support from donor agencies, as well as local support from countries that have been able to afford it. A majority of the support has been directed towards HIV care and treatment. | Accordingly, the past ten years have witnessed a remarkable increase in the number of HIV-infected persons receiving antiretroviral therapy (ART) in low- and middle-income countries--from 300,000 in 2003 to 9.7 million in 20121,2. Expanded access to ART in these countries has led to significant proportions of eligible persons enrolled on ART, reaching coverage rates as high as 61% based on the World Health Organization (WHO) treatment guidelines eligibility criteria of CD4 <350 cells/uL) in 2012.1 In 2013, WHO revised its guidelines to indicate eligibility at CD4 <500 cells/uL; under these criteria, only 34% of eligible persons were on ART in 2013.1 Nevertheless, these changes in access to ART were estimated to have averted 4.2 million deaths through 20122.1 | HIV treatment programs in low- and middle-income countries have been supported by a variety of sources, including over $50 billion through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 20133. PEPFAR programs are coordinated by the U.S. Department of State’s Office of the U.S. Global AIDS Coordinator (OGAC) in Washington, D.C.,; oversight of in-country expenditures is supported by additional U.S. government(USG) agencies with the majority of funds concentrated in 36 countries and regions 4 in sub-Saharan Africa, South and Central Asia, Eastern Europe, Central America and the Caribbean. PEPFAR supports a range of HIV care and treatment services besides ART including clinical (e.g. monitoring to determine eligibility for ART and prevention and treatment of opportunistic infections) and non-clinical services (e.g. psychological, social, and preventive)4. Services implemented through PEPFAR support in each country are determined through a dialogue between the USG, and host governments. PEPFAR country operating plans and budgets are submitted annually and reviewed by USG staff.

BACKGROUND: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised. METHODS: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness. RESULTS: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes. CONCLUSIONS: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

BACKGROUND: Support groups for people living with HIV are integrated into HIV care and treatment programs as a modality for increasing patient literacy and as an intervention to address the psychosocial needs of patients. However, the impact of support groups on key health outcomes has not been fully determined. METHODS: We searched electronic databases from January 1995 through May 2014 and reviewed relevant literature on the impact of support groups on mortality, morbidity, retention in HIV care, quality of life (QOL), and ongoing HIV transmission, as well as their cost-effectiveness. RESULTS: Of 1809 citations identified, 20 met the inclusion criteria. One reported on mortality, 7 on morbidity, 5 on retention in care, 7 on QOL, and 7 on ongoing HIV transmission. Eighteen (90%) of the articles reported largely positive results on the impact of support group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in care, and improved QOL. Because of study limitations, the overall quality of evidence was rated as fair for mortality, morbidity, retention in care, and QOL, and poor for HIV transmission. CONCLUSIONS: Implementing support groups as an intervention is expected to have a high impact on morbidity and retention in care and a moderate impact on mortality and QOL of people living with HIV. Support groups improve disclosure with potential prevention benefits but the impact on ongoing transmission is uncertain. It is unclear whether this intervention is cost-effective given the paucity of studies in this area.