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Introduction In 2023, the Ugandan government enacted the Anti‐Homosexuality Act (AHA), which included expanded and intensified criminal penalties for consensual same‐sex relations. While arrests, harassment and violence have been reported, evidence of the AHA's impact on HIV healthcare delivery is limited. Community‐led monitoring (CLM) is an accountability mechanism that uses community‐gathered evidence to advocate for improved healthcare quality and is well‐positioned to describe changes in access and quality of care. Methods Data from the CLM programme in Uganda were used to identify changes in healthcare delivery and use related to the AHA. As part of the CLM programme, routine survey data were collected from clients and managers in 320 public health facilities and 50 drop‐in centres (DICs) from 2022 to 2024. Survey data were analysed using a difference‐in‐differences logistic model to measure changes in indicator measures before and after the AHA was signed into law. Seven semi‐structured individual interviews were conducted with DIC facility managers, deductively coded and thematically analysed. Results In public health facilities and DICs, the proportion of respondents identified as men who have sex with men (MSM) declined significantly after AHA. In facilities, all categories of key populations (KPs) reported high levels of discrimination. After the AHA, MSM reported significant reductions in key HIV‐related services compared to other populations, including lower rates of pre‐exposure prophylaxis (PrEP) counselling, lower participation in support groups and having fewer friendly staff interactions. In DICs, all types of clients were less likely to be referred to health facilities, receive PrEP and find the DIC easy to access after the AHA was signed. DIC managers described experiencing harassment, violence and staffing challenges due to AHA, which they responded to by leveraging partnerships with local and global allies, providing virtual services, and seeking registration as full‐service clinics. Conclusions Data from the Uganda CLM programme provide an early view of the impact of the AHA on service delivery in public health facilities and DICs. While DICs and health facilities developed strategies to build resiliency and adapt, the AHA created significant barriers to care. These findings provide empirical warnings of the barriers experienced by KPs when accessing healthcare services in a criminalized context.

Introduction Despite international commitment to achieving the end of HIV as a public health threat, progress is off‐track and existing gaps have been exacerbated by COVID‐19's collision with existing pandemics. Born out of models of political accountability and historical healthcare advocacy led by people living with HIV, community‐led monitoring (CLM) of health service delivery holds potential as a social accountability model to increase the accessibility and quality of health systems. However, the effectiveness of the CLM model in strengthening accountability and improving service delivery relies on its alignment with evidence‐based principles for social accountability mechanisms. We propose a set of unifying principles for CLM to support the impact on the quality and availability of health services. Discussion Building on the social accountability literature, core CLM implementation principles are defined. CLM programmes include a community‐led and independent data collection effort, in which the data tools and methodology are designed by service users and communities most vulnerable to, and most impacted by, service quality. Data are collected routinely, with an emphasis on prioritizing and protecting respondents, and are then be used to conduct routine and community‐led advocacy, with the aim of increasing duty‐bearer accountability to service users. CLM efforts should represent a broad and collective community response, led independently by impacted communities, incorporating both data collection and advocacy, and should be understood as a long‐term approach to building meaningful engagement in systems‐wide improvements rather than discrete interventions. Conclusions The CLM model is an important social accountability mechanism for improving the responsiveness of critical health services and systems to communities. By establishing a collective understanding of CLM principles, this model paves the way for improved proliferation of CLM with fidelity of implementation approaches to core principles, rigorous examinations of CLM implementation approaches, impact assessments and evaluations of CLM's influence on service quality improvement.

In perhaps the best-known example, CSO campaigns, policy advocacy and scientific partnerships have proven crucial in accelerating the development and global accessibility of treatments for HIV, altering the course of HIV infection programmes and contributing to millions of lives being saved.2 As public health researchers and advocates focused on infectious diseases in Uganda, we have seen how ongoing action from CSOs—such as The AIDS Support Organization, which cares for 100 000 Ugandans living with HIV while leading additional testing, counselling and public awareness efforts3—has brought the country within the reach of achieving the UNAIDS 95-95-95 targets.4 Thanks to their established relationships with constituents and proximate understandings of local realities, CSOs are uniquely positioned to mobilise communities behind evidence-based public health recommendations, including in settings where more distal governmental and academic institutions may struggle to make an impact.5 6 Despite the potential benefits and history of success, governments, local authorities, donors and international development organisations often do not meaningfully involve civil society in initial responses to disease outbreaks.7 8 This missed opportunity for advancing health equity has been sharply illustrated by the COVID-19 pandemic. Early in the pandemic, Rajan et al analysed national COVID-19 task forces and found, among other deficiencies, that CSOs were ‘hardly involved in national government decision-making nor its response efforts’.9 An Office of the United Nations High Commissioner for Human Rights report 2 years later concluded ‘few, and in most cases no, participatory mechanisms were established for discussion and decision-making’ between CSOs and other COVID-19 stakeholders.10 Lack of meaningful engagement with CSOs weakens public health, decreasing the ability of authorities to anticipate and respond to delivery challenges and sidelining organisations with established community trust.8 Finding a gap in civil society involvement in the COVID-19 response in Uganda, in September 2021, we formed the Vaccine Advocacy Accelerator—Uganda (VAX-Uganda): a coalition of CSOs, health workers and academics working to increase access to and uptake of COVID-19 vaccination throughout Uganda, where, at the time, less than 1% of the population had completed a primary vaccination series.11 Inspired by the impact of Ugandan CSOs on the HIV pandemic, we aimed to equip Ugandan CSOs with funding and training to similarly support community-level COVID-19 responses and facilitate knowledge exchange between community-based CSOs, academic partners and national and international stakeholders. Creating a COVID-19 vaccination civil society coalition VAX-Uganda was conceptualised by the Coalition for Health Promotion and Social Development (HEPS-Uganda), a Ugandan CSO advocating for various health and human rights causes, and the Global Health Collaborative, an academic partnership between Mbarara University of Science and Technology (in Uganda) and Massachusetts General Hospital (in the USA) overseeing multiple research, clinical and educational initiatives in Uganda. Service delivery The AIDS Support Organization in Uganda cares for 100 000 people living with HIV and offers testing and counselling services.3 The Botswana Retired Nurses Society provided comprehensive, palliative and home-based treatment for individuals living with HIV, reaching underserved communities in need.3 BRAC Bangladesh coordinated community health workers who offered directly observed therapy for tuberculosis and connected patients with health providers.14 The Uganda Red Cross Society provided volunteers for understaffed vaccination sites in five districts in western Uganda. 3.