70021 +,9 LQ WKH &DULEEHDQ $ 6\VWHPDWLF 'DWD 5HYLHZ  HIV in the Caribbean: A Systematic Data Review: 2003-2008 7DEOH RI &RQWHQWV Table of Contents ............................................................................................................................. ii List of Figures................................................................................................................................... v List of Tables .................................................................................................................................... v Acronyms and Abbreviations ......................................................................................................... 1 Acknowledgments............................................................................................................................ 2 Foreword ........................................................................................................................................... 3 Executive Summary ......................................................................................................................... 4 Section 1: Introduction: Purpose and Methods ............................................................................ 6 Epidemic, Response and Policy Synthesis .............................................................................. 6 Background..................................................................................................................... 6 Methods .......................................................................................................................... 6 Section 2: Data Overview and Prevalence Estimates................................................................... 7 Overview of Regional Epidemic ............................................................................... 7 Data quality, variability and availability .................................................................... 9 Mining Surveillance Data: A proxy for regional data quality? ................................ 11 Section 3: Spatial Distribution of HIV........................................................................................... 12 National Distribution: Urban vs. Rural .................................................................................... 12 Regional Distribution..................................................................................................... 12 Overview for Data Rich Countries ................................................................................ 13 Haiti ........................................................................................................................ 13 Dominican Republic ............................................................................................... 16 Jamaica .................................................................................................................. 17 Section 4: Regional Trends........................................................................................................... 21 Why are rates decreasing? .................................................................................... 22 Is there further evidence of positive behavior change in the region? .................... 22 Is feminization of the epidemic really occurring? ................................................... 22 Section 5: Knowledge, Attitudes and Beliefs .............................................................................. 24 Section 6: Behavioral Risks and Transmission Dynamics ........................................................ 25 What is driving the Epidemic? ................................................................................................ 25 Sexual Debut.......................................................................................................... 25 Sexual Partners and Partner Concurrency ............................................................ 25 Condom Usage ...................................................................................................... 26 Correlating sexual partner and condom usage data .............................................. 26 ii HIV in the Caribbean: A Systematic Data Review 2003-2008 Contribution of STDs.............................................................................................. 27 Homophobia and Stigma........................................................................................ 27 Section 7: Risk groups including most-at-risk populations ...................................................... 28 STD clients ................................................................................................................... 28 Substance Abuse.......................................................................................................... 29 MSM.............................................................................................................................. 29 Commercial Sex Workers ............................................................................................. 29 Prisoners....................................................................................................................... 30 MSM.............................................................................................................................. 31 Section 8: Regional Response...................................................................................................... 32 Regional Response ................................................................................................ 32 Regional Funding ................................................................................................... 33 Section 9: Conclusions and Discussion...................................................................................... 39 Section 10: Recommendations..................................................................................................... 41 Section 11: Next Steps .................................................................................................................. 44 Final Note ........................................................................................................................................ 45 Bibliography ................................................................................................................................... 46 Appendices ..................................................................................................................................... 50 Appendix 1. Caribbean Regional HIV Prevalence Estimates and International Funding ...... 50 Appendix 2. Estimated Foreign Donor HIV Funding 2003-2007............................................ 50 Appendix 3. MSM, Homophobia and HIV Risk in the Caribbean Compiled by Dr Marcus Day ........................................................................................................................................... 50 Appendix 1. Caribbean Regional HIV Prevalence Estimates and International Funding* ..... 51 Appendix 2. Estimated Foreign Donor HIV Funding 2003-2007* .......................................... 53 Appendix 3.............................................................................................................................. 56 MSM, Homophobia and HIV Risk in the Caribbean Compiled by Dr Marcus Day ....... 56 MSM / HIV Related Abstracts from the Caribbean Compiled by Dr Marcus Day........ 60 Breaking history: Building an network of gay and other men who have sex with men (MSM) across the small islands of the Caribbean ......................................... 60 The effects of social stigma and legislative discrimination on the allocation of resources for HIV prevention in the Caribbean...................................................... 61 Attitudes of general practitioners towards homosexuals in the Caribbean ............ 62 Ten imperatives for action: Lessons learned In prevention of HIV/STI transmission for gay and other MSM in Latin America and the Caribbean................................. 63 The MSM task force and HIV/AIDS: a citizenship initiative to direct public policies in Latin America and The Caribbean ..................................................................... 64 Increasing access to HIV testing and counseling through integration with primary health care services: lessons learned from Jamaica ............................................. 65 Against the odds: targeted HIV/AIDS interventions to men who have sex with men (MSMs) in the Jamaican context............................................................................ 66 iii HIV in the Caribbean: A Systematic Data Review 2003-2008 Homophobic violence and sexual behaviour: Challenges in sexual behaviour change for gay and other MSM in Jamaica ........................................................... 67 HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? ............................................................................. 68 Homosexuality and HIV/AIDS stigma in Jamaica .................................................. 69 Hated to Death: Homophobia, Violence and Jamaica’s HIV/AIDS Epidemic ........ 70 On “Judgementsâ€?: Poverty, Sexuality-Based Violence and Human Rights in 21st Century Jamaica .................................................................................................... 71 Stigmas, Coping and the Impact of Gender on Patterns of Social Ostracism: A Qualitative Study of HIV+ Jamaicans..................................................................... 72 Appendix 4. Country Reports ................................................................................................. 73 Aruba ............................................................................................................................ 74 The Bahamas ............................................................................................................... 80 Barbados ...................................................................................................................... 89 Belize ............................................................................................................................ 98 Haiti............................................................................................................................. 110 Jamaica....................................................................................................................... 154 Netherlands Antilles.................................................................................................... 185 OECS.......................................................................................................................... 194 Antigua and Barbuda ........................................................................................... 195 Commonwealth of Dominica ................................................................................ 217 Grenada ............................................................................................................... 235 St Kitts / Nevis ...................................................................................................... 254 Saint Lucia............................................................................................................ 281 Saint Vincent and the Grenadines ....................................................................... 300 Trinidad and Tobago................................................................................................... 323 Turks and Caicos Islands ........................................................................................... 361 iv HIV in the Caribbean: A Systematic Data Review 2003-2008 /LVW RI )LJXUHV Figure 1. HIV Prevalence Rates, Caribbean 2001-2007.......................................................... 7 Figure 2. ANC Rates, 2005-2007 ............................................................................................. 8 Figure 3. HIV prevalence among 15 to 24 year old ANC clients at La Altagracia Hospital, Santo Domingo.................................................................................................................... 8 Figure 4. Geographic Distribution New HIV Infections, 2007................................................. 12 Figure 5. HIV Trends: the General Population and Pregnant Women in Haiti: 1982-2012 ... 14 Figure 6. HIV Prevalence among Antenatal Clinic Attendees in Jamaica (1989 – 2007)...... 17 Figure 7. HIV Sero-Prevalence among Those Most at Risk - Jamaica.................................. 18 Figure 8. HIV Prevalence among STD Clinic Attendees in Jamaica: 1986, 1990 - 2007 ...... 18 Figure 9. Reported Risk Behaviour among Adults with AIDS in Jamaica 1982-2006 ........... 19 Figure 10. HIV and Social Vulnerability among MSM 2007 ................................................... 19 Figure 11. HIV Prevalence among Female Sex Workers Santo Domingo, 1991 - 2004 ....... 22 Figure 12. Estimated Percent of Adults Living with HIV in the Caribbean: Females-Males: 1990-2007 ......................................................................................................................... 23 Figure 13. HIV Prevalence Among STI Patients in the Bahamas 2000-2007 ....................... 28 Figure 14. HIV Prevalence among STI Patients in Jamaica: 2000-2007............................... 28 Figure 15. Seroprevalence Studies Among MSM .................................................................. 29 Figure 16. Seroprevalence Studies Among CSW .................................................................. 30 Figure 17. HIV Prevalence Among Female Sex Workers in Guyana: 1989-2005 ................. 30 Figure 18. Seroprevalence Studies Among Prisoners ........................................................... 31 Figure 19. Estimated HIV Expenditures Bahamas and Dominican Republic ........................ 36 Figure 20. Estimated HIV Expenditures Haiti......................................................................... 37 Figure 21. Estimated HIV Expenditures Trinidad and Tobago............................................... 38 /LVW RI 7DEOHV Table 1. Data availability: Caribbean Region, 2003-2008...................................................... 10 Table 2. Data Availability: Surveillance variables, 2003-2008 ............................................... 11 Table 3. Prevalence of HIV by Gender and Characteristics* ................................................. 15 Table 4. Examples of Regional and National Priorities .......................................................... 32 Table 5. Regional Funding Allocation- GFATM and USG PEPFAR ...................................... 34 v HIV in the Caribbean: A Systematic Data Review: 2003-2008 Acronyms and Abbreviations AIDS Acquired immune deficiency syndrome ANC Antenatal clinic ART Antiretroviral therapy BCC Behavior change communications BSS Behavioral surveillance survey CAREC Caribbean Epidemiology Center CSW Commercial sex worker DHS Demographic Health Survey GAIS Guyana AIDS Indicator Survey GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HIV Human immunodeficiency virus MARP Most at-risk populations MSM Men-who-have-sex-with-men MTCT Mother-to-child transmission of HIV OECS Organization of Eastern Caribbean States OVC Orphans and other vulnerable children PANCAP Pan-Caribbean AIDS Partnership PEPFAR President’s Emergency Plan for AIDS Relief PLWHA People Living with HIV/AIDS PMTCT Prevention of mother to child transmission STI Sexually-transmitted infection UNAIDS United Nations Program on HIV/AIDS VCT Voluntary Counseling and Testing 1 HIV in the Caribbean: A Systematic Data Review 2003-2008 Acknowledgments This data review is the result of a joint collaboration between WHO/PAHO/CAREC, UNAIDS and the World Bank. The following persons are acknowledged for their contributions to this report. Bilali Camara-UNAIDS Marcus Day-St. Lucia Peter Figueroa- Jamaica Daniel Halperin- World Bank Elizabeth Holt- World Bank Serena Koenig, Haiti 2 HIV in the Caribbean: A Systematic Data Review 2003-2008 Foreword This report is the result of a comprehensive, regional, data-driven review of the HIV epidemic in the Caribbean. Several reports have been published about the Caribbean but none have specifically focused on a thorough review of data sources, data collection strategies and detailed epidemiology of the HIV epidemic. In the past, the Caribbean epidemic has largely been characterized as a generalized, heterosexual epidemic on the verge of explosion. In addition, assumptions based on anecdotal and observational information have been made about the regional epidemic. This data review represents an effort to produce an evidence-based characterization of HIV/AIDS in the region. It should also create an important and useful snapshot of the epidemic that should provide a framework for conceptualizing the epidemic and targeting programmatic efforts in the region. 3 HIV in the Caribbean: A Systematic Data Review 2003-2008 Executive Summary According to UNAIDS, the Caribbean region is the second most affected by HIV in the world. This is despite what appears to be a stabilizing and in some countries declining prevalence. Since 2001, the regional HIV prevalence estimates have ranged between 1.1%-1.6%. While male cases continue to predominate in the region, the number of cases in women has continued to increase. In Trinidad and Tobago, for the first time, the number of reported cases among women in 2007 surpassed that in men by 1%. The predominant mode of transmission in the region is thought to be heterosexual although several countries have a significant burden of cases reported with unknown risk factors. HIV remains one of the leading causes of death among persons ages 15-44 but deaths have declined significantly due to the regional availability of ART. Although this general information is well-known about the Caribbean epidemic, primarily through UNAIDS annual reports, detailed epidemiological information has not been available to concretely determine and understand the trajectory and drivers of the epidemic. Without this information, it is difficult to determine if national and regional programmatic responses are appropriately focused to yield the highest impact or target the most affected populations. Given these things, WHO/PAHO/CAREC, UNAIDS and WB assembled a joint committee to sanction the undertaking of an epidemiological synthesis for the region. The goal of the synthesis was to gather previously unpublished or unanalyzed country-level data and together with known regional data further characterize and develop a more focused and accurate epidemiological snapshot of the region. Ultimately, most of the data gathered during this exercise did not yield new information but several issues were highlighted by this exercise. First, regional data collection is fragmented and inconsistent. The absence of systematic or coordinated data collection from country to country was tangible when attempting to characterize the epidemic. Since national data are not collected at parallel timeframes, the ability to confidently estimate regional prevalence or describe regional trends is limited. Consequently, this fragmentation is also evident throughout the data presentation in this report. Second, there is tremendous variation in quality and availability of public health data from country to country. This is partly due to variations in country capacity but also secondary to the need for development and implementation of a regional surveillance strategy that is user-friendly, reliable, acceptable and tailored to country capacity. Third, although several behavioral surveys shed light on risk behavior in the region, the biggest information gap revealed by this exercise is the absence or incomplete collection of data on HIV transmission risk category. As described in the report, the number of heterosexual cases may be over-reported while cases of MSM risk are likely underreported. This limits the ability to determine the drivers of the epidemic and for purposes of this exercise, contributes to the inability to conduct a full epidemiological synthesis. Fourth, MARPs continue to be at high risk for HIV infection as demonstrated by numerous behavioral and serosurveys across the region from 2003-2008. Rates of HIV in MSM are as high as 30% in Jamaica and nearly as high among CSW in Guyana. Clearly, prevention interventions are urgently warranted for these groups. Fifth, stigma is pervasive in the region and its prevalence in the OECS is staggering. It seems and “all hands on deck approachâ€? including efforts to raise HIV awareness, strengthen political will, expand community engagement and implementation of structured anti-stigma campaigns will be necessary to combat this poisonous mentality. Finally, attempts were made to determine to exact magnitude of HIV-related regional funding over the past several years and analyze this information in conjunction with the regional response. The absence of an archive of financial resource data and its allocation by technical area limits the ability to assess the impact of these resources. Since the availability of future resources, 4 HIV in the Caribbean: A Systematic Data Review 2003-2008 particularly from the international donor community, is not guaranteed, it is within the region’s best interest to develop a mechanism to effectively track all HIV-related funding and ensure it is targeted most appropriately to reduce HIV transmission in the region. Although the above challenges limited the outcomes of this synthesis, it is important to acknowledge the importance of this exercise. Establishing an information baseline is necessary to determine the most appropriate next steps and directions for implementing an effective regional data collection strategy. This awareness is critical simply because if the region doesn’t know its epidemic, it cannot realistically reduce the impact of the HIV epidemic on its people. 5 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 1: Introduction: Purpose and Methods Epidemic, Response and Policy Synthesis Background The Caribbean epidemiological synthesis is an attempt to characterize and analyze the most recent trends in the regional HIV epidemic. The work was sanctioned by a joint multi-agency team including members from PAHO, UNAIDS and World Bank. All Caribbean countries except Cuba and the US Virgin Islands were invited to participate but country human resource challenges limited the inclusion of data from every country. Therefore, this report is an analysis of data from the following countries: Aruba, Bahamas (Bah), Barbados (Bds), Belize, Dominican Republic (DR), French Territories, Guyana, Haiti, Jamaica, Netherlands-Antilles, the OECS, Trinidad and Tobago (TT), Turks and Caicos. Focal persons were assigned to each country and were charged with collecting HIV-related epidemiological, surveillance and research data for the previous five years. The purpose of an HIV epidemiological synthesis is to assess and analyze new or recent data to provide strategic direction for the program development and implementation. New data sources include any unpublished, unexplored or unanalyzed data, the latest surveillance data, as well as, biological and behavioral surveys, STI data, program monitoring data and quantitative or qualitative research data. The synthesis also tests and explores an existing hypothesis about the epidemic and discusses relevant data- based policy implications. For the Caribbean synthesis, we aimed to: 1. analyze HIV transmission patterns, 2. determine epidemiological and behavioral drivers in the Caribbean and 3. analyze the national and regional responses relative to findings from the analysis. Methods To obtain the most accurate and up-to-date overview of the epidemic, data were only reviewed for 2003-2008. A data collection tool was developed to guide data collection. Data were reviewed and collated from a variety of sources including demographic health surveys, epidemiological and behavioral surveillance data, research studies and program monitoring and evaluation data. 6 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 2: Data Overview and Prevalence Estimates Overview of Regional Epidemic The Caribbean Region is thought to have the second highest rates of HIV in the World (UNAIDS 2007, CAREC, 2003). Since HIV was first identified in the Caribbean 27 years ago, more than 300,000 infections have been reported in the region. The true regional HIV prevalence is unknown since at the onset of the epidemic the regional focus of HIV- related data collection was cumulative AIDS cases rather than HIV rates such as prevalence and incidence (CAREC 2003). However, beginning in 2001, a regional prevalence estimate was generated and as shown in Figure 1, regional rates have either plateaued or continued to decrease. It appears the regional prevalence estimate has never surpassed 2%. Figure 1. HIV Prevalence Rates, Caribbean 2001-2007 2 1.5 1 0.5 0      Prevalence The most recent national prevalence rates, which are largely based on UNAIDS projections estimates (UNAIDS 2007) are shown in Appendix 1. In many countries, given the absence of population-based epidemiological data, ANC rates have been used to estimate prevalence in the general population. Several ANC surveys have been conducted over the last few years and with the exception of Bahamas and Haiti, rates are similar to slightly higher than those reported for the region in most recent years (Figure 2). TT has conducted two ANC surveys in the last five years. The explanation for the appreciable difference in seroprevalence found in the studies is unclear. 7 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 2. ANC Rates, 2005-2007 Country HIV Prevalence Rate (%) Year Haiti 2.2 2005 DR 1.0 2006 Jamaica 1.1 2007 Guyana 1.5 2006 Trinidad and Tobago 1.5 and 2.2 2005 Bahamas 3.0 2006 Belize 1.9 2007 The burden of disease remains among 15-49 years and HIV is also one of the leading causes of death in this age group. The gender ratio varies slightly from country to country but the number of HIV infection in women is increasing. This has led to speculation about the feminization of the epidemic (UNAIDS, 2008). However, HIV prevalence data in some countries show a decline in female prevalence rates across the region. For example, Figure 3 from the DR, depicts the decline in cases among pregnant women, a sub-group that traditionally has served as a proxy for national prevalence. (Halperin, 2009) Figure 3. HIV prevalence among pregant women 15-24 years Santo Domingo 1991-2006 2.5 2 y = -0.0477x 2 + 0.5661x HIV % 1.5 1 0.5 0 1991 1992 1993 1994 1995 1996 1997 1999 2000 2004 2005 Years HIV % 15-24 years Source: Halperin, et al. JAIDS, 2009 HIV continues to be highly stigmatized throughout the region (Adamakoh 2003, Ottosson, 2007). Despite the influx of financial support from international donors such as GFATM 8 HIV in the Caribbean: A Systematic Data Review 2003-2008 and PEPFAR, the region continues to struggle to find an aggressive and coordinated HIV response owing largely to infrastructure and human resource challenges. Data quality, variability and availability The regional variation in data collection and availability is striking. Table 1 illustrates the availability of recent HIV data by data category and Table 2 highlights the availability of surveillance variables by country. HIV/AIDS prevalence, absolute case number and cumulative AIDS cases are the most commonly and consistently reported indicators for the region. Up to now, no countries have reported incidence data. In fact, HIV did not officially become a reportable disease in the region until 2006. (www.CAREC.org). Nearly all countries are able to report cumulative AIDS case data which provide little insight about the epidemic in “real-timeâ€?. Two countries provided a synopsis of newly reported HIV cases in addition to cumulative AIDS cases but only one country disaggregated new HIV—rather than AIDS-- infections by age and gender. Although one of the original objectives of the synthesis was to epidemiologically characterize the last 1000 infections, these data were not available since as shown in the tables, data collection across the region is not uniform. In addition, countries have not yet implemented strategies to track and monitor HIV incidence. Several countries have conducted behavioral surveys among risk groups with data most commonly collected among MSM. No countries outlined the contribution of laboratory –based data reporting and for some countries this may be due to poor laboratory capacity. Laboratory reporting is an important link in the surveillance chain and is essential to achieve completeness of reporting. The DHS which is considered superior to ANC surveillance for epidemiological data collection due to its methodological strengths and improved representativeness, (Boerma, 2003) has been conducted in only two countries—DR and Haiti. Notably absent are data on transmission risk. This critical information gap tempers the interpretation of national data limits the ability to characterize the regional epidemic. Regional characterization is also challenging because data collection across the region is not coordinated to ensure country data are collected among similar populations and timelines. The randomness and variability of data collection across the region create challenges for making country-to-country comparisons, or evaluating the impact particularly if regional campaigns or strategies are being implemented. 9 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table 1. Data availability: Caribbean Region, 2003-2008 Cumulative Incidence Prevalence AIDS DHS Any Behavioral Surveillance Lab Data Aruba X Bahamas X ? X—MSM, Prisoners Barbados X X X—Men Belize X X X-Prisoners DR X X X X—Gen pop, MSM, CSW French ? X X--MSM Terr Guyana X X X--Gen pop, MSM, CSW, Youth, Miners Haiti X X X X—Gen pop Jamaica X X X—STD, MSM, CSW, Prisoners Nether- Antilles OECS X X X-Prisoners Trinidad X X X-MSM, Prisoners & Tobago Turks & Caicos 10 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table 2. Data Availability: Surveillance variables, 2003-2008 Country Gender Age Transmission Risk** Geography Aruba X Bahamas X X Barbados X X Belize X DR X X X French Terr X Guyana X X ? Haiti X X X Jamaica X X X X Nether- X Antilles OECS X +/-* Trinidad and X X X Tobago Turks & X Caicos Mining Surveillance Data: A proxy for regional data quality? For this data review data access “on the groundâ€? was limited in several countries. Therefore the results of a data mining exercise conducted at CAREC may provide a context for interpreting regional data (CDC/CAREC unpublished data). The data mining exercise was an inventory of all HIV-related data sources at CAREC to assess the availability, timeliness, completeness and to some extent, quality of country surveillance data. Overall, there was considerable variability by country for each of these surveillance parameters. One of the most important findings was that countries were not uniformly reporting age and gender. This is substantiated by data submissions for this synthesis as illustrated in Table 2. The value of the data mining exercise was in highlighting the need to ensure data and surveillance systems at the country level are operational and effective. 11 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 3: Spatial Distribution of HIV National Distribution: Urban vs. Rural The Caribbean epidemic is as much rural as it is urban. This is largely due to the predominance of small countries with limited infrastructure and capacity such as those in the OECS, French territories or Netherland-Antilles. In addition, disease burden in Haiti is equally rural and urban (Cayemittes, 2007). Therefore, for many countries data stratification by national geography or departments provides little additional insight. The exceptions are Jamaica and TT, where the country is divided into parishes and counties, respectively; examination of data by these smaller geographic units provides some insight into the country’s epidemiology. For example, when HIV data in Jamaica are stratified by parish the highest burden of disease is consistently found in the most urban parishes, Kingston/St. Andrews and St. James/Montego Bay (Jamaica MOH, 2006). Likewise in Trinidad and Tobago, data stratified by county revealed an unexpected finding: 64% of all new cases of HIV in 2007 were reported from a single county- St. George. Additional data are unavailable to further assess the epidemiology of infections in this county. However, it is known to be one of the poorest, most disadvantaged counties in TT (TT MOH, 2007). Regional Distribution When region-wide spatial distribution is examined, the regional burden of disease is largely concentrated in three countries: DR, Haiti and Jamaica. According to UNAIDS, in 2007, 17,000 cases of new HIV infection were reported (UNAIDS 2007, 2008). Of these, 35% and 34% were reported in DR and Haiti, respectively, followed by 12% from Jamaica. Cumulative HIV/AIDS burden also rests in these countries since 82% of all HIV cases since the onset of the epidemic (47% from Haiti, 24% from DR and 1l% from Jamaica) were reported from these countries. (CAREC, 2007) Figure 4. Geographic Distribution New HIV Infections, 2007 35 30 25 20 15 10 5 0 Haiti DR Jamaica T&T Bah Others In this report, countries are categorized as data rich, data intermediate and data limited. This designation as derived based on: 1. the availability of epidemiological data for the report and 2. Country disease burden relative to the other countries in the region. 12 HIV in the Caribbean: A Systematic Data Review 2003-2008 Country designations are: Data Rich and Haiti are categorized as rich due to high disease burden and availability of data from multiple seroprevalence and behavioral surveys. Jamaica which has the third highest burden of disease, is also included in this category secondary to its extensive history of data collection at a variety of venues and among several at-risk populations. In addition, Jamaica has conducted the most epidemiologic and seroprevalence data in the region. Data Moderate-Bahamas, Guyana, Barbados, Trinidad and Tobago given their intermediate level of data collection Data Limited- Aruba, Belize, French Territories, Netherlands-Antilles, OECS and Turks and Caicos given either the country-size and/or capacity to collect data or implement ongoing surveillance. Overview for Data Rich Countries Since nearly 80% of regional HIV burden rests in Data Rich countries, a closer examination of recent data (2003-2008) from each of these countries is warranted. Haiti C S Epidemiological trends show that Haiti has a declining HIV prevalence. Figure 5 illustrates this decline as well as prevalence projections up to 2012 (Gaillard 2007). International donor support has allowed the country to dramatically improve access to HIV care and treatment across the country. As of September 2008, 93,715 people were in HIV care and 21,509 had been treated with ART which is dramatically increased since 2001, when fewer than 300 patients were on ART (Severe, 2005). Because Haiti’s highest programmatic priority is now achieving universal access to treatment for HIV/AIDS, for the last several years, data from Haiti have not been epidemiological in nature nor focused on MARPs. 13 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 5. HIV Trends: the General Population and Pregnant Women in Haiti: 1982-2012 HIV Trends: the General Population and Pregnant Women in Haiti: 1982-2012 General Population Pregnant Women 5 4 3 2 1 0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 20 20 -1 M M U S S In 2005-2006 a population-based survey on Morbidity, Mortality and Utilization of Services (MMUS) and seroprevalence study among pregnant women were conducted among women ages 15-49 and men ages 15-59. (Cayemittes M, 2007) Nearly 10,000 households were enrolled and women were sampled 2:1. Epidemiological findings included: 1. 60% of the population is 80 Commercial sex 25.0 STD history 47.1 Crack, cocaine 8.5 IV drug use 1.1 No obvious risk 20 In addition, Jamaica has data describing the social vulnerabilities associated with HIV. (Figure 10). Although data were collected among MSM, the association between HIV and social vulnerabilities such as homelessness, poverty and imprisonment is clear. Figure 10. HIV and Social Vulnerability among MSM 2007 % HIV+ % HIV+ Social Factors OR, 95% CI n=64 n=137 Ever homeless 48.4 28.8 2.3, 1.1-5.0 Ever in prison 40.5 29.9 1.6, 0.8-3.3 Unemployed 32.4 31.3 1.0, 0.6-1.9 Victim of physical violence 46.7 29.2 2.1, 1.0-4.7 Low socio-economic status 40.0 23.8 2.1, 1.2-3.9 Ever paid for sex 39.4 30.4 1.5, 0.7-3.2 Ref. Figueroa et al 2008 19 HIV in the Caribbean: A Systematic Data Review 2003-2008 Given the wealth of epidemiological data and insights gleaned from ongoing data collection, researchers and public health officials in Jamaica have postulated about the drivers of the epidemic in the country. One such insight relates to the prevalence of ongoing risky sexual behaviors despite public health campaigns to raise awareness and encourage monogamy. Researchers attribute the slow behavior change in risky sexual practices among men to the tendency for masculinity to be associated with the number of active sexual partner. It is felt that this practice among men having an ‘outside woman’ is a deeply engrained cultural practice. It is possible these issues are prevalent and some of these explanations may help explain the high rates of infection among some groups, not only in Jamaica but throughout the region (Figueroa 2004, 2005). 20 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 4: Regional Trends As shown in data rich countries, the Caribbean epidemic appears to be either at a plateau or declining (UNAIDS 2007, 2008, Cayemittes 2006, Gaillard 2007, Halperin 2009). Since combined HIV infections in Haiti and the DR represent at least 60% of the total number of infected persons in the greater Caribbean region, declines in these two countries, along with similarly declining or stable trends in several other Caribbean countries like TT and Jamaica, strongly suggest that the overall HIV epidemic in the region is declining. For example, in the DR, the prevalence among Haitian immigrants declined from 2002-2007 from 5.0% to 3.2% (Halperin 2009). In addition, there are several examples of declining rates in data rich countries that provide evidence for the regional decline in rates. First, HIV prevalence rates in Jamaica have been steady for the last 3-5 years and have plateaued at 1.6%. (UNAIDS 2007, Jamaica MOH). Second, HIV rates in the DR peaked at 2.7% in 2001. Following improvements in national surveillance methodology, particularly implementation of the DHS in 2002, the official country estimate was revised to 1.1% in 2006. Third, national household surveys found 1.0% (CI 0.9%-1.1%) adult prevalence in 2002 and 0.8% (0.6%-0.9%) in 2007 (Halperin 2009). Third, HIV-1 prevalence among CSW in 2006, the last year for which data are available from several national sites, ranged from 1.4% in Puerto Plata to 4.1% in La Romana (down from 12.5% in 1996). Figure 11 below illustrates the general downward trend in prevalence among CSW at sites in the DR’s capital city. Median prevalence at all sites nationally was about 5% in 1991 and declined to an estimated 3% by 2006. Fourth, the decline in HIV rates in Haiti has been well-described with decreasing seroprevalence demonstrated in both the general population and among pregnant women as shown in Figure 5 (Gaillard 2006). Finally, in addition, a recent prospective study found an HIV incidence rate of only 0.5% (95% CI: 0 to 2.9%) among a population of CSW and STI patients in Santo Domingo. (DIGECITSS, 2007). Therefore the collective evidence from these countries suggests a regional decline in HIV prevalence. 21 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 11. HIV Prevalence among Female Sex Workers Santo Domingo, 1991 - 2004 16 15 14 13 12 11 10 % 9 8 7 6 5 4 3 2 1 0 1991 1992 1993-94 1994 1995 1996 1997 1998 1999 2000 2001 2002 2002-03 2004 Years 90% CI HIV Prevalence % 90% CI 5 per. Mov. Avg. (HIV Prevalence %) Why are rates decreasing? Health officials in the DR have confirmed the continued decline in prevalence rates such as those illustrated above among CSW. They attribute the apparent reduction in the rate of new HIV infections to changes in sexual behavior, particularly increased condom use among female sex workers and their clients and probably an overall reduction in multiple partnerships among men (Halperin 2009). They also believe prevention programs have helped contribute to these successful behavioral changes. Although this has not been systematically evaluated, it is possible similar explanations apply in other countries. Is there further evidence of positive behavior change in the region? Although transmission risk and behavioral risk factor information is not available for most countries, it is useful to examine data that are available. In Jamaica reported condom use is relatively high and reports of escalating condoms sales are common (Hope Enterprises, 2003). While self-reported behavioral data is often viewed with some suspicion, it is possible that the rates of HIV in the region have stalled or declined as a result of increased condom usage, particularly among MSM and CSW. Haiti Behavioral Surveillance Surveys (BSS) conducted in 1999 and 2003 among youth in the Haitian capital, Port-au-Prince, show the proportion of males ages 15-19 and 20-24 reporting sexual activity with occasional partners fell from 50% and 60% in 1999 to 12% and 20% in 2003, respectively (Hallet 2006, Gaillard 2006). Among females of the same age groups this reported behavior dropped from 31% and 52%, in 1999 to only 2% for both age groups in 2003, respectively. Modest increases in reported condom use were also found in this youth study. Is feminization of the epidemic really occurring? Surveillance data for the last five years suggest that while the rates of HIV among women have been increasing, there is still a male predominance across the region. Figure 12. Except in Haiti, the number of cumulative cases among males in the region outnumbers 22 HIV in the Caribbean: A Systematic Data Review 2003-2008 females. In addition, among recent infections, for the majority of countries, male cases exceed those in females. For example, Jamaica has had a clear male predominance with 1.3-1.4% males in the number of reported cases and the number of female cases has never surpassed that in men. In addition, in the OECS, 72% of reported cases have been among men. This was also true in Aruba, Belize, Barbados, Bahamas, French territories and the Netherlands-Antilles where the range of reported cases among men was 56- 62%. Among data-rich countries, in 2007, 63% of cases were reported in men and near the beginning of the epidemic, just over 50% were in women (UNAIDS 2008). While this latter point might suggest a shift in the gender balance among cases, these estimates were generated through a variety of sampling schemes and methodology rather than through consistent, routine and robust surveillance programs. It is possible that a female predominance is occurring in specific countries such as TT approximately 56% of reported cases have been consistently reported among men until 2006 when the ratio was 1:1. The following year, 47% were among female compared to 46% among males. When TT data are further examined by age, 73% of cases age 15-29 were among females. However, health officials suspect the increase in HIV testing services through PMTCT programs for women of childbearing age may be contributing to this increase. Figure 12. Estimated Percent of Adults Living with HIV in the Caribbean: Females-Males: Females-Males: 1990-2007-UNAIDS/WHO F emales Males 120% 100% 80% 63% 59% 57% 76% 70% 60% 40% 20% 37% 41% 43% 24% 30% 0% 1990 1995 2000 2005 2007 1990-2007 23 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 5: Knowledge, Attitudes and Beliefs The most recent KAB data in the region are from Guyana and the OECS in 2005 and Haiti and Trinidad and Tobago in 2006 (CAREC.org, CAREC/PAHO/WHO 2006, MOH Guyana 2006). Guyana data were collected through the GAIS among the general population, OECS data were conducted by implementation of a BSS among the general population, in-school youth, minibus and taxi drivers, Haiti and TT data were collected via DHS in 2005 and a national survey in 2006, respectively. All countries targeted persons age 15-49. Direct comparisons are not possible across surveys since the probes and inquiries varied from country to country. However, despite the variability, a few themes are from these surveys are notable. First, in general awareness of HIV was high since the majority of participants in all countries had heard of HIV. However, when probes detected a more detailed understanding of HIV, HIV understanding decreased. For example, in OECS only 27% and 44% of in-school youth and taxi drivers, respectively and 50% of Guyanese participants could identify ways of prevention of or reject major misconceptions about HIV transmission. Additionally, in Guyana, 27% believe HIV was transmitted by sharing utensils. In TT, 69% knew the difference between HIV and AIDS. In Haiti, knowledge of HIV/AIDS was assessed during the MMUS in 2005-2006. Virtually all Haitian adults had heard of HIV/AIDS, but only 32% of females and 41% of males were aware of HIV prevention strategies such as condom use and monogamy or modes of transmission. Knowledge was significantly lower among males and females who had never been to school, who live in rural areas, and who are in the bottom economic quintile. Second, in the OECS respondents who ever had an HIV test were: 18-27% among those age 15-24, 35-62% among age 25-49 and 48% among taxi drivers. Similar testing patterns were seen in other groups suggesting the need to improve access to HIV testing, particularly among young adults. Finally, HIV-related stigma is high in the region. The GAIS revealed 63% of persons would refuse to buy from an HIV-positive shopkeeper or vendor. In TT 63% of participants declined to admit if they had a close friend or relative who was HIV-positive or who died from AIDS. While the degree of stigma suggested in these surveys is striking, stigma-related data from the OECS BSS are even more compelling. Among in- school youth, only 40% had accepting attitudes toward PLWHA. But worse, accepting attitudes were in a meager 1-4% among the general population age 15-24, 5-8% among those 25-49 and 5% among taxi drivers. The high degree of stigma in these countries suggests the need for broad and expansive anti-stigma and discrimination programs in the region. 24 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 6: Behavioral Risks and Transmission Dynamics What is driving the Epidemic? As illustrated in Table 2, risk transmission is not routinely collected and is never completely reported. Although it appears that some countries collect routine data on transmission, as of yet there is no regional strategy to ensure consistent collection of this information. Therefore, without these data it is difficult to use data to delineate with confidence the drivers of the epidemic. The region is thought to have a heterosexual epidemic but this has not been completely substantiated by consistently reported surveillance data. For example, recent TT surveillance data captured HIV transmission category in only 42% of reported cases. In Aruba, 70% of cases have unknown risk factors. In 2008, Bahamas surveillance data showed 100% heterosexual risk despite finding nearly 9% prevalence among MSM the year before. Furthermore, in Jamaica, 24% of AIDS cases have no identified risk factor (Jamaica MOH 2006, Figueroa . However, over the last few years, several countries have collected behavioral data through seroprevalence or behavioral surveillance studies or though routine STD screening. Although the data were not collected uniformly, they are instructive (Hope 2008, Figueroa 2005, 2009, CAREC/PAHO/WHO 2006, Macro Intrnl 2006, MH Guyana 2006). Sexual Debut Information about sexual debut from Guyana, Haiti, TT, and the OECS show that sexual debut at less than 15 years of age was reported between 9% and 11% of participants in Guyana and TT, respectively and the median age of sexual debut in both countries was 18 years. In Haiti, among persons 15 to 24 years, 15% of females and 43% of males were sexually active before the age of 15. In the OECS sexual debut before age 15 was reported among 40% of taxi drivers, 22%- 26% of 15-24 year olds and 25-32% among 25-49 year olds. This data suggest a need for youth-based prevention interventions to delay sexual debut and reduce HIV risk behavior. Other areas warranting further exploration across the region include sexual partners and partner concurrency and condom usage. Sexual Partners and Partner Concurrency There is limited data on sexual partners and partner concurrency. While several participants admit to having multiple sexual partners, the frequency of concurrency among these persons is often unknown. Data from a 2007 men’s health study in Barbados showed that 47% of men had >1 sexual partner but concurrency was not queried specifically. Furthermore, 62% of MSM-identified men in this study reported having >2 partners in the previous 12 months and of these, 35% had not used a condom during last sex. In 2004, the Guyana AIDS Indicator Survey revealed MSM on average had 3.4 concurrent partners and 9% of all men and 1% of all women had > 1 partner in the previous 12 months. Fifty-seven percent of MSM reported having >2 CSW sex partners and 23% of all MSM surveyed reported having CSW partners. In the DR, 27% reported > 2 partner in the past 12 months. 25 HIV in the Caribbean: A Systematic Data Review 2003-2008 The MMUS in Haiti showed 29% of sexually active females and 62% of males had engaged in unprotected sex with a casual or extramarital partner in the previous 12 months and data from Jamaica suggest that multiple sexual partnerships are common in Jamaica especially among men. The proportion of Jamaican men aged 15 – 45 years reporting more than one sexual partner in the past 12 months ranges between 49% and 59% in various surveys. In addition, among men aged 15 – 24 years, as many as 76.2% report having sexual intercourse with more than one partner in the last 12 months. Finally, a 2006 KAB in TT revealed 85% of participants age 15-49 reported > 1 sex partners the previous 12 months while a Jamaica survey reported 80% of respondents had multiple sex partners. Condom Usage Data on condom usage have been collected through a variety of surveys primarily among MSM and CSW. Most data on condom usage have been collected via KAB or BSS in Barbados, Guyana, TT and the OECS. The most commonly collected condom usage data have been queries about: 1. general frequency; 2. at last sex; 3. unprotected sex in the previous year; 4. usage with CSW and other non-regular partners; 5. CSW usage with clients vs. non-clients. A 2004 survey in Guyana revealed 89% and 46% of CSW reported condom use with clients and non-clients, respectively. In addition, in this study, 71% of MSM reported regular condom usage suggesting that CSW recognize the risks associated with unprotected sex with casual partners. Data from the 2005 OECS BSS collected in the general population, in-school youth and taxi drivers queried participants about condom use with casual partners. Nearly 40% of youth, 55-73% of the general population and 59% of taxi drivers reported condom usage with these partners. In 2007, a KAB in Barbados revealed 80% of CSW and 46% of men admitted to unprotected sex in the last 12 months. Also in 2007, a KAB administered in TT, found 62% of young adults 15-24 compared to only 38.5% of 25-49 year old reported condom usage. In Haiti, 26% of females and 42% of males reported condom use at last sex in the MMUS. Fifty-five percent of sexually active young females and 95% of young males had high-risk intercourse in the prior 12 months. Twenty-nine percent of young females and 43% of males had used a condom with the last act of high-risk sexual intercourse. In the DR reported usage in 2007 increased from 25%-40% to 68% among men compared to women but reasons for this shift were unclear. It is possible that men surveyed were more likely to engage in casual sex but these data were not reported. Finally, condom usage appears to be on the rise in Jamaica where condom usage among CSW is high with 87% and 76% reporting usage in two separate studies and 83% and 66% of young adults age 15-24 reporting condom usage with non-marital partners. Overall, in the region, a wide range of condom usage was reported with casual partners, particularly among CSW and MSM but reported condom usage seems high. It is uncertain if these increases in condom usage are the result of marketing and BCC efforts across the region or general increased availability of condoms in the region. Correlating sexual partner and condom usage data It is possible that increases in actual condom usage are contributing to the decline in HIV prevalence in the region. As described, numerous studies have been conducted across 26 HIV in the Caribbean: A Systematic Data Review 2003-2008 the region to determine the frequency of sexual risk behavior, primarily among MSM and CSW. However, to understand the contribution and impact of this risk behavior on the epidemic, these data should be correlated with condom usage. Is it possible that most studies collect such information but this analysis was not available for the synthesis. Therefore, data correlating sexual partners or concurrency with condom usage is warranted. Contribution of STDs Since HIV status is generally not yet correlated with HIV positivity, there aren’t enough data in the region to quantify the relationship between STDs and HIV or determine their contribution to HIV transmission. However, some data are available on HIV/STI co- infection prevalence. See Section 7. Homophobia and Stigma HIV-related stigma is pervasive in the region as suggested by KAB surveys (Adamakoh, 2003, Ottosson 2007). It is also well known that several countries have written laws forbidding homosexuality and that such offenses are punishable by imprisonment for 2 years to life. Countries with such buggery offenses published include: all six OECS, Barbados, Belize, Guyana, Jamaica and Trinidad and Tobago. It is possible that this legislation indirectly contributes to the inability to obtain accurate behavioral risk and transmission data. As illustrated in the KAB results, many in the region are concerned with confidentiality. Taken together, these issues are likely impacting both the availability of accurate data and willingness for MSM to be tested and seek treatment for HIV. HIV-related stigma in Jamaica is well-known throughout the region. Perspectives from public health officials in Jamaica suggest the stigma associated with HIV/AIDS and marginalized groups is a critical factor contributing to the continued spread of HIV in Jamaica and maybe the region. The initial association between homosexual men and AIDS, as described in the USA, remains imprinted in the minds of most Jamaicans. This complicates the response to HIV because the stigma against homosexuality is very strong. Although overt discrimination against PLHIV is no longer common HIV related stigma remains strong and very few PLHIV are willing to be open or public with their status. This makes the epidemic virtually invisible in the mind of most persons who do not appreciate that they could be at risk. Heterosexual men are concerned that if they are HIV infected persons may believe that they are really homosexual. However, most HIV infected women are also concerned about revealing their HIV status. The strong stigma associated with HIV and male homosexuality in Jamaica drives the HIV epidemic underground and makes it more difficult for persons at risk to seek services including HIV testing. At the same time it makes it more difficult for HIV program staff to reach those most at risk especially MSM. Among MSM there is also significant denial of risk and failure to face up to the reality of HIV and AIDS within their community. HIV prevalence rates among MSM have been unacceptably high (approximately 30%) for over 15 years and warrants attention. 27 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 7: Risk groups including most-at-risk populations Many sub-population or MARP surveys have been conducted across the region. Sub- populations of interested include: MSM, Substance Users, CSW, STD clients and prisoners. STD clients HIV prevalence in STD client populations is not consistently available. This is likely due to sporadic access to HIV testing at STD clinics in the region. However, HIV and STI co- infection trend data are available in countries such as Jamaica and Bahamas (Buensuceso 2007, CAREC 2003, Jamaica MOH 2006). Figures 13 and 14 illustrate these trends in Bahamas and Jamaica, respectively. Figure 13. HIV Prevalence Among STI Patients in the Bahamas 2000-2007 7.00% 6.00% 5.80% 5.30% 5.00% 4.80% 4.40% 4.00% 4.10% 3.60% 3.30% 3.00% 2.00% 1.00% 0.00% 2000 2001 2002 2003 2004 2005 2006 Source: Bahamas MOH, 2006 Figure 14. HIV Prevalence among STI Patients in Jamaica: 2000-2007 7.00% 6.51% 6.50% 6.00% 5.00% 4.60% 4.00% 4.06% 3.60% 3.00% 2.00% 1.00% 0.00% 2000 2001 2002 2005 2007 Source: Jamaica MOH, 2006 28 HIV in the Caribbean: A Systematic Data Review 2003-2008 Interestingly, these countries show opposite trends in co-infection rates but explanations for the differences are unclear and are likely due to country-specific data collection and epidemic response. In 2006, TT reported an HIV/STI co-infection rate of 2.2% which represents a six-fold decline from 13.6% in 1991 and 6% in 2002. (TT MOH, 2006). In addition, in 2005-2006, in a serosurvey of 180 newly diagnosed HIV patients, 42% were found to be co-infected with an STI. (Buensuceso J. 2007) For all countries, data on specific STDSs in HIV-positive clients was not provided. Data from KAB in Guyana showed 2.5% prevalence of STD history among survey participants but this was not correlated with HIV infection. Substance Abuse Even fewer data are available on HIV rates among substance users. Early in the epidemic, numerous studies and articles were published describing the association between drug use and HIV, namely crack cocaine. Little focus has been directed toward drug use in the past five years. In 2006, a study by Canada society for International health revealed 17% of drug users were HIV-positive. In addition a study in St. Lucia to determine if crack-cocaine users from the same socio-economic background had higher prevalence of HIV. Investigator found 7.5% positivity rate among crack and non-crack users. MSM Over the last 20 years, numerous serosurveys have been conducted among Caribbean MSM. Each of these surveys, regardless of the study site, add to evidence that MSM are likely the most disproportionately affected population in the region (Lee R 2006, Persaud 2005). Current studies from Jamaica show alarming rates of infection among MSM but this is similar to rates found in a previous studies in 1996 and 1999. (Figueroa 2005, 2009, UNAIDS 2008). Figure 15. Seroprevalence Studies Among MSM Country HIV Prevalence Rate Year Bahamas 8.8% 2007 Dominican Republic 11% 2004 French Territories 27% ? Guyana 21% 2005 Suriname 6.7% 2005 Jamaica 31.8% 2007 Trinidad& Tobago 20% 2005 Commercial Sex Workers As shown in Figure 16 several studies around the region, commercial sex workers are also at increased risk for HIV infection (Couture 2008). In fact, because of the exceptionally high rates among CSW in countries like Suriname and Guyana, the rate of 29 HIV in the Caribbean: A Systematic Data Review 2003-2008 infection in this group is nearly 17 times that of the general population in the region. (UNAIDS 2008). Figure 16. Seroprevalence Studies Among CSW Country HIV Prevalence Rate Year Dominican Republic 3.4%, 2.7% 2004, 2006 Guyana 26% 2005 Suriname 21%, 23% 2003, 2005 Jamaica 9% 2004 Haiti 10%, 7% 2005, 2007 Furthermore, among Guyanese CSW, although the rates have decreased, the prevalence of infection in this group remains alarming (Allen 2006). Figure 17. HIV Prevalence Among Female Sex Workers in Guyana: 1989-2005 50% 45% 46% 43% 40% 35% 30% 31% 26.60% 25% 20% 15% 10% 5% 0% 1989 1997 2000 2005 In many countries, CSW is illegal and this creates challenges for conduct rigorous epidemiological studies or surveillance in this group. To date, no regional prevention strategy for CSW has been developed. Prisoners Seroprevalence studies have been conducted among prisoners in the OECS, Bahamas, Belize and Jamaica (UNAIDS 2008, Jamaica MOH 2006, CAREC/MOH Belize) (Figure 18). While the rates are significantly lower than those seen among MSM and CSW, disease prevalence is a concern in this population. It is unclear if targeted HIV prevention programs for prisoners have been developed in the region. 30 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 18. Seroprevalence Studies Among Prisoners Country HIV Prevalence Rate (%) Year Dominica 2.6 2005 St. Vincent 4.1 2005 Jamaica 3.3 2006 Antigua 3.0 2005 Grenada 2.2 2005 St. Kitts and Nevis 2.4 2005 Bahamas 2.3 2003-6 Belize 5.0 ? The results of these surveys highlight need for urgent prevention-intervention strategies targeting specific at-risk groups. The consistently high HIV prevalence among these groups compared to general population in each country support the likelihood that the Caribbean epidemic is largely fueled by risk behaviors in specific risk groups rather than throughout the general population. While rates in all of the above sub-groups surpass that in the general population, alarming rates I MSM, particularly in Jamaica, in conjunction with information about the prevalence f homophobia and stigma in t the region highlight the need for further attention to this group. MSM As highlighted above, the rates of HIV among MSM are concerning and the Caribbean region shares this challenge other regions in the world. (Baral, et al. 2007). Authors of a systematic review of HIV infection among MSM in Low and Middle income countries suggest this group is underserved and warrant urgent prevention and care. Caribbean data suggest this is true since data from some countries in the region show the rates of HIV in MSM have remained unchanged or worse over the last decade. For example, in the most recent seroprevalence study of MSM, conducted in 2004 in Santo Domingo, Puerto Plata, and Samaná, 11% of 597 men were HIV positive. This prevalence level was identical to that found in the previous serosurvey conducted a decade earlier in Santo Domingo (Tabet 1996, Toro-Alphonso 2005). Also, surveillance data in some countries such as Jamaica and Trinidad and Tobago (Jamaica MOH 2006, Figueroa 2009, TT MOH, 2007) reveal high prevalence of unknown transmission risk. Perhaps if the “unknown riskâ€? category is reclassified as covert homosexual activity, MSM may account for more than 25% of cases in the region. As discussed, in nearly every country, men comprise a greater proportion of infected populations yet represent on average 25% of the tested population. The failure of patients to disclose homosexual activity may be due, in part, to perceived homophobia in the medical community. Because additional studies and discussion are warranted among this population, additional MSM-related data are shown in Appendix 3 which contains a summary of formative work conducted in the region followed by a compilation of MSM and HIV- related abstracts from the region. 31 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 8: Regional Response Regional Response Most countries have adopted a national strategic plan (NSP) that outlines national goals, objectives and priorities for the HIV response. Table 4 displays NSP-related priorities and technical areas of focus by country. In many cases, the NSP financial resource projections do not accompany the plan which creates challenges for monitoring and ensuring resources, particularly donor resources, are strategically and appropriately linked to country priorities. Table 4. Examples of Regional and National Priorities Strat Testing Advocacy/ Stigma & Target Plan scale- human discrimi- Human vulnerable Country Year SI* Care/Rx Prevention up rights nation resources groups Other PANCAP 2008- Y Y Y Y Y Y Y PLWHA Enabling 2012 environment, coordination, capacity development Aruba 2003- Y Y Y CSW, immigrants, MSM, Youth, 2007 PLWHA Bahamas 2006- Y Y Y Y Care 2010 decentralization Barbados 2008- Y Y PLWHA, Programme 2013 OVC, MSM, Management CSW, STI and Institutional Performance Curacao 2003- Y Y Y Sex workers, Institutional 2008 prisoner, strengthening immigrants, homosexuals French NONE Departments Haiti ? Y Jamaica 2007- Y Y Y Y Y Y Y 2012 St Lucia 2005- Y Y Y Y Y Capacity 2009 Development St Maarten 2007- Y Y Y Y 2011 Trinidad and 2004- Y Y Y Y Y MSM, Youth, Programme Tobago 2008 Young Management females, and PMTCT Institutional Performance Turks and NONE Y Y Y Y young people, vulnerable Caicos groups, PLWHA *Includes surveillance, research, all epidemiologic data 32 HIV in the Caribbean: A Systematic Data Review 2003-2008 While there is some variability in the technical program and priority areas from country to country, all countries work within a set of regional priorities established by PANCAP (UNAIDS 2002). While larger countries such as Jamaica and Trinidad may have greater resources and therefore able to focus the response on more components, the range of programmatic areas include the following: Prevention, including PMTCT and MARPs, Blood safety, BCC, education, awareness and marketing, Care and Treatment and VCT. However, despite the priorities listed in the NSP, the most commonly reported priority areas across the region appear to be blood safety, PMTCT and care and treatment. Table 4 provides examples of some country-specific and regional priorities. Regional Funding HIV/AIDS-related financial support in the region has been substantial and according to PANCAP, over the last several years funding has exceeded $1.3 billion. (PANCAP.org). The vast majority of regional funding has been secondary to support from international donor agencies (Appendix 2) and data that assess the exact magnitude of these contributions are inconsistent and difficult to obtain. Although there is no system in place to track every dollar of HIV funding coming to the region, data from donor agencies suggests resources continue to be substantial. For example, looking forward, GFATM alone has committed $552 million dollars over the next five years for the regional response. (http://pancap.org/index.php?option=com_content&task=view&id=170&Itemid=76). In addition, the USG through PEPFAR funds country-based HIV programs in Haiti and Guyana as well as regional programs at a cost of over $140 million annually. These international donors alone will contribute over $1 billion to the region over the next five years. Table 5. 33 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table 5. Regional Funding Allocation- GFATM and USG PEPFAR DONOR Country Amount Approved GFATM (Annually In USD) Haiti 159,733,983 Cuba 36,224,962 Dominican Republic 94,254,870 Jamaica 23,318,821 Multi-country Americas (CARICOM) 12,046,368 Multi-country Americas (OECS) 8,898,774 Multi-country Americas (CRN+) 3,662,376 Haiti 18,821,754 Cuba 14,369,743 Haiti 6,199,554 Jamaica 15,219,930 GFATM Total 552,485,118 USG PEPFAR Belize 481,000 Dominican Republic 17,000,000 Guyana 21,000,000 Haiti 93,000,000 Jamaica 1,500,000 Regional Programs 10,400,000 PEPFAR Total (Annual) 143,381,000 Subtotal 5-year project period 716,905,000 Grand Total GFATM-PEPFAR $1,269,390,118 34 HIV in the Caribbean: A Systematic Data Review 2003-2008 UNAIDS Expenditure Estimates UNAIDS has made attempts to track country expenditures for some Caribbean countries by routinely requesting that small and medium-income countries submit annually HIV/AIDS-related expenditures by source and spending category. For example, spending categories may include areas such as prevention, OVC or Care and treatment. In 2008, data for HIV/AIDS-related expenditures were only available for a few Caribbean countries. Reasons for this are unclear. Among countries assessing and submitting data on expenditures were Bahamas, Dominican Republic, Haiti and Trinidad and Tobago and their estimated expenditures are shown below. These reported expenditures are best estimates and should be interpreted with caution, particularly since: 1. Detailed information about how resource allocations were derived in 2006 is unknown and 2. It is beyond the scope of this report to make this determination. However, assuming allocations have remained relatively unchanged, examination of these submissions highlight the need to consider if spending categories and descriptions are consistent with national priorities outlined in the NSP and with the most recent country data. The DR allocation as shown below suggests the country prioritizes care and treatment and management, while Bahamas, shown in (Figure 19) has the highest expenditures allocated for workforce incentives followed by care and treatment. Noteworthy is the lack of domestic and minimal international funding allocated for prevention in the Bahamas. As reported, seroprevalence data from Bahamas shows an 8% prevalence rate among MSM and while the country can boast of remarkable reductions in MTCT, the rate of HIV among pregnant women is 3% (UNAIDS 2008). This suggests resources are also needed to address these prevention gaps. 35 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 19 Estimated HIV Expenditures Bahamas and Dominican Republic Source: UNAIDS.org 36 HIV in the Caribbean: A Systematic Data Review 2003-2008 Expenditure data from Haiti are shown in Figure 20 and illustrate the majority of funding is for care and treatment which seems consistent with the country’s single, primary mission to scale up access to HIV treatment. Figure 20 Estimated HIV Expenditures Haiti Finally, TTs expenditures shown in Figure 21 highlight the country’s prioritization of prevention. Programmatically this allocation is somewhat supported by country data provided for this report. While Trinidad and Tobago has limited information on specific transmission risk, review of country data reveal a few trends that may support the reported funding allocation. These include: 1. Prevalence appears to be decreasing, which may be a result of prevention efforts, 2. MSM have high rates (20% in 2004) of HIV and 3. the epidemic’s epicenter appears to be in a single county As previously noted, challenges with data collection, particularly HIV transmission risk and 64% prevalence of new Trinidad infections reported from one county suggest additional resources and prioritization of data collection as well as epidemiological and behavioral assessments are warranted. In addition, the recent KAB suggest the need to address the high prevalence of HIV stigma and based on the allocation shown it is difficult to determine if such activities are included in the resource allocation. However, it is possible the increased resource allocation for prevention is also directed toward identifying prevention-intervention for this community. 37 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 21 Estimated HIV Expenditures Trinidad and Tobago 38 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 9: Conclusions and Discussion Although data availability is limited in the Caribbean region, this data assessment was important because the exercise highlighted several issues that warrant additional attention across the region. These include: 1. Strategies are needed to improve national and regional data quality and availability. Although a significant amount of data have been generated in the Caribbean, data quality and availability across the region is too incomplete and inconsistent to accurately characterize or completely describe trends in the epidemic. To date, regional estimates have been derived by UNAIDS projection exercises but the accuracy of these estimates rely heavily on the integrity of country data. Given the findings associated with data availability, including the CDC/CAREC data inventory, it is impossible to confidently estimate the magnitude or trajectory of the epidemic. In addition, it is not possible to conduct a rigorous epidemiological synthesis from the data available since this involves an epidemiological characterization of the last 1,000 new HIV infections in the region including, knowledge of transmission risk for the majority of cases. 2. The region suffers from a series of concentrated epidemics. Hypotheses have been generated about the nature of the epidemic but not all can be substantiated by the data presented. For example, it has been postulated that the Caribbean region has the second highest rates of HIV in the world and suffers from a generalized epidemic which, if not emergently addressed, would quickly expand to rival the magnitude seen in Africa. (UNAIDS, CAREC, PANCAP). Based on national prevalence estimates shown in Appendix 1 and data in this report, it seems there is more evidence to support a concentrated epidemic picture than there is to support a generalized epidemic or perhaps a mixed picture. However, given the need to improve regional data availability and expand testing programs throughout the region, it is possible the true scale of the epidemic is unknown. Traditionally, generalized epidemics have been categorized as having a seroprevalence of >1. While it is not clear if this designation is also appropriate to apply to regions as well as countries, scientists and epidemiologists have begun to challenge the wisdom of this somewhat arbitrary characterization and have emphasized the importance of understanding the local epidemiology of HIV/AIDS (Wilson 2008). Clearly, further dialogue about the science and practicality of this designation is warranted, particularly since international funding allocation is often linked to the perception of a generalized epidemic. 3. Interventions for MARPs, including youth are urgently warranted. The need to aggressively target MARPs with prevention interventions is irrefutable. Unlike the prevalence in the general population, the overall prevalence among MSM and CSW has not decreased appreciably. Although prevalence data among youth are not as abundant as other MARPs, given the high rates of reported sexual debut, engagement in multiple or concurrent partnerships and inconsistent condom usage, primary prevention efforts are needed for youth. 4. Stigma is pervasive in the region. Additional exploration is needed to understand and address stigma and discrimination in the region, particularly in the OECS. Many countries have prioritized this program area but it is unclear what concrete action steps have been taken to address the issue in tangible ways. 39 HIV in the Caribbean: A Systematic Data Review 2003-2008 5. Regional funding allocation may not be consistent with the most urgent regional priorities. The region has been relatively well-funded over the last several years but it is uncertain if funding has been strategically allocated to show impact or demonstrate how donor funding has influenced the decline in the HIV cases in the region. It is also unclear if regional funding allocation is completely linked to national and regional priorities. 40 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 10: Recommendations Several programmatic issues were raised from this data review, each of which should be addressed with some urgency. Therefore, the following recommendations should be considered in planning the way forward for the region: 1. Establish data collection infrastructure needed to conduct a detailed epidemic, policy and response synthesis and “know the epidemicâ€? Developing and implementing the most effective epidemic response is challenging if regional leaders and stakeholders don’t “know the epidemicâ€? (Wilson 2008). An epidemic, response and policy synthesis can provide data to guide the regional response but this conducting this exercise is not possible unless the regional data collection infrastructure is improved. Conducting an epidemic synthesis demands the availability of data for HIV incidence, recent trends, risk factors and modes of transmission. Preparing the region for such a thorough and in-depth analysis requires a multi-pronged strategy that includes efforts to: a. create a demand for and awareness about importance of public health data collection throughout the region and b. build practical, feasible and sustainable data collection and surveillance systems tailored to country capacity. Specific recommendations for each are below: a. Create a demand for and awareness about importance of public health data collection throughout the region The Caribbean region suffers from limited public health data. This gap is partly due to limited human resource capacity throughout the health sector but it is also due to the need for regional prioritization of public health data collection. Improving the quality and availability of data throughout the region involves creating a regional culture that understands, values and prioritizes consistent, high-quality data collection. To achieve this the region should consider the following action steps: 1. Develop public health leadership capacity in every country through training and if necessary by partnering with established and reputable public health institutions. 2. Develop an action plan to systematically engage healthcare personnel in country, i.e. “on the groundâ€?, to discuss the importance of high quality data collection. This includes providing concrete examples to ensure understanding of the critical link between mundane tasks such as data form completion and developing an effective regional response. 3. Seize opportunities for the regional public health leadership to engage political leadership to ensure a similar understanding among national and regional decision- makers. 41 HIV in the Caribbean: A Systematic Data Review 2003-2008 b. Build practical, feasible and sustainable data collection and surveillance systems tailored to country capacity Consistent, ongoing collection of basic surveillance data is the best mechanism to maintain an accurate snapshot of what is happening with the epidemic. Therefore, the region should invest resources in establishing a practical, feasible and sustainable surveillance system in the region. Clearly the regional variability in infrastructure and human resource capacity prohibits implementation of a standard one-size-fits-all surveillance system. Country assessments have previously been conducted to determine the local capacity to conduct clinical and laboratory surveillance. These assessments should be utilized to build a strategy to implement surveillance programs tailored to country capacity. Each country should monitor and report a minimum variable set that includes age, gender and mode of transmission. The region should consider tasking an organization like CAREC to standardize reporting formats to ensure the region’s ability to consistently report regional data and trends. Because absolute numbers provide little insight about the dynamic nature of the epidemic, the region should transition from reporting absolute and cumulative numbers of AIDS cases to determining and monitoring disease rates including incidence. HIV incidence is the determination of the number of new cases in of HIV infection in a given period. Therefore, knowledge of incidence and epidemiological characterizations of new infections are the most effective ways to understand who is being impacted by the by the epidemic and how. Finally, implementing functional surveillance systems requires expansion of HIV testing programs that are liked to surveillance systems. Testing expansion should involve tracking not only the number of seropositives but the number of people tested for HIV. This will allow ongoing calculation of seroprevalence rates and will provide information about HIV testing uptake, both of which are important when drawing conclusions about regional disease burden. 2. Develop a multi-pronged regional prevention strategy targeting MSM, CSW and Youth While it is difficult to identify the source of the last 1,000 infections in the region, the seroprevalence data between 2005 and 2007 among MARPs are alarming and signal a need to intervene now among these groups. Therefore, the region should consider evaluating current approaches to these populations and abandoning strategies that are not effective. Aggressive and proactive approaches for HIV risk reduction among MSM, CSW and youth should be pursued. Data from this review highlight specific areas of concern that should be the focus of targeted prevention interventions. These include: the frequency of multiple and/or concurrent partnerships, early sexual debut, inconsistent condom usage with casual partners, and programmatically, the lack of systematic integration of HIV and STD testing. The region should look within and develop its own culturally appropriate strategies and evidence-based approaches to tackle each of these issues. If needed, additional formative research should be conducted to learn and seek suggestions for what it might take to favorably impact these behaviors. Regional leaders should listen with a keen ear and implement programs and policies that mirror and support the suggestions. Given the continued transmission despite prevention resources expended, new Caribbean-based approaches should be explored. 42 HIV in the Caribbean: A Systematic Data Review 2003-2008 3.Tackle stigma head on and with a unified voice. Most countries have prioritized stigma reduction in their NSPs yet it remains pervasive. As with MARPs, aggressive approaches should be adopted to address stigma in the region. This is critical since several stigma-related meetings, campaigns and activities have occurred across the region but it is difficult to appreciate the collective impact of these activities. A multi-pronged strategy is needed to chip away at stigma in the region. Efforts should be made to engage and encourage regional leadership to speak openly about HIV/AIDS at every opportunity. In addition, public health and health sector personnel must model anti- stigma behavior. As recommended for MARP interventions, formative work should be conducted among diverse groups, including regional leadership and suggestions from these interviews incorporated into regional anti-stigma strategies and programs. 4. Assess and address mis-matches between programmatic priorities and funding allocation. Each country should develop a strategy to track its resources and ensure allocations are aligned with program priorities. The same should happen at the regional level. Without this the region will suffer from lack of programmatic focus, program redundancy and duplication of efforts. A coordinated response will allow the region to maximize its resources and begin to show tangible impact in the region. Donor cooperation should be enlisted to ensure funding for the region is complementary and completely consistent with national and/or regional priorities. 43 HIV in the Caribbean: A Systematic Data Review 2003-2008 Section 11: Next Steps The future of the Caribbean epidemic will undoubtedly be determined by the implementation of a targeted and coordinated response. Although many of the data presented in this report were previously known, the data assessment is instructive because it provides an opportunity to assess the availability of data and establish a baseline for improving the systematic collection of epidemiological data in the region. It also highlights information and program gaps that should be prioritized for action. In an era of shrinking resources, it is imperative for the region to capitalize on currently available funding, even if shifts in allocation are needed, to ensure these resources are aligned to support programs and activities that will directly and concretely address ongoing transmission. Addressing each of these regional challenges demands an awareness and understanding of the epidemiology of HIV/AIDS because without this, it is impossible to generate the appropriate public health response to the epidemic (Frieden T 2005, Wilson D, 2008). Therefore, immediate next steps and public health actions to consider include developing processes to: 1. Increase access to HIV testing, even in non-traditional and non-medical settings 2. Ensure HIV-positive persons are immediately linked to care 3. Denounce HIV stigma from the highest platforms in the region 4. Discover new approaches for engendering trust and reaching MARPS with prevention services. 44 HIV in the Caribbean: A Systematic Data Review 2003-2008 Final Note Even though the myth of an exploding epidemic that rivals Africa has not been realized in the Caribbean, the region is at a critical moment. An opportunity is before the region to reduce HIV transmission before it tightens its grip even further. The region needs a change in strategy—one that involves implementation of politically and scientifically aggressive collaborative action. In addition, a collective decision from government to the ground is needed to stop the spread of HIV in the region. 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Accessed October 2008. 48 HIV in the Caribbean: A Systematic Data Review 2003-2008 UNAIDS. Twenty seven years of the HIV epidemic in the Caribbean: A comprehensive analysis of the status and trends of the HIV epidemic in support of an accelerated implementation of universal access. 2008. UNAIDS Unpublished data. Caribbean Regional Support Team. Wilson D, Halperin D. Know your epidemic, know your response: a useful approach, if we get it right. Lancet: 2008;372:9673. 49 HIV in the Caribbean: A Systematic Data Review 2003-2008 Appendices Appendix 1. Caribbean Regional HIV Prevalence Estimates and International Funding Appendix 2. Estimated Foreign Donor HIV Funding 2003-2007 Appendix 3. MSM, Homophobia and HIV Risk in the Caribbean Compiled by Dr Marcus Day 50 HIV in the Caribbean: A Systematic Data Review 2003-2008 Appendix 1. Caribbean Regional HIV Prevalence Estimates and International Funding* "Wider- Reported Reported Caribbean" Population AIDS HIV Estimated Estimated USG World Region (000) Cases Cases PLWHA**** Prevalence PEPFAR Bank GFATM Anguilla ** 8,000 99 990 0.8 Antigua & Bar. 68,000 142 409 1,128 0.94 - 1.6 Aruba * 101,000 451 451 Bahamas 300,003 4,382 8,124 6,150 3.00 Barbados 267,000 1,531 2,572 4,134 1.1 - 1.5 x Belize 249,000 560 2,024 5,120 2.00 x Bermuda ** 63,000 539 539 Bonaire * BVI ** 24,000 306 306 Cayman ** 35,000 48 48 Cuba 11,200 1,577 2,744 3,200 <0.1 x Curacao * 972 Dom. Repub. 8,400,000 6,119 130,000 0.8-1.1 x x Dominica 73,000 150 257 115 0.2 x Fr. Guyana *** Grenada 98,000 129 227 1,122 1.30 x Guadaloupe *** Guyana 761,000 2,430 25,000 24,941 2.5 x x x Haiti 8,000,000 250,000 210,000 2.2-3.1 x x Jamaica 2,600,000 7,063 22,715 1.2 - 1.4 x x x Martinique *** Montserrat ** 11,000 28 28 0.4 - 2.0 Puerto Rico + 3,900,000 S. Marrten *,*** Saba * St. Kitts & 41,000 75 208 347 0.5 - 0.9 x Nevis St. Lucia 156,000 192 377 877 0.6 - 2.0 x St. Vincent &G 16,394 334 607 1,002 1.00 x Statia * Suriname 419,000 2,470 3,983 1.00 Trinidad, 1,300,000 4,900 11,500 16,217 1.5-2.0 x Tobago 51 HIV in the Caribbean: A Systematic Data Review 2003-2008 "Wider- Reported Reported Caribbean" Population AIDS HIV Estimated Estimated USG World Region (000) Cases Cases PLWHA**** Prevalence PEPFAR Bank GFATM Turks, CI ** 14,000 972 *Partial but greatest proportion of all international donor financial support * Netherlands: Bonaire, Curacao, Saint Maarten, Statia, Saba ** British: Anquilla, Bermuda, British Virgin Islands, Cayman, Montserrat, Turks and Caicos *** French: French Guyana, St. Marten, Guadeloupe, Martinique + US: Puerto Rico, US Virgin Islands Note: The "wider Caribbean" includes all of the above. a = CARICOM Associate ****The estimated PLHWA figures are from UNAIDS and PAHO/CAREC 2002 and 2003 reports. 52 HIV in the Caribbean: A Systematic Data Review 2003-2008 Appendix 2. Estimated Foreign Donor HIV Funding 2003-2007* Donor Major Areas of Assistance Estimated Funding and Time Period Caribbean Development Bank Supports national and regional responses to $US 10 million HIV/AIDS within the framework of the 2001-2004 Regional Strategic Plan of Action. Canadian International For CAREC $US 5.5 million 2001-2005 Development Agency No estimate "Enhanced Support to HIV/AIDS in the Caribbean" (ESAC) $Cdn 950,000 PMTCT in Haiti $Cdn 5 million Early childhood program in Jamaica (UNICEF) $Cdn 7 million Strengthening STI Program in Haiti $Cdn 4.8 million STI and Health Information Program in Guyana GFATM $US 10 million "Building a Faith-Based Response to the $US 1.5 million HIV/AIDS Epidemic 2003-2006 European Union Strengthening HIV/AIDS programs of 6 $US 7 million regional institutions. German Technical Cooperation Support to CAREC, and bilateral projects in $US 1.9 million Agency Haiti, Jamaica, the Dominican Republic 2000-2004 Supra-Regional Youth and Health Project No estimate (cultural exchanges, south-south cooperation) Public/Private sector initiative No estimate Global Fund to Fight AIDS, TB, The following applications for HIV/AIDS US$225.176 Million grant over 5 and Malaria funding have been approved in the years Caribbean: Belize, Cuba, Dominican The Dominican Republic US$14.7 million Republic, Guyana, Haiti, Jamaica, Guyana US$ 9.5 million Suriname, OECS, PANCAP, Haiti (disbursement begun) CRN+ US$18 million (US $ 9.4 million disbursed) US$ 7.5 million Jamaica US$26 million Cuba (disbursement begun) US$ 2.6 million OECS (regional) US$ 12.6 million CARICOM/PANCAP (regional) ILO Dissemination of a Code of Conduct on No estimate HIV/AIDS in the workplace. A regional project on HIV/AIDS in the workplace with regional and national components and an association with the business community. 53 HIV in the Caribbean: A Systematic Data Review 2003-2008 Donor Major Areas of Assistance Estimated Funding and Time Period Inter-American Development A basic healthcare and AIDS service support US $1 million Bank program for Haiti. Also integrating HIV/AIDS issues into its social portfolio in areas of education, women and youth. TA to Jamaican government through funding of consultancies. Japan International Cooperation In the design phase. A regional assessment TBD Agency undertaken in 2001. Kingdom of the Netherlands Funding for Haiti and Jamaica phased out, No estimate funding for Suriname to be reinstated. Support to the region through UNAIDS. PAHO/WHO Support for policy advocacy, health No estimate planning, and reform. United Kingdom Department for Support for CAREC $US 2.4 million International Development 2002-2005 New support to CARICOM in any area of TBD priority, including policy advocacy and legislation, coordination Will initiate a public/private partnership project TBD UNAIDS Coordination and resource mobilization Ongoing through regional and national Theme Groups on HIV/AIDS. Support for CRIS and monitoring UNGASS indicators. UNDP Limited support for policy advocacy, national Limited strategic planning and South/South cooperation through an HIV/AIDS Trust. UNICEF Support for adolescent prevention programs $500,0000 estimated and care and support programs for children. U.S. Department of Labor Initiative in the Dominican Republic, Haiti, $2 million estimated Jamaica and Barbados to reduce HIV infection rate in the workplace and to improve workplace environment for PLWHA. U.S. Health and Human Services New initiative on "twinning" Caribbean- (funded by CDC through a HRSA) Administration based HIV/AIDS service organizations with US counterparts. U.S. National Institutes of Health Support for an HIV vaccine trial facility in $500,000 estimated Haiti, sponsoring regional conferences, and funding local research on drug use and its role in HIV/AIDS epidemic. U.S. President’s Emergency Plan Focus on prevention, care and treatment for US$120.9 Million grant over 2 for AIDS Relief1 PLWHA Dominican Republic, Guyana, years) Haiti, Jamaica, Regional 1 The first of two major Presidential Initiatives on HIV/AIDS, the PMTCT Initiative specifically targets Haiti and Guyana. 54 HIV in the Caribbean: A Systematic Data Review 2003-2008 Donor Major Areas of Assistance Estimated Funding and Time Period William J. Clinton Foundation Campaign to rapidly scale up ARV provision by helping countries to develop business plans for care and treatment of PLWHA, generating funds from the private and public sectors, and negotiating reduced prices for ARVs. World Bank A concessionary lending program for US$155 million Barbados, the Dominican Republic, Jamaica, and St. Kitts & Nevis. Guyana and Haiti qualify for grants as Highly Indebted Poor Countries. US$9 million Grant support to CARICOM/PANCAP *Source USAID Caribbean Regional Program 55 HIV in the Caribbean: A Systematic Data Review 2003-2008 Appendix 3 MSM, Homophobia and HIV Risk in the Caribbean Compiled by Dr Marcus Day The Caribbean is known to have the second highest prevalence of HIV/AIDS, with heterosexual transmission considered the predominant method of spread. Further analysis reveals that MSM may actually account for more than 25% of cases if men with "unknown" risk factors are reclassified as having covert homosexual activity. Many countries claim a ’heterosexual" driven epidemic and yet the figures belie that. In every country so far males make up a greater percentage of infected populations (around 70%) and yet represent on average 25% of the tested population. The failure of patients to disclose homosexual activity may be due, in part, to perceived homophobia in the medical community. The authors of this study contacted all licensed general practitioners in 5 Caribbean islands. Questionnaires distributed included The Index of Attitudes towards Homosexuality (Hudson and Ricketts, 1980) and questions from the International Social Survey Program 1998/1999. Chi Square, Student’s t-Test and multiple regression were used to determine the demographic and other factors related to level of homophobia amongst physicians. 75% of practitioner participated. High levels of homophobic attitudes were noted in Caribbean born and educated physicians. The tolerance scores calculated were among the lowest internationally when compared to world-wide country data. This study supports our hypothesis that homophobic attitudes exist among physicians in the Caribbean. This institutionalized homophobia may impact negatively on risk factor identification and consequently has important implications for 2 HIV prevention campaigns. These deeply homophobic attitudes lead many men who have sex with men to lead underground lives. Further, experts have concluded that MSM account for a substantive proportion of HIV-positive persons in the Region. The challenge is to reach Caribbean 3 MSM for effective HIV education, behavior change, prevention and care. AIDS prevention in the Caribbean has predominantly focused on risk reduction in the general population; however significant numbers of HIV infections occur in stigmatized groups, including men who have sex with men (MSM), commercial sex workers (CSW) and migrants. Although funding for HIV prevention has increased in the region, the allocation of resources directed towards these vulnerable groups do not adequately address risk reduction in stigmatized populations, resulting in few or no programs in many countries. Both social stigma and legislative discrimination may be partly responsible for the non-inclusion of high impact HIV/AIDS interventions in national 4 strategic plans. Jamaica is probably the extreme and is well known internationally for its violent homophobia, promoted through its popular music. This has a strong impact on Jamaican MSM’s comfort with their sexuality and on their sexual behavior leading to low self esteem, conflictive relationships, spontaneous and high risk public sex, low prioritisation of condom use and resistance to accessing services. Safer sex practices are a low 2 A E Radix , , et al. Attitudes of general practitioners towards homosexuals in the Caribbean. Poster Exhibition: The XV International AIDS Conference: Abstract no. TuPeD5048 3 R Carr , , et al. Breaking history: Building an network of gay and other men who have sex with men (MSM) across the small islands of the Caribbean. Poster Exhibition: The XV International AIDS Conference: Abstract no. WePeE6635 4 A.Radix, et al. The effects of social stigma and legislative discrimination on the allocation of resources for HIV prevention in the Caribbean. : AIDS 2006 - XVI International AIDS Conference: Abstract no. CDD1293" 56 HIV in the Caribbean: A Systematic Data Review 2003-2008 priority to such MSM presenting on-going challenges to organisations working in HIV 5 prevention with this group. In the Caribbean there is evidence that within the communities of sexual minorities are a 6 large proportion of MSM who do not identify as gay or bisexual In a focus group in Guyana, one of the major issues raised was the difficulty of living a life in hiding. Many participants stated that because of homophobia and the views of society they were in many ways forced to create alternate lifestyles, which while they maintained different levels of contentment, were in some ways dangerous when considering STI’s especially HIV and the possibility of discovery and of loosing their family(several 7 participants were also married). Contrary to the simplicity of donor designations, MSM does not nearly reflect the diverse forms of ‘homosexual’ identities that exist in the Caribbean. There are male to female transgendered persons, male bisexuals, male all sexuals, openly gay, closet gays (down low). These subcultures also belie a commonly held belief of the unity of a “homosexualâ€? culture. In the context of the Caribbean class more then race dictates much in terms of interaction between men engaged in same sex behaviours. These relations mostly 8 imitate the power relations existing in the general populations and create segregated minorities within the minority. The flamboyance of effeminate gay men and transgendered individuals are often blamed by other MSM for the stigma shed on 9 homosexuality in general . Members of these core ‘gay’ subcultures interact sexually among themselves and with men who do not share a ‘gay’ identity in any of its forms and engage as the active partner in insertive sex with both men and women. The latter also constitute a diverse group with 10 differences around class, age and ethnicity . There is a great deal of alcohol consumption among men in the Caribbean. It is the “lubricantâ€? of social in (heavily promoted in leisure contexts interaction and is often used as much an excuse for the expression of feelings, particularly sadness, weakness and affection for other men, as it is a relatively well-accepted explanation for homosexual 11 interactions across all classes. The quote below taken from an inmate of Her Majesty’s Prison in Saint Kitts speaks directly to this dis-inhibiting effect that alcohol plays. Say well, alcohol would gay you more drunk. You aint tinking in your senses that how alcohol do gah you; … mek you do things you aint want 5 " I McKnight, et al. Homophobic violence and sexual behaviour: Challenges in sexual behaviour change for gay and other MSM in Jamaica. CD Only: The XV International AIDS Conference: Abstract no. D12149" 6 Parker R, Ca´ceres C. Alternative sexualities and changing sexual cultures among Latin American men. Culture, Health Sexuality 1999, 1:201–206. 7 SPECTRUM HEALTH NET - FOCOUS GROUP DISCUSSION REPORT, Supervised by Stacey Gomes, 7th November 2007 in Butcher Shop St Parika 8 Herdt G. Same sex, different cultures. Exploring gay and lesbian lives. Boulder and Oxford: Westview Press; 1997. 9 Ca´ceres C, Rosasco A. The margin has many sides: diversity among gay and homosexually active men in Lima. Culture, Health Sexuality 1999, 1:261–275. 10 Ca’ceres, C.F., HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS 2002, 16 (suppl 3):S23–S33 11 Ca’ceres, C.F., HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS 2002, 16 (suppl 3):S23–S33 57 HIV in the Caribbean: A Systematic Data Review 2003-2008 to do … sex with man, mash up people vehicle, and do tings out of de 12 way and dem tings Transactional sex (offering or getting sex in exchange for money, gifts or drugs ) is important among men of all sub-groups. Male to female transgendered persons will often sell sex to men who pretend they mistook them for women. “Half of the men who get blow jobs from me probably don’t know that I 13 have a dick.â€? Some working class men will depend more heavily on the financial aid they get from an older gay friend, or on the product of more formal sex work with more affluent gay men. In focus group sessions conducted in Antigua most of the men who participated claimed to have engaged in transactional sex with gift giving a recognized norm. One man of 24 claimed that he gave gifts to 18 year olds for sex and received gifts from 40 year olds, such is the fluidity of the transactions. 14 In a Trinidad study 1 in 4 MSM reported also having sex with women in the past year, and that group of men had lower levels of knowledge about HIV transmission than did those that had sex only with men. In many other Caribbean countries, MSM are virtually invisible due to fear, discrimination, social unacceptability or arrest. The criminality of certain sexual behaviours and the stigma associated with such criminality discourage MSM from accessing health care service. Sex between men remains illegal in 10 Caribbean countries. The act of insertive 15 anal intercourse is referred to in the various national legislations as “buggery , act of 16 17 18 gross indecency , carnal intercourse against the order of nature , unnatural connexion 19 and the abominable crime of buggery . Such terms illustrate the national attitudes toward same sex relations. When these attitudes penetrate the health care delivery system we have an environment which is toxic to good health care provision. Consequently, MSM are often under-represented in HIV surveillance systems and in prevention and care programs. It has become increasing apparent that that situations leading to the sexual transmission of HIV should no longer be seen principally from the narrow view of ‘risk behaviour’ but rather a vulnerability created an a confluence of forces such as legislative prohibitions which enforce societal stigma and discrimination. “It is not who they are that puts gay, bisexual and other men who have sex with men at risk for HIV,â€? he had written. “It is the political, legal, economic, social, cultural forms of marginalization and exclusion that make MSM vulnerable. Criminalization of sexual activity conducted between consenting, adult men in private reinforces the perpetuation of 12 National Council on Drug Abuse Prevention, Focus Assessment Study on Drug Use: Identifying Patterns among Prisoners Prior to Incarceration 2004, Office of the Prime Minister Federation of St. Kitts and Nevis - West Indies Cited as NCDAP/FAS/Prisoners 2004 13 Interview conducted by the author with a crack using male to female transgendered sex worker in Port of Spain, Trinidad in August 2003. 14 Bartholomew C. Transmission of HTLV-1 and HIV among homosexual men in Trinidad. JAMA 1987, 257:2604–2608. 15 Antigua and Barbuda, Barbados, Saint Vincent and the Grenadines, Trinidad and Tobago 16 Belize, Guyana, Saint Lucia 17 Belize 18 Grenada 19 Jamaica, St Kitts/ Nevis 58 HIV in the Caribbean: A Systematic Data Review 2003-2008 homophobia at all levels of society, and drives this vulnerable group away from the information and education that is necessary to save their 20 lives and the lives of the men and women who are their partners.â€? As is typical of the Caribbean, Trinidad and Tobago implemented a National AIDS Strategy in 2003 and while men who have sex with men are listed as a risk population local MSM advocates say the funds for their communities have not followed. "Commendably, since 2003 our National AIDS Strategic Plan has recognized MSM as an important population and our organisation, Friends for Life, as a critical part of the response. But going on five years later it’s still just good intentions. As far as resources go, we are yet to see any impact of the plan on the ground in services for MSM. That’s a 21 failure of the promise of leadership.â€? In a recently published meta analysis of research looking at HIV risk among men who have sex with men in low and middle income countries, researchers found 83 published studies that reported HIV prevalence in 38 low- and middle-income countries in Asia, Africa, the Americas, and Eastern Europe. When the results were pooled MSM were found to have a 19.3-times greater chance of being infected with HIV than the general 22 population. These findings indicate that MSM living in low- to middle-income countries have a greater risk of HIV infection than the general populations of these countries. The subgroup analyses indicate that the high HIV prevalence among MSM is not limited to any one region or income level or to countries with any specific HIV prevalence or injection drug use level. Although the small number and design of the studies included in the meta- analysis may affect the numerical accuracy of these findings, the clear trend toward a higher HIV prevalence of among MSM suggests that HIV surveillance efforts should be expanded to include MSM in those countries where they are currently ignored. Efforts should also be made to include MSM in HIV prevention programs and to improve the efficacy of these programs by investigating the cultural, behavioral, social, and public policy factors that underlie the high HIV prevalence among MSM. By increasing surveillance, research, and prevention among MSM in low- to middle-income countries, it should be possible to curb HIV transmission in this marginalized population and reduce 23 the global burden of HIV. 20 Joel Simpson, a human rights lawyer based in Trinidad who serves on the CFLAG Civil society organization representing all sexuals) Steering Committee, quoted in the Trinidad Guardian “Outside the Conference: Caribbean Gay Men Tackle HIVâ€? published December 4 2007 21 Luke Sinnette, President of Friends for Life, quoted in the Trinidad Guardian “Outside the Conference: Caribbean Gay Men Tackle HIVâ€? published December 4 2007 22 Baral S, Sifakis F, Cleghorn F, Beyrer C (2007) Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review. PLoS Med 4(12): e339 doi:10.1371/journal.pmed.0040339 23 Baral S, Sifakis F, Cleghorn F, Beyrer C (2007) Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review. PLoS Med 4(12): e339 doi:10.1371/journal.pmed.0040339 59 HIV in the Caribbean: A Systematic Data Review 2003-2008 MSM / HIV Related Abstracts from the Caribbean Compiled by Dr Marcus Day Breaking history: Building an network of gay and other men who have sex with men (MSM) across the small islands of the Caribbean 1 1 2 R Carr , I McKnight , S Lewis 1 2 Jamaica AIDS Support, Kingston, Jamaica; International HIV/AIDS Alliance, Brighton, United Kingdom Issues: The Caribbean is home to deeply homophobic attitudes, leading many men who have sex with men to lead underground lives. Further, experts have concluded that MSM account for a substantive proportion of HIV-positive persons in the Region. The challenge is to reach Caribbean MSM for effective HIV education, behavior change, prevention and care. Description: In 2003, Jamaica AIDS Support, a Jamaican NGO specialising in care and prevention for marginalised groups, collaborated with the International HIV/AIDS Alliance through a USAID sponsored project to develop community organisations of MSM in the Eastern Caribbean. By mobilising the MSM Caribbean Diaspora via the internet, key persons in the Eastern Caribbean gay and other MSM communities were identified for in- country HIV education and MSM community mobilisation. At a series of workshops, these key persons expanded their groups of mobilised MSM within their countries and also formed a regional MSM network that provides support to the country groups. Lessons Learned: Underground communities can be reached if a relationship of trust and respect for confidentiality is established early. The involvement of persons from those key populations who are involved in HIV care and/or prevention activities is also beneficial when it provides role models of successful interventions. Class relations also have to be considered carefully when working with MSM groups in the Caribbean. Recommendation: Outreach to hard-to-reach communities needs to make use of innovative strategies for making contact with and gaining the trust of marginalised social groups for effective community mobilisation. The XV International AIDS Conference Abstract no. WePeE6635 Suggested Citation " R Carr , , et al. Breaking history: Building an network of gay and other men who have sex with men (MSM) across the small islands of the Caribbean. Poster Exhibition: The XV International AIDS Conference: Abstract no. WePeE6635" 60 HIV in the Caribbean: A Systematic Data Review 2003-2008 The effects of social stigma and legislative discrimination on the allocation of resources for HIV prevention in the Caribbean 1 2 3 4 A. Radix , D. Bansal , C. Jack-Roosberg , C. Buncamper Background: AIDS prevention in the Caribbean has predominantly focused on risk reduction in the general population; however significant numbers of HIV infections occur in stigmatized groups, including men who have sex with men (MSM), commercial sex workers (CSW) and migrants. Although funding for HIV prevention has increased in the region, the allocation of resources directed towards these vulnerable groups is undetermined. This study summarizes existing prevention programmes in Caribbean countries and examines the role that social stigma and laws criminalizing homosexuality and commercial sex work may have on the distribution of funds and/or prioritization of resources. Methods: National AIDS Program coordinators of all Caribbean Community (CARICOM) member countries, Aruba, and the Netherlands Antilles were invited to participate in the study. A 22-item questionnaire was applied detailing national priorities of HIV prevention programs, target groups, sources of funding, distribution of funds, legislation concerning homosexuality and commercial sex work, and their perceived impact on priority setting or initiation of programs. Results: 95% of countries participated. Although all had services directed at youth, voluntary counseling and testing, condom social marketing and mother-to-child transmission, fewer than 30% had programs for HIV prevention in vulnerable groups, including MSM, CSW and migrants. Where programs existed, they were predominantly organized by the non- governmental sector. The majority of respondents (72%) agreed that political or legal constraints, such as laws prohibiting sodomy or prostitution, hindered prevention campaigns targeting vulnerable populations Conclusions: HIV prevention programs in the Caribbean do not adequately address risk reduction in stigmatized populations, resulting in few or no programs in many countries. Both social stigma and legislative discrimination may be partly responsible for the non-inclusion of high impact HIV/AIDS interventions in national strategic plans. Changes in societal attitudes and laws may be necessary before full access to preventive strategies is achieved by high risk groups. AIDS 2006 - XVI International AIDS Conference Abstract no. CDD1293 Suggested Citation "A.Radix, et al. The effects of social stigma and legislative discrimination on the allocation of resources for HIV prevention in the Caribbean. : AIDS 2006 - XVI International AIDS Conference: Abstract no. CDD1293" 61 HIV in the Caribbean: A Systematic Data Review 2003-2008 Attitudes of general practitioners towards homosexuals in the Caribbean 1 2 3 A E Radix , C Buncamper , G van Osch 1 2 A. M. Edwards Medical Centre, Saba, Netherlands Antilles; AIDS Support Group Saba, 3 Saba, Netherlands Antilles; Sr. Maarten AIDS committee, St. Maarten, Netherlands Antilles Background: The Caribbean is known to have the second highest prevalence of HIV/AIDS, with heterosexual transmission considered the predominant method of spread. Further analysis reveals that MSM may actually account for more than 25% of cases if men with "unknown" risk factors are reclassified as having covert homosexual activity. The failure of patients to disclose homosexual activity may be due, in part, to perceived homophobia in the medical community. Several North American studies have identified that up to one third of medical practitioners hold homophobic attitudes, but data from the Caribbean region is lacking. Methods: The authors contacted all licensed general practitioners in 5 Caribbean islands. Questionnaires distributed included The Index of Attitudes towards Homosexuality (Hudson and Ricketts, 1980) and questions from the International Social Survey Program 1998/1999. Chi Square, Student’s t-Test and multiple regression were used to determine the demographic and other factors related to level of homophobia amongst physicians. Results: 75% of practioners particpated. High levels of homophobic attitudes were noted in Caribbean born and educated physicians. The tolerance scores calculated were among the lowest internationally when compared to world-wide country data. Conclusion: This study supports our hypothesis that homophobic attitudes exist among physicians in the Caribbean. This institutionalized homophobia may impact negatively on risk factor identification and consequently has important implications for HIV prevention campaigns. Physicians and health educators in the region may benefit from sensitization training to reduce negative attitudes towards homosexuals. The XV International AIDS Conference Abstract no. TuPeD5048 Suggested Citation "A E Radix , , et al. Attitudes of general practitioners towards homosexuals in the Caribbean. Poster Exhibition: The XV International AIDS Conference: Abstract no. TuPeD5048" 62 HIV in the Caribbean: A Systematic Data Review 2003-2008 Ten imperatives for action: Lessons learned In prevention of HIV/STI transmission for gay and other MSM in Latin America and the Caribbean 1 2 3 4 1 5 6 R Mayorga , K Morrison , O Montoya , A Díaz , J L López , A Reis , L C Freitas , R H 7 8 9 10 Freda , F Munoz , L F Leal , M Cerqueira 1 2 OASIS, Guatemala, Guatemala; Instituto Nacional de Salud Pública, Cuernavaca, 3 4 5 Mexico; Equidad, Quito, Ecuador; Letra S, Mexico, Mexico; Grupo Dignidade, Curitiba, 6 7 Brazil; Grupo Arco-Iris, Rio de Janeiro, Brazil; SIGLA, Buenos Aires, Argentina; 8 9 10 MUMS, Santiago, Chile; LCLCS, Bogotá, Colombia; GGB, Salvador da Bahia, Brazil Issues: After almost 20 years of prevention interventions in Latin America and the Spanish Caribbean (LAC), what have we learned about what approaches work and what is needed? In the region, most epidemics are still concentrated in MSM. Although this has not been reflected in national budget priorities nor in international donor responses, there is a new international and regional movement to try to effectively address the situation. A regional network, ASICAL and an international NGO, the International HIV/AIDS Alliance joined efforts in a regional workshop. Description: 35 persons working in prevention of HIV transmission for gay and other MSM from around the region met to analyse interventions and their context and to identify and articulate lessons learned in how we undertake prevention, the results of our work, and how we evaluate our efforts. They also collectively identified concrete examples of good practice from throughout the region in diverse areas of prevention, capacity building and advocacy. Lessons learned: Although much good work has been done in the region, it has happened with few resources, little formal training and within difficult social and political situations. The deliberations and analysis of the group lead to the elaboration of the 10 imperatives for HIV/STI prevention for gay and other MSM in LAC. These imperatives for action outline the steps needed to effectively confront an ever-expanding epidemic in the region. Recommendations: Intervention methodologies need more rigorous evaluation and articulation. Effective methodologies need to be shared and amplified. Research and training in the region are desperately needed along with technical support, increased funding and an effective communications system. Collaboration and strategic alliances between regional networks, institutions and funders is vital. Above all there is a desperate need for improving the socio-political environment of MSM in the region. The XV International AIDS Conference Suggested Citation " R Mayorga , , et al. Ten imperatives for action: Lessons learned In prevention of HIV/STI transmission for gay and other MSM in Latin America and the Caribbean. Poster Exhibition: The XV International AIDS Conference: Abstract no. WePeC6094" 63 HIV in the Caribbean: A Systematic Data Review 2003-2008 The MSM task force and HIV/AIDS: a citizenship initiative to direct public policies in Latin America and The Caribbean 1 2 3 A Díaz Betancourt , C García de León-Moreno , J A Izazola Licea , M S M Members of 4 5 the regional Executive Task Force , T Asical 1 2 Letra S/ LAC MSM Task Force/ASICAL, Mexico City, Mexico; AVE de 3 4 Mexico/LACCASO, Mexico City, Mexico; SIDALAC, Mexico City, Mexico; MSM Task 5 Force, Mexico City, Mexico; ASICAL, LAC, Mexico I. Lack of perception in HIV/AIDS dinamics and homophobia did not allow the recognition of the disease direction in the region for 20 years, placed in MSM. As a result, lack of policies, budgets and strategies focused to these population were not considered. Thus, civil society, ASICAL and other actors together with the support of UNAIDS fostered the Task Force that promotes public policies and movilizes actors involved to contribute in an integral response before the HIV/AIDS epidemis in gay men, transgender and other MSM in Latin America and The Caribbean. D. This initiative has promoted the creation of 4 National Task Forces; has elaborated a regional stock of actors and strategies to exchange information, a file for people involved in the decision making process, participated in meetings with Thematic Groups and the group that gathers directors of the regional AIDS National Programs to include this topic in its strategical plans. Has participated in regional and subregional Fora carrying out meetings with UNAIDS and its agencies, with civil society organizations and other actors to move forward in this topic. Local, regional and international finantial agencies were movilized. Health Ministers of Central America and Mexico were sensitiziced. The follow- up UNGASS session was influenced and supports were compromised. LL. Social civil society job back up by UNAIDS achieved movilization of strategic regional actors; thus, a comparative advantage can be acquire to implement initiatives in stigmatized and discriminated populations. Inclusion in strategical planning of the decision-making process can reverse HIV/AIDS impact in MSM. The development of National Task Forces will allow to place advocacy activities. R. Monetary investment in a sustainable way can create an impact to the epidemics in this population. The promotion of National Task Force can create an efficient impact. The gender topic is key issue for the region to produce a more effective impact. The XV International AIDS Conference Abstract no. E11072 Suggested Citation " A Díaz Betancourt , , et al. The MSM task force and HIV/AIDS: a citizenship initiative to direct public policies in Latin America and The Caribbean. CD Only: The XV International AIDS Conference: Abstract no. E11072" 64 HIV in the Caribbean: A Systematic Data Review 2003-2008 Increasing access to HIV testing and counseling through integration with primary health care services: lessons learned from Jamaica 1 2 2 1 3 1 K Curran , P Figueroa , R E Vernon , C Schenck-Yglesias , J Stuart-Dixon , M Schuette 1 2 JHPIEGO, Baltimore, United States; Jamaica Ministry of Health, Kingston, Jamaica; 3 Jamaica Ministry of Health, Montego Bay, Jamaica Issues: Limited access to HIV testing and counseling (T&C) is a major barrier to HIV/AIDS prevention and care interventions in Jamaica. The development of stand-alone VCT sites is not feasible given resource constraints that preclude the hiring of additional counselors or laboratory technicians. Description: JHPIEGO, an affiliate of Johns Hopkins University, provides technical assistance to the Jamaican Ministry of Health (MOH) to promote the integration of HIV T&C with primary health care services. This support has been provided as part of a Caribbean regional program funded by USAID. Jamaica MOH policy promotes universal voluntary T&C for antenatal care (ANC) and STI patients, and encourages T&C for other patients. JHPIEGO has focused on training ANC nurses, STI contact investigators and peer educators in HIV counseling. The MOH has decentralized testing to the clinic level by adopting a rapid test algorithm. Local teams have developed and are implementing T&C performance standards for group education, pre- and post-test counseling, HIV testing and management systems. Lessons Learned: Between June 2002 and December 2003, 546 counselors representing 212 service delivery sites were trained and 28 local trainers developed using materials adapted to the Caribbean context. T&C is now available at clinics in all 13 parishes in Jamaica, and uptake of T&C has increased markedly as access improved. The number of ANC clients tested for HIV in one quarter in 2003 was 3,638, close to the 2002 annual total of 3,723. Recommendations: Integration of T&C with primary care services is an effective strategy for increasing access to and use of T&C. Because integration means additional work for clinic staff, strategies such as the use of group education sessions and peer educators to support counseling are essential. The XV International AIDS Conference Abstract no. E12454 Suggested Citation " K Curran , , et al. Increasing access to HIV testing and counseling through integration with primary health care services: lessons learned from Jamaica. CD Only: The XV International AIDS Conference: Abstract no. E12454" 65 HIV in the Caribbean: A Systematic Data Review 2003-2008 Against the odds: targeted HIV/AIDS interventions to men who have sex with men (MSMs) in the Jamaican context I. Cruickshank Issues: Delivering HIV-related services to MSMs in the context of extreme homophobia and a legal framework that supports discrimination is difficult. Initiating and sustaining successful community interventions in this hostile context requires tight links between service providers and members across the community. Description: Evolving from an informal “support groupâ€?, Jamaica AIDS Support is now the leading agency in HIV and related interventions among MSM in Jamaica as well as advocacy around MSM issues. Strategies including formal clinics for MSMs & PLHA, peer education programmes, structured “communityâ€? meetings, socials, sporting activities and party interventions have been used to reach “targetedâ€? populations of MSMs across the island across class lines. Lessons learned: Although limited by a legal framework criminalising consenting sex between adult males, the agency has achieved significant progress in some areas of its interventions. Due to the high levels of homophobia programmes activities have to be grounded in these dynamics. Greater reliance has to be placed on informal networks rather than formal promotion of outreach events and activities. Clinics specifically geared to MSMs and their issues have served to increase JAS’ reach to this community through providing a welcoming environment and respect for privacy. While there is a fair level of success, throughout is a high incidence of repeat contacts and a low level of /new contacts, suggesting “saturationâ€?. However JAS is still reaching less than 10% of the estimated 120,000 MSMs in the island due to the risks associated with self – identificationm Also, since the MSM population in Jamaica reflects the class structure of the society standardised outreach is not effective. Recommendations: A dynamic approach to outreach interventions is required in contexts of high homophobia. A socio-legal framework to support MSM interventions is required to increase effectiveness. Service providers must also seek out the hard-to- reach, which may mean more affluent AIDS 2006 - XVI International AIDS Conference Abstract no. THPE0460 Suggested Citation " I. Cruickshank Against the odds: targeted HIV/AIDS interventions to men who have sex with men (MSMs) in the Jamaican context. : AIDS 2006 - XVI International AIDS Conference: Abstract no. THPE0460" 66 HIV in the Caribbean: A Systematic Data Review 2003-2008 Homophobic violence and sexual behavior: Challenges in sexual behavior change for gay and other MSM in Jamaica I McKnight, R Carr Jamaica AIDS Support, Kingston, Jamaica Issues: Jamaica is well known for its violent homophobia, promoted through its popular music. This has a strong impact on Jamaican MSM’s comfort with their sexuality and on their sexual behavior leading to low self esteem, conflictive relationships, spontaneous and high risk public sex, low prioritisation of condom use and resistance to accessing services. Safer sex practices are a low priority to such MSM presenting on-going challenges to organisations working in HIV prevention with this group. Description: Jamaica AIDS Support, a Jamaican NGO specialising in outreach to marginalised groups, has developed a programme of activities and support to address the psychosocial, strategic and practical needs of the MSM community. This includes bi- monthly meetings in safe spaces, providing daily drop-in facilities for one on one counselling, MSM-supportive VCT, conflict resolution, institutional and national rights advocacy, emergency support and provision of condoms and lubricant free of cost at point of demand. The sexual realities of MSM, impacted by the constant threat of violence because of sexual orientation, play an integral part in the response. Discussions, interventions and counselling with MSM provide a platform for programme planning, service delivery and outcomes while building honest and trusting relationships between project staff and clients. Lessons Learned: Outreach programs to violently marginalised groups must remain sensitive to the range of issues that impact on the groups’ ability to make choices that effect permanent behavior change. Programs must include members of the target group and ensure that safe spaces free of stigma, discrimination and violence ensure healthy lifestyles can become part of a holistic examination of self preservation and healthy sexual choices. Recommendations: Outreach to MSM in pervasive, violent and homophobic societies must encompass and address a wide range of issues to enable sexual behavior change to take place. The XV International AIDS Conference Abstract no. D12149 Suggested Citation " I McKnight, et al. Homophobic violence and sexual behavior: Challenges in sexual behavior change for gay and other MSM in Jamaica. CD Only: The XV International AIDS Conference: Abstract no. D12149" 67 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? Carlos F Ca´ceres Objectives: To assess the epidemiological and social/cultural context of, and the social response to, the HIV epidemic among gay and other men who have sex with men (MSM) in Latin America and the Caribbean. Methods: A review of epidemiological surveillance reports to the Pan American Health Organization/UNAIDS; published studies on HIV prevalence/incidence among MSM in the region; social/cultural studies on homosexuality; documents analysing risk and vulnerability among MSM and publications documenting the social response to the MSM epidemic. Results: The regional HIV epidemic is concentrated in MSM populations in most urban centres (HIV prevalence 5–20%). Incidence rates (1.5–3.3 in Brazil and Peru) are still moderately high, and call for continued programmatic action. Transmission from bisexual men to women is increasingly observed, demonstrating that the neglect of intervention will fuel co-existent epidemics. MSM in the region are culturally diverse, with mediation of social class, sex, and ethnicity. Around core gay subcultures, non-gay identified MSM interact with them and frequently exchange sex for goods. Examples are shown of sexual meanings affecting prevention messages focused on individual risk, as well as of the role of structural vulnerability on potential exposure to infection, calling for programmes beyond individual rational decision making. The social response to the AIDS epidemic has, in most countries, included programmes oriented to MSM, usually from civil society organizations, and has strengthened gay organizing. Conclusion: Renewed, imaginative efforts are needed from governments and community organizations to strengthen culturally sensitive prevention work, and integrate it into community empowerment and the promotion of sexual rights. Suggested Citation Ca´ceres C.F., HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS 2002, 16 (suppl 3):S23–S33 68 HIV in the Caribbean: A Systematic Data Review 2003-2008 Homosexuality and HIV/AIDS stigma in Jamaica Ruth C. White Department of Society, Justice and Culture Seattle University, USA Robert Carr2 Jamaica AIDS Support (JAS), Jamaica Abstract This paper reports on a study of the relationship of homophobia to HIV/AIDS-related stigma in Jamaica. Ethnography, key informant interviews and focus groups were used to gather data from a sample of 33 male and female adults during the summer of 2003. The sample included health and social service providers, HIV positive men and women, and men and women with same sex partners in urban and rural Jamaica. A strong and consistent relationship between homophobia and HIV/ AIDS-related stigma was reported, but the relationship varied according to geographic location, social class, gender, and skin color (complexion)—to the extent that this coincided with class. Stigma against people living with HIV/AIDS and homosexuality was implicated in low levels of use of HIV testing, treatment and care services and the reluctance of HIV positive people to reveal their sero-status to their sexual partners. Data reveal a pressing need for anti-stigma measures for both homophobia and HIV/AIDS, and for training for health and human service professionals. Suggested Citation White, R., Carr, R., Homosexuality and HIV/AIDS stigma in Jamaica, Culture, Health & Sexuality July 2005; 7(000): 1–13 ISSN 1369-1058 69 HIV in the Caribbean: A Systematic Data Review 2003-2008 Hated to Death: Homophobia, Violence and Jamaica’s HIV/AIDS Epidemic Rebecca Schleifer Abstract: In 2004, Jamaica launched an ambitious project to provide antiretroviral treatment to people living with HIV/AIDS and to address underlying human rights violations that are driving the epidemic. These are promising initiatives. They will be compromised, however, unless government leaders make a sustained commitment to end discrimination and abuse against people living with and at high risk of HIV/AIDS. The government knows that although HIV/AIDS is stigmatized as a “gay disease,â€? in reality, in Jamaica as in most of the Caribbean, the most common means of transmission is heterosexual sex. It also knows that if the epidemic in Jamaica continues to accelerate, all Jamaicans will suffer. This fact should encourage high-level Jamaican government officials to act quickly and forcefully to eliminate discriminatory laws and abusive practices that violate basic rights to equality, dignity, privacy, and health and undermine HIV/AIDS prevention and treatment efforts. This includes speaking out strongly and acting forcefully against homophobic violence and abusive treatment of homosexual men and women and of sex workers. If the Jamaican government chooses instead to let popular prejudices continue to undermine its attempts to establish rights-based HIV/AIDS policies, the consequences for all Jamaicans will be dire. Thousands of Jamaicans will be consigned to lives of horrific abuse and thousands will face premature and preventable death. (excerpt) Suggested Citation Schleifer, R., Hated to Death: Homophobia, Violence and Jamaica’s HIV/AIDS Epidemic, Human Rights Watch Vol. 16, No. 6 (B)) New York, New York 70 HIV in the Caribbean: A Systematic Data Review 2003-2008 On “Judgementsâ€?: Poverty, Sexuality-Based Violence and Human Rights in 21st Century Jamaica Robert Carr, Executive Director Jamaica AIDS Support This article will examine poverty, social justice, human rights, homophobia and violence in contemporary Jamaican society and the relationships among these phenomena. In the second half of 2002 three gay men were granted asylum in the United Kingdom (UK) on the premise that were they to be deported to Jamaica it would be tantamount to a death sentence (Thompson, 2002). “Homophobia runs so deep in societyâ€? ran the subtitle of a report in The Observer, a UK-based newspaper, “that asylum can be the only chance of survival.â€? “More than 30 gay men have been murdered in Jamaica in the past five yearsâ€? the article continues. The article further reported, “a group of university students were almost beaten to death.â€? Reports of homophobia running deep in Jamaica are not new although documentation has been sparse on its real world effects. In a 1993 survey of literature on sexuality, Chevannes noted that there was little social scientific literature on the topic of homosexuality in Jamaica. Since then there has been a slow growth in literature documenting the realities of being gay in Jamaica and the wider Caribbean, much of which is qualitative. Jamaica AIDS Support, for example, in collaboration with the Ministry of Health, undertook a Knowledge, Attitudes, and Practices survey of men who have sex with men (MSM)1 in Jamaica. There has also been much debate over the past two years over the nature of homosexuality and its origins that is further explored below. The present study, however, concerns the issue of violence against men on the basis of their sexual orientation. The researcher chose to undertake the task of collecting the data for this study under the aegis of his role at the University where he teaches a graduate level qualitative research methods course. The data were so strong that the decision was taken to produce a scholarly article on the subject, both to develop the social scientific knowledge base on what it means to be working class and gay in Jamaica, but also to contribute to the local and regional debate on human rights. As a social worker, the researcher also deemed it imperative that these issues be brought to the attention of the social work community so that we can further the process of educating ourselves and to begin to address a critical social issue that falls squarely within our mandate for advocacy and support for the disadvantaged. Suggested Citation Carr, R. On “Judgementsâ€?: Poverty, Sexuality-Based Violence and Human Rights in 21st Century Jamaica, The Caribbean Journal of Social Work, Volume 2, July 2003, pp. 71-87 71 HIV in the Caribbean: A Systematic Data Review 2003-2008 Stigmas, Coping and the Impact of Gender on Patterns of Social Ostracism: A Qualitative Study of HIV+ Jamaicans Robert Carr University of the West Indies Abstract This study investigated the nature of social stigmas poor urban and rural HIV+ Jamaicans contend with in their daily lives, and their coping mechanisms. Fifteen poor HIV+ Jamaicans (seven women and eight men) from urban and rural settings were interviewed in depth. Stigmas were found to be related to fears of contamination. A gendered hierarchy was also found in which men were less stigmatized than women and women less stigmatized than men who failed to meet community standards of masculine behavior. High levels of psychological and physical abuse were reported by women. A strong link was found between the treatment of poor HIV+ Jamaicans and the abuse sanctioned for sex/gender transgressors. Dominant coping mechanisms were secrecy, family support, and religion. Suggested Citation Carr, R., Stigmas, Coping and the Impact of Gender on Patterns of Social Ostracism: A Qualitative Study of HIV+ Jamaicans, Unpublished University of the West Indies 72 HIV in the Caribbean: A Systematic Data Review 2003-2008 Appendix 4. Country Submissions ARUBA ..........................................................................................................................74 The BAHAMAS..............................................................................................................80 BARBADOS...................................................................................................................89 BELIZE ..........................................................................................................................98 HAITI ...........................................................................................................................110 JAMAICA .....................................................................................................................154 Netherlands Antilles ....................................................................................................185 OECS ..........................................................................................................................194 ANTIGUA AND BARBUDA ...................................................................................195 COMMONWEALTH OF DOMINICA .....................................................................217 GRENADA ............................................................................................................235 ST KITTS / NEVIS ................................................................................................254 SAINT LUCIA........................................................................................................281 SAINT VINCENT AND THE GRENADINES.........................................................300 TRINIDAD AND TOBAGO ..........................................................................................323 TURKS AND CAICOS ISLANDS ................................................................................361 73 HIV in the Caribbean: A Systematic Data Review 2003-2008 ARUBA Introduction: Aruba is located 32 km off the northern coast of Venezuela. It is divided into 8 administrative regions which in turn are divided into zones. Total population was 103 484 in 2006 and is composed by different nationalities and was 103,484 in 2006. The population density is 575 inhabitants per km2. Aruba is part of the Kingdom of the Netherlands; the Head of State is the Queen Beatrix of the Netherlands who is represented on the island by a Governor General. In total height Ministers appointed by a legislative council constitute the executive council of Aruba. The economy is tourism based with the United States being the major tourist market. Venezuela, Colombia and the Netherlands (main land) contribute to the tourism sector which is the main employer and stimulant of the foreign exchange market. 1. Summary of National Strategic Plan: The National Strategic Plan for an expanded repose to HIV/AIDS was developed in 2002 with the technical support of CAREC-SPSTI and covered the period 2003-2007. Key expected results included in that plan were: • Strengthening of National AIDS Programs in Aruba to develop, implement and evaluate prevention, behavioral and communication interventions targeting vulnerable populations (e.g. Youth, PLWHA, MSM, male and female commercial sex workers, immigrant population) strengthened. • Increased capacity of Aruba to deliver efficient and effective HIV/AIDS/STI services in clinical and diagnostic management, including care and psychosocial support (e.g. MTCT, VCT, PLWHA and youth and male friendly sexual reproductive health services) • Health information, surveillances and research capabilities strengthened to generate reliable data on HIV/AIDS/STI transmission and status to allow for focused decision- making, policy formulation, planning, implementation and evaluation • Advocate for the increased use of research data by decision-makers for effective policy formulation and implementation of the HIV/AIDS expanded response • Management and coordination capacity of the NAP strengthened to coordinate an expanded response approach to policy planning, program implementation and evaluation of HIV/AIDS programs This strategic plan was implemented during the past 5 years under the leadership of the Department of public health, Division of Contagious Diseases with the involvement of an NGO the Women’s Club of Aruba and the UNAIDS Theme Group. It has come to an end without a mid- term evaluation, but national public health authorities have started to plan for a national situational analysis and the development of a new National Strategic plan for the next 5 years to come. 2. Data Collection Procedures ands surveillance systems The department of Public Health of Aruba has a surveillance system for contagious diseases. In 1987, the department started reporting of cases of HIV/AIDS. Key components in the surveillance system are: the physicians, the laboratory, and the Department of Public Health. That latter has a section called the Service of Contagious Diseases which keeps records of all HIV/AIDS cases and analyze the information on annual basis for publication. Confirmatory testing of HIV is done at central laboratory level which plays an important role in reporting of cases directly to the Service of Contagious Diseases and to the physicians who have requested an HIV test. There is 74 HIV in the Caribbean: A Systematic Data Review 2003-2008 no distinction between a case of HIV and a case of AIDS in the reporting system in Aruba. Therefore, cases are reported as HIV/AIDS cases. As soon as a case is confirmed, the Service of Contagious Diseases establishes a procedure to get the patient involved in the national care and treatment programs where each PLWHIV is closely monitored and is provided with ongoing counseling services and medical care including antiretroviral treatment which is available to every patient who needs that treatment. 3. Prevention efforts: past and present, successful and unsuccessful Prevention efforts in Aruba focus on primary prevention i.e. health education trough mass media, billboard, leaflets, and posters and targeting young people, FSW and general population. However no comprehensive assessment took place to understand impact achieved by these prevention programs among all these population groups. But for FSW, it is stated in the 2008 UNGASS Report that 100% of legal FSW are reached by prevention messages, 95% of them reported condom use at last sexual intercourse with client and 100% are tested for HIV and know their result before starting to work. In the same 2008 UNGASS report it is also stated that only 5.2% of females and males aged 15- 24 can correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission and 25% of them have had sexual intercourse before the age of 15. Knowledge and rejection of myths are very low and age of first sexual intercourse is early. These two points bring to the conclusion that prevention programs are not achieving desired impact among young people. Prevention in health care settings includes four components: • blood safety with 100% of donated blood units screened for HIV under quality assurance manner • safety of donated organs and tissues with 100% screening of HIV antibodies among donors • universal precautions which are rigorously used in all health care settings • Prevention of mother-to-child transmission of HIV: 100% of pregnant women were tested for HIV in 2007 and none was found HIV positive. 4. Graphs with Trends re epidemiological status A cumulative total of 481 cases of HIV/AIDS were reported in Aruba since the HIV epidemic started in 1987 to the end of 2007. During the last five years 103 cases of HIV/AIDS were reported that corresponds to an average of 20 to 21 cases per year. Reported New Cases of HIV/AIDS: 1987-2007, Aruba 45 40 39 35 36 36 35 30 30 29 27 27 26 25 25 24 24 22 21 20 20 20 17 16 15 10 5 2 3 2 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: MOH, DPH, Aruba, 2007 75 HIV in the Caribbean: A Systematic Data Review 2003-2008 In terms of sex distribution among reported cases of HIV/AIDS the majority i.e. 62% are males while 34% are females (sex ratio: 2:1) and 4% are unknown. Reported Cases of HIV/AIDS: Sex Distribution, 1987-2007, Aruba 4% 34% Males Females Unknow n 62% Source: MOH, DPH, Aruba, 2007 With 70% of the reported cases of HIV/AIDS in the unknown category for mode of transmission, it can be concluded that the mode of transmission of HIV is poorly documented in Aruba that makes the interpretation of such important information very difficult. For the remaining cases data regarding mode of transmission indicates that 15.70% were infected through heterosexual contacts, 10.70% through homo-bisexual contacts, 2.5% through mother-to-child transmission of HIV, 0.4% through sex work and 0.4% through injecting drug use. Reported Cases of HIV/AIDS: Mode of Transmission, 1987-2007, Aruba 0.40% 15.70% Unknow n 0.40% Bisex 2.50% Homosex 7.20% MTCT 3.50% IDU Heter 70% FSW Source: MOH, DPH, Aruba, 2007 5. Care and treatment programs As soon as the diagnosis of an HIV infection is established, in collaboration with the physician requesting the HIV test, the Service of Contagious Diseases starts the implementation of a follow- up management plan which includes clinical management, psychological support and access to the national support group E-FARO. Through the national insurance system patients are taken care of and access to antiretroviral drugs is included in that insurance package. The ART coverage is estimated at more than 95% in 2007. The number of people under ART represents 22.4% of the total reported cases of HIV/AIDS i.e. 90 PLHIV. However there is no strong follow-up system in terms of information collected among persons under ART therefore 76 HIV in the Caribbean: A Systematic Data Review 2003-2008 there is no measurement of impact being achieved by ART programs regarding decline in mortality or improvement of quality of life of PLHIV. 6. Influence of migration With the expansion of the tourism sector came the need to import foreign workers. In 2006 alone 2 364 persons became residents in Aruba. Actually more than 33.3% of the population of Aruba consists of non-nationals. Business travelers, tourists, laborers and sex workers constitute the majority of migrants. Studies have shown that females increasingly dominate the migration streams, indicating that migration is not family-bound, nor spouses and that has as consequence the implosion of sex work and potential rapid spread of STI and HIV. Nationals from Colombia and Venezuela are the most important component of the migrant population. As demonstrated below, despite the limitation regarding the very large unknown nationality category, many nationalities are represented in the reported new cases of HIV/AIDS in Aruba. In the category “othersâ€? are included nationals of Brazil, Philippines, Africa, Peru, Guyana, India, Dominican Republic, Venezuela and Curacao. Source: MOH, DPH, Aruba, 2007 7. Data in specific groups: MSM, FSW, Bisexual, pregnant women, DU (injection and non Injection): Since 70% of reported cases of HIV fall in the category of unknown mode of transmission, that information is not clearly indicating the major routes of transmission of HIV in Aruba. Prostitution is legal in Aruba and there is a formal sexual network between Aruba and Colombia, the Dominican Republic and very few Caribbean countries. The legal sex work is happening in many bars are found in St Nicholaas where a total of 100 to 150 FSW on regular basis work in that red light area. The public health approach used to protect public health is to test all FSW at arrival before they start working and send back all FSW who are found HIV positive. But no HIV testing is done during their three months of legal stay. However a policy for weekly STI screening and diagnosis is in place. Information from that HIV testing practice is not well documented to add value to national epidemiological surveillance, but from the perspective of public health workers and pimps, it seems to have some protection of public health in Aruba because sex work is controlled and FSW have unlimited access to condoms and public health services. That perception, however, needs to be proven by results of a scientific evaluation of that approach to HIV/STI control in Aruba. IDU is not an issue in Aruba; however, Crack-Cocaine use and use of other drugs are serious challenges. In 2007, the National Drug Control Program estimated that in Aruba there were 2 000 people addicted who are classified as “problematic addictedâ€?. Despite the lack of testing among 77 HIV in the Caribbean: A Systematic Data Review 2003-2008 that population, national decision makes agree that the majority of that population is engaging in risky sexual behaviours and crime. The role played by MSM in the HIV epidemic is not known and because of stigma and discrimination, no male PLHIV would disclose easily his sexual orientation. It is noticeable that during the past four months (January to April 2008) only one case of HIV was reported and that was a homosexual. Taking into account the sex ratio male to female, the conclusion is that MSM are playing an important role in the HIV epidemic in Aruba. 8. Co-infection STI/HIV, TB/HIV and HepB/HIV There is no double screening policy in place in Aruba, so information regarding co-infections is lacking, but national authorities are working on updating national policies in this area to include double screening. Reporting of new cases of STI show that during the last four months has shown that 43 new cases of STI were reported among them new STI, among these 44% were Hepatitis B, 42% syphilis, 7% Chlamydia, 11.6% HSV2 and 2.3% Gonorrhea. Contrary to the traditional observation that STI are common in the younger population groups i.e. 15-24 years old, in Aruba, 79% of cases of STI are occurring among males and females older than 24 years of age. Overall 60.5% of STI occurred among males. b. New Cases of STI: STI cases diagnosed in the last 4 months Aruba Chlamydi Gonorrhe Syphili HSV HepB Total a a s 2 Fem.15-24 0 0 1 0 4 5 Females >24 2 0 3 0 7 12 Males15-24 1 1 0 0 2 4 Males>24 0 0 14 2 6 22 Children<15 0 0 0 0 0 0 Total 3 1 18 2 19 43 Despite the lack of information on the status of cervical cancer in Aruba, it is acknowledged by national authorities that HPV vaccine is being promoted and administered in the private sector. 9. Data on human resources issues No data on human resources exist, but the HIV/AIDS program is equipped with some staff to support its activities. But a review of skills in that program will be essential. To increase human resources the civil society should be much more involved and in a meaningful way, health services should be more integrated and other key programs (e.g. National Drug Control Program) and ministries closely involved in responding to HIV (Ministry of Tourism, and Ministry of Education). 10. Stigma and Discrimination Despite the absence of results of surveys conducted on this area, the absence of specific mode of transmission in the majority of HIV/AIDS cases demonstrate the lack of willingness from PLHIV to disclose their sexual orientation. Furthermore, many attempts were made to establish a network of PLHIV, but unfortunately because of the stigma and discrimination attached to HIV disease few people are ready to come out and form a support network. The existing Network of PLHIV the E-FARO is composed of 8 active members who receive support from several national non governmental structures: Lion Club, Marriot Hotel, Kiwanis, the Anglican Church, and the media (Bondia Aruba). The fact that more than 90 PLHIV are on ART in Aruba and only 8 participate in the support group may underscore the magnitude of fear to face stigma and discrimination after disclosure. 78 HIV in the Caribbean: A Systematic Data Review 2003-2008 11. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities • Focus of the national response should be kept on most vulnerable population groups in terms of research, planning and programming: FSW, MSM, Crack-Cocaine Users and Young People. • Patients Monitoring systems should be strengthened and should include clinical monitoring • Surveillance systems should be strengthened to achieve completeness of data (e.g. mode of transmission) and increase data i.e. knowledge about the epidemic through population based surveys on HIV and related issues. • Strengthening the coordination and links between HIV and Substance Abuse/Drug control programs. • Policy regarding assessment of co-infections HIV/STI, HIV/Tb should be promoted and introduced. • Strengthen the involvement of civil society 79 HIV in the Caribbean: A Systematic Data Review 2003-2008 The BAHAMAS The Commonwealth of The Bahamas is archipelago of some 700 islands and cays located 55 miles from Florida. Twenty-nine of these islands and cays are inhabited, although 95% of the population lives on just seven islands with 85% of the population living in New Providence and Grand Bahama. The population is estimated at 316 000 with a population pattern that indicates that the country is in demographic transition with the characteristics of an industrialized country. About 85% of the population is black and 15% is white. The 200 census has shown that 52% of non-citizens are Haitians and that migration has an impact of the HIV epidemic in the Bahamas (see section on migration). 1. Summary of National Strategic Plan: The road map developed by the national authorities in the Bahamas has a total of 10 lines of action to scale-up HIV prevention, care, treatment and support. These lines of action include: Action 1: Update the National HIV/AIDS Strategic Plan and implement a bi-annual review, evaluation and renewal process. Action 2: Develop a strategy for ongoing sustainable funding Action 3: Strengthen the National Monitoring and Evaluation capacity Action 4: Decentralize and integrate comprehensive HIV/AIDS prevention, treatment, care and support services into the primary level of care throughout the Bahamas. Action 5: Strengthen the capacity of clinic-based, home-based and community-based support services Action 6: Strengthen behavioral change communication and public awareness programs Action 7: Develop a comprehensive human resource management plan to support the effective implementation of the renewed National HIV/AIDS Strategic Plan Action 8: Strengthen the capacity of HIV/AIDS and related laboratory services Action 9: Strengthen physical, transportation, communication and information systems infrastructure to support the effective implementation of the renewed National HIV/AIDS Strategic Plan. Action 10: Strengthen policy and legislation where required to protect persons living with, or affected by HIV/AIDS, and other vulnerable populations from discrimination. 2. Data Collection Procedures ands surveillance systems The Ministry of Health is responsible for health policy and planning, regulation and monitoring, public health services financing, development and implementation of public health programs, community health services, and the provision and management of environmental health. It is estimated that 85% of the population of the Bahamas receive its care through the public health system. The National Health Information and Research Unit (NHIRU) is the main agency in the MOH responsible of planning, implementing, monitoring and coordinating the collection, analysis and dissemination of statistical information related to health services delivery and to health situation in the country. Various subsystems, such as the hospital information system, the primary health care system, environmental health information system, the surveillance system, and laboratory services system; collect, process and report aggregated data to the NHIRU. In 1989 HIV infection became a notifiable disease in the Bahamas. New initiatives were undertaken to improve quality, timeliness and completeness of data by introducing i-PHIS (Public Health Information System) through an agreement with the Public Agency of Canada (PHAC) and i-PHIS was piloted in four sites and plans exist for its full implementation during 2006-2007. 3. Prevention efforts: past and present, successful and unsuccessful 80 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention efforts in the Bahamas have been developed together with care and treatment programs. “There is no prevention without careâ€? has become the motto with the HIV/AIDS Center and highlights the integrated approach of prevention, treatment, care and support adopted within the Bahamas. That approach is singled out as the major source of the success of prevention programs. Prevention programs included health care settings and community based intervention: a. Voluntary Counseling and Testing: integrated VCT services are provided in all community health clinics and are used by patients attending these centers; the outcome of this intervention should be assessed in terms of number of tests done on annual basis including demographic analysis of people being tested for HIV antibodies. b. Prevention of Mother-to-Child Transmission of HIV: very impactful PMTCT programs are running in the Bahamas, indeed the outcome has been a reduction in MTCT of HIV and in 2007 the PMTCT coverage was 89% and since 2003 no HIV+ child was born to an HIV+ mother who has received ART during pregnancy. c. Blood safety: since 1985, HIV screening in donated blood units was introduced as a public health policy in the Bahamas and information available for 2006 indicated a 100% of all donated blood units were screened for HIV. Post exposure prophylaxis is reinforced for occupational injuries and sexual exposures. d. Contact Tracing and partner notification: this is a key component of the national response to HIV and it is undertaken by skilled counselors to reach out to partners of patients diagnosed with HIV infection. The impact of this approach needs to be evaluated and lessons learned from that public health intervention. e. Knowledge and behavioral change programs: these programs are targeting young people (Focus on Youth through the Ministry of Education’s Health and Family Life Education curriculum and the Youth Ambassadors for Positive Living), young adults and the general population. f. Outreach programs for most-at-risk populations (CSW and MSM): these interventions have been limited by the difficulty in reaching these groups. In 2007 only 48% of MSM were reached by prevention programs and 45% of MSM reject myths and have a comprehensive knowledge of HIV prevention measures. During that year, 60.47% of MSM have been tested for HIV and who know their results and also 69% reported having used a condom during last anal sex. It is recognized by national authorities that this specific area of reaching out to the most at risk populations needs rapid strengthening and scale-up. 4. Graphs with Trends regarding epidemiological status The first case of AIDS was reported in 1983 in the Bahamas. As of December 2006, the Bahamas had a cumulative total of 10 841 reported HIV infections with the majority of them in the age group 20-39 years-old. Among those 3 805 died and 7 036 are still alive. Among the latter 1 693 i.e. 24% are living with an AIDS diagnosis and 76% i.e. 5 343 of are living with HIV that has not progressed to AIDS. In 2007 it was estimated that 3% of the adult population was living with HIV in the Bahamas. AIDS has been the leading cause of death in the 15-49 year age group since 1994. Trends in reported cases of AIDS per year show that during the 23 years of its existence in the Bahamas, the HIV/AIDS epidemic is affecting more males than females, and that from 1989 to 1995 there was a sustained increase in both males and females cases, but since 1995, there is a slight and inconsistent declining trend for both sexes. During the period 2000-2006, on average 286 cases of AIDS were reported per year. The highest number of reported cases of AIDS was observed among males in 1995 and among females in 1997. During the period 2000-2006, the 81 HIV in the Caribbean: A Systematic Data Review 2003-2008 male to female sex ratio among reported cases of AIDS was 1.6:1, 1.33:1, 1.37:1, 1.45:1, 2:1, 1.4:1 and 1.39:1 respectively. Graph 1 New Cases of AIDS, By Sex and Year:1985-2006 Males Females 300 250 200 150 100 50 0 1985-1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: 2008 UNGASS Country Report Newly Reported Cases of HIV Because of the lack of clear documentation of mode of transmission of HIV among reported cases of HIV or AIDS, the national authorities documented recently diagnosed cases of HIV infection during the first quarter of 2008. Four important facts came out of this effort: 1. No HIV case was reported in the homosexual or bisexual mode of transmission 2. All adult cases are in the heterosexual mode of transmission including one female case of whom the age was unknown. Among adult cases, the male to female sex ratio is 1.4:1 3. There were 4 cases among children and only one case is reported as MTCT of HIV and the remaining 3 were classified as suspicious cases of MTCT of HIV 4. During that period of time six cases of HIV (4 males (all > 24 years-old) and 2 females (1 <24 years-old and 1> 24 years-old)) who met the clinical and laboratory criteria of AIDS were newly diagnosed with AIDS i.e. 6.4% (6/94) of all persons newly diagnosed with HIV were cases of AIDS. st Table 1: HIV Newly Diagnosed Cases: HIV cases diagnosed (1 Quarter, 2008) BAHAMAS Homosexual Bisexual Heterosexual MTCT Others Don’t Total Know Females15- - - 5 - 0 0 5 24 Females - - 29 - 0 0 29 >24 Males15-24 0 0 3 - 0 0 3 Males>24 0 0 46 - 0 0 46 Children<15 - - 0 4 0 0 4 Total 0 0 83 4 0 1 88 Source: National Surveillance and Information Unit The accuracy of reporting of mode of transmission of HIV may be weak in the Bahamas. Overall 94 cases of HIV infection were reported with 88 cases of HIV and 6 cases of AIDS. Among cases 82 HIV in the Caribbean: A Systematic Data Review 2003-2008 of HIV 55.7% of cases were reported among males, 39.7% among females and 4.5% among children. Among adult HIV cases 90% were reported among persons older than 24 years. New Cases of STI A total number of 313 cases of STI were reported during the last four month of 2007with 266 cases of Chlamydia (85% of total reported STI cases) and 51 cases of gonorrhea (25% of total reported cases of STI). There was no information collected on sex or age of these patients and no cases of syphilis, HSV2, trichomoniasis, chancroid and other STI were reported. New cases of Cervical Cancer: The HPV vaccine has not yet been introduced in the public sector but some physicians are administering it in the private sector. A total number of 14 cases of cervical cancer were reported during the last six months of 2007. The majority of cases of cervical cancer occurred in the age group 36-45 (57%) and all cases were diagnosed among women who are more than 36 years old. HPV vaccine should be introduced large scale. 5. Care and treatment programs Care and treatment services are currently centralized at the National HIV/AIDS Center in Nassau, and delivered through clinics in the Princess Margaret Hospital in New Providence and at the Rand Memorial Hospital in Grand Bahama. There are multiple entry-points to HIV/AIDS services and these include the Princess Margaret Hospital Adult Clinic, the Princess Margaret Hospital Antenatal Clinic, the Princess Margaret Hospital Pediatric Clinic, the Princess Margaret Hospital inpatient infectious diseases services, the Rand Hospital outpatient and inpatient care, the HIV/AIDS in the prison system, the National Tuberculosis Control Program, the Sexually Transmitted Infections Clinic, the Substance Abuse and mental health services, and the Hospice Services. The government of Bahamas has committed to provide antiretroviral treatment (ART) to all eligible HIV-infected persons in the country, regardless their immigration status. Increased availability and affordability of ARV drugs will ensure universal access to ART. The Clinton Foundation has been instrumental in negotiating lower prices and a secured supply of required medications, and has also facilitated funding for ARV medications. The Bahamas has adapted regional guidelines for PMTCT, pediatric and adult patients including protocols for TB co- infections. The Bahamas serves also as a resource center for other Caribbean countries, including Turks and Caicos, Antigua and Barbuda, St Kitts and Nevis and Belize, providing expertise and assistance with medication acquisition, when required. In 2006, 1 252 persons living with HIV were under ART, 573 males, 679 females including 108 children. The coverage rate of Adults and Children with Advanced HIV Infection receiving ART was estimated at 48.5% with 92% treatment coverage for children. Challenges to providing universal access to ART include insufficient human resources and infrastructure to adequately provide care and follow-up, fear of stigma and discrimination, low literacy among persons living with HIV and challenges posed in tracing immigrants living with HIV and centralization of the ART services. In terms of quality of treatment, the percentage of adults and children with HIV infection known to be on treatment 12 months after initiation of antiretroviral therapy was 69.66% in 2006 i.e. almost 30% of patients are lost to follow-up or die during the 12 months they initiated ART. As result of the ART programs deaths due to AIDS have declined from 18.4% in 1996 to 8.8%in 2005 6. Influence of migration 83 HIV in the Caribbean: A Systematic Data Review 2003-2008 Migration has played and continues to play a role in the history of HIV in the Bahamas. At early stage, there were more non-Bahamian represented in the reported HIV cases than Bahamians, but very quickly a shift occurred because more and more nationals appeared in the national HIV statistics and variations in the percentage of Bahamians and non-Bahamians were observed. But since 2002, there is a stable trend which indicates that one quarter on all new cases of HIV infection reported on annual is reported among non-Bahamians (Haitians in majority, Jamaicans, and Dominicans). Graph 2 Percentage Distribution of HIV Infections Reported Annually, By Bahamian Citizenship:1985-2006 Non Bahamians Bahamians 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: 2008 UNGASS Report 7. Data in specific groups: MSM, FSW, Bisexual, pregnant women, DU (injection and non Injection) a. HIV Trends Among Prisoners Between 2003 and 2006 a total number of 10 166 prisoners were tested for HIV in the Bahamas and 230 were found positive yielding to an overall HIV prevalence rate of 2.26%. HIV trends among prisoners did not vary significantly during the four years of observation; it remained between 2% and 2.4%. Graph 3 HIV Prevalence Among Prison Population: Bahamas 2003-2006 3.00% 2.50% 2.40% 2.40% 2.30% 2.00% 2.00% 1.50% 1.00% 0.50% 0.00% 2003 2004 2005 2006 Source: DPH Surveillance Report, Bahamas, 2007 84 HIV in the Caribbean: A Systematic Data Review 2003-2008 b. HIV Prevalence Among Men who have Sex with Men: This was a hard to reach population by the national response to HIV, for the first time in 2007 an HIV prevalence survey was conducted among MSM using a snowball sampling and the result shoed an 8.18% prevalence rate. In 2007, 57% of MSM older than 25 years and 36%of MSM younger than 25 years have a comprehensive knowledge of HIV prevention measures. c. HIV Trend Among Pregnant Women HIV prevalence among pregnant women has slightly declined between 1993 and 2006, however during the past 5 years it has remained stable around 3%. This is one of the highest prevalence rates among pregnant women in the Caribbean. The HIV prevalence among young pregnant women 15-24 years-old was 1.26% in 2006. Also, national authorities reported that repeat pregnancies among known HIV+ women is keeping the prevalence rate at 3% as observed during the past several years. Graph 4 HIV Prevalence Among Pregnant Women The Bahamas:1993-2006 5.00% 4.50% 4.30%4.20% 4.00% 3.80% 3.50% 3.60% 3.60% 3.30% 3.00% 3.10% 3.00% 3.10%3.10% 3.10% 2.90%2.80% 2.70% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: 2008 UNGASS Report d. Status of Substance Abuse in the Bahamas The HIV epidemic started in 1983 with a high number of HIV/AIDS cases among Crack-Cocaine Users. Despite that important event, there is no sero-surveys conducted among that group, but as in the rest of the Caribbean countries, it is important to understand the magnitude of drug abuse in the Bahamas. Between 2000 and 2006 a total number of 3 181 new cases of drug abuse were treated at the Community Counseling and Assessment Centre corresponding to an average of 530 cases per year. Graph 5 85 HIV in the Caribbean: A Systematic Data Review 2003-2008 New Cases of Drug Abuse Treated at the Community Counselling and Assessment Centre, the Bahamas:2000-2005 600 540 557 563 549 500 510 462 400 300 200 100 0 2000 2001 2002 2003 2004 2005 Source: Community Counseling and Assessment Center (CCAC), 2006 Marijuana is the most commonly used in the Bahamas followed by the poly drug category, then alcohol, cocaine and others. Graph 6 Number of New Clients Treated For Substance Abuse and Variety of Drug, The Bahamas: 2004 and 2005 Alcohol Cocaine Marijuana Polydrug Others 350 299 298 300 250 200 150 130 108 103 82 100 50 29 10 0 0 0 2004 2005 Source: Community Counseling and Assessment Center (CCAC), 2006 After the early stage of the HIV epidemic, the impact of substance abuse on the spread of HIV in the Bahamas has not been assessed and understood, a situation which needs correction. 8. Co-infection STI/HIV and TB/HIV a. TB and HIV Co-infection: National HIV/AIDS and TB programs work closely because of the evidence regarding the link between these two conditions. The prevalence of HIV among TB patients was one of the highest in the Caribbean in 2005 i.e. 38% in 2005. National protocols including double screening HIV patients for Tb and vice versa and DOT exist to handle HIV and TB co-infections and in 2006, the percentage of Estimated HIV-Positive Incident TB Cases that Received Treatment for TB and HIV was 81.25% b. HIV and STI Co-infection: 86 HIV in the Caribbean: A Systematic Data Review 2003-2008 Without any doubt, during the period 2000-2006, annual HIV prevalence among STI patients has shown an increasing trend from 3.3% in 2000 to 5.3% in 2006, a 63% increase during these six years. Graph 7 HIV Prevalence Among Patients with STI The Bahamas: 2000-2006 7.00% 6.00% 5.80% 5.30% 5.00% 4.80% 4.40% 4.00% 4.10% 3.60% 3.30% 3.00% 2.00% 1.00% 0.00% 2000 2001 2002 2003 2004 2005 2006 Source: 2008 UNGASS Report 9. Data on human resources issues No assessment was conducted to estimate human resource needs for the Bahamas to respond to HIV. However, the limited human resource base is identified by national authorities as a serious challenge to respond effectively to HIV in the Bahamas, e.g. the low ART coverage is the consequence of lack of human resources. That challenge needs to be addressed if Bahamas has to achieve universal access to HIV prevention, care, treatment and support at the end of 2010. 10. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities: a. At this point in time, the focus of the national response should be on most-at risk population groups: - MSM: should be considered as priority group and interventions should be put in place to address issues among them - FSW: this group should be identified and considered as a priority group and public health interventions put in place to address their issues - Substance Abusers: should be a priority group and part of the national response to HIV and policies develop to ensure that their needs in terms of HIV prevention and services are met. - Migrant Populations: special programs have to be put in place to understand their needs and attend these needs. b. In terms of new strategies consideration should be given to collaboration with countries which have made some inroad in reaching out to these most-at-risk populations e.g. - Dominican Republic or Curacao for FSW (e.g. NGOs working with FSW i.e. COIN, or Campo Alegre respectively) - Barbados for MSM (e.g. the NGO working with MSM and Lesbians: United Gays and Lesbians Against AIDS Barbados (UGLAAB) or Jamaica AIDS Support (JAS)) - Dominican Republic Migrant populations (e.g. NGOs working in the Bateyes) - Strengthening linkages with Caribbean Drug Abuse Research Institute (CDARI) in St Lucia to provide integrated and comprehensive HIV and support services to persons abusing substances 87 HIV in the Caribbean: A Systematic Data Review 2003-2008 - Strengthening collaboration with country of origin of migrant populations to ensure needs of the migrants are met in terms of prevention, care and treatment. c. Finally a key strategy is to address the human resources need. A human resource need assessment should be undertaken within the process of decentralization of programs and services, that will ensure that Bahamas will achieve progress and targets set for Universal access to HIV prevention, care, treatment and support. Bibliography 1. The Commonwealth of the Bahamas. Scaling-up HIV/AIDS Prevention, Treatment, Care and Support Services. The Good News. An overview of Scaling-Up Achievements, Lessons Learned and Best Practices. Ministry of Health. May 2006. 2. The Bahamas Roadmap to Scale-up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services: 2006-2010. February 2006. 3. The Government of the Bahamas. Monitoring the Declaration of Commitment on HIV and AIDS (UNGASS). Country Report 2008. January 2008. 4. Draft Consolidated Analysis of 2008 UNGASS Country Reports, UNAIDS-CAR/RST, July 2008 88 HIV in the Caribbean: A Systematic Data Review 2003-2008 BARBADOS Barbados is the most easterly island in the Caribbean chain. Its population is estimated at 270,000 with blacks being the predominant race. The island’s main religion is Christianity and there are small groups of Hindus, Muslims and Jews. One of the major events in the cultural calendar is the ‘Crop Over’ festival, a culmination of weeks of activity. The country’s economic base includes tourism, agriculture, small and international business and manufacturing. 1. Summary of National Strategic Plan: From October 2006 to November 2007, the National Strategic Plan for HIV prevention and Control 2008-2013 (NSP) was produced to guide the development and implementation of appropriate programs and policies to tackle the challenges presented by the constantly changing face of the HIV/AIDS epidemic. The plan is built on Goal Three of the National Strategic Plan of Barbados: 2005-2025, “Strength and Unityâ€?: Building Social Capital, and is framed within the context of other national, regional and global priority development goals. The overarching objective of the strategy is the “mitigation of the social and economic impact of HIV and AIDS on the population, particularly among youth, thereby significantly promoting sustainable development of the nationâ€?. The five programmatic areas included in the NSP are: 1. Prevention and control of HIV transmission 2. Diagnosis, treatment and care of PLHIV 3. Support for PLHIV 4. Programme Management and Institutional Performance 5. Surveillance, Monitoring, Evaluation and Research 2. Data Collection Procedures and Surveillance Systems To implement these five programmatic areas there are the following six strategic objectives: i. Increase knowledge of the transmission and prevention of HIV and STIs ii. Effect positive behavior change to prevent and reduce the spread of HIV/STIs iii. Strengthen treatment, care and support services for PLHIV and orphans and vulnerable children (OVC) and vulnerable and high-risk groups iv. Boost the educational and economic opportunities for PLHIV and the most-at- risk v. Build capacity and strengthen institutional and managerial structures across the private sector, civil society and government to deliver effective and sustainable programs vi. Strengthen institutional structures that will enable successful scale-up and execution of surveillance and monitoring and evaluation of programs to allow for evidence-based decision making. The plan is being implemented under the leadership of the National HIV/AIDS Commission of Barbados (NHAC) which is primarily a coordinating body and composed of a chairman and a fifteen-member Secretariat: Director, Deputy Director, Assistant Director, Behavior Change Communication Specialist, Public Relation/ Liaison Officer, Senior Accountant, Accountant, two Administrative Officers and a small cadre of support staff. 2. Data collection procedures and surveillance systems Data collection and publication is the responsibility of the Surveillance Unit at the National HIV/AIDS Programme, Ministry of Health, National Insurance and Social Security. Standardized 89 HIV in the Caribbean: A Systematic Data Review 2003-2008 forms are used to report cases of HIV or AIDS. Data collected from testing sites and the sole public clinic responsible for medical management of PLHIV (the Ladymeade Reference Unit) and private clinicians is sent to the Surveillance Unit for collation, analysis and publication on a semi- annual basis. The concept of monitoring and evaluation was discussed nationwide and a comprehensive framework was developed under the leadership of the NHAC with the objective of analyzing information from different sources (epidemiological surveillance, surveys, studies, monitoring and evaluation of programs and treatment) to develop a better understanding of HIV and driving forces behind the epidemic and the impact being achieved in responding to it. To that end, four technical working groups were established: the M&E working group, sub-committees on research, capacity building, data analysis (and use for decision-making) and an additional sub-committee on key populations at higher risk. 3. Prevention efforts: past and present, successful and unsuccessful The prevention of HIV transmission through transfusion of contaminated blood or blood products is under control. Indeed, 100% of donated blood units were screened under a quality assured manner in 2006 and 2007 as indicated in the 2008 UNGASS Country Report. Programs aimed at prevention of mother-to-child transmission of HIV (PMTCT) among pregnant women have been successful in expanding their coverage rate and reaching 85% and 95% of their target in 2006 and 2007, respectively. This brought the rate of mother-to-child transmission to below 3% in 2007. The age distribution of new cases of HIV from 1994 before PMTCT was introduced to the end of 2006, has shown that the percentage of infants and children among new cases of HIV has declined as impact achieved by PMTCT programs in that country. Barbados: Age Distribution of New Cases of HIV in Percentage 1994-2006-Impact of PMTCT Programs 0-4years-old 5-14years-old 15-49years-old >49years-old 120.00% 100.00% 80.00% Percentage 60.00% 40.00% 20.00% 0.00% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Age Groups Source: National Monitoring and Evaluation Framework and Operational plan, 2008 The men who have sex with men (MSM) initiatives undertaken with UGLAAB (United Gays and Lesbians Against AIDS) have made some progress as demonstrated in the 2008 UNGASS Country Report (85% MSM tested for HIV and know their result and 65% of MSM used a condom at last anal sexual encounter). Prevention efforts among young people have also shown some progress. However, several other programs might benefit from being more focused. Indeed, for many years attempts to implement comprehensive programs among female sex workers and ‘beach boys’ have remained relatively small scale. 90 HIV in the Caribbean: A Systematic Data Review 2003-2008 4. Graphs with trends re: epidemiological status From 1984 when the first case was diagnosed to the end of 2007, a cumulative total of 3 408 cases of HIV were reported to the epidemiology and surveillance department, Ministry of Health, Barbados. In 2007 it was estimated that 2% of the adult population in Barbados was living with HIV. The trend in reported cases of HIV increased from 1984 to 2000 and thereafter has slightly declined from 219 cases to 163 cases at the end of 2007 (26% reduction). Reported Cases of HIV By Year, Barbados: 1987-2007 250 200 150 100 50 0 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 Source: 2008 UNGASS Country Report, Barbados Trends in reported cases of HIV by year and sex have shown that males are more affected by HIV than females and the male to female sex ratio has remained above 1 during the 23 years of the existence of HIV in Barbados. The HIV epidemic among females shows a lower intensity but it is sustained over time while the epidemic among males has shown a slight decline since 1994 when the reported total number was 120. However, between 2005 and 2007, the reported yearly number of cases among males has again increased. 91 HIV in the Caribbean: A Systematic Data Review 2003-2008 Reported HIV Cases By Year and Sex, Barbados: 1984-2007 Females Males 140 120 100 80 60 40 20 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: 2008 UNGASS Country Report, Barbados 1 317 people have died of AIDS in Barbados since the start of the epidemic in 1984. The reported number of deaths due to AIDS has consistently increased from 1984 to 1998 when the highest number of deaths was reported but since then the trend in mortality has declined systematically and in 2007 there were only 23 deaths due to AIDS in Barbados. This represents an 80% decline in the reported number of deaths due to AIDS from 1998 to 2007. Reported Cases of Deaths due to AIDS, Barbados: 1987-2007 120 100 80 60 40 20 0 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 Source: 2008 UNGASS Country Report, Barbados The decline in the number of deaths due to AIDS started in 1998 and 1999 for females and males, respectively, but is has become consistent and significant since 2001 among both sexes with a very sharp decline of death due to AIDS among males between 2001 and 2007. 92 HIV in the Caribbean: A Systematic Data Review 2003-2008 Reported Cases of AIDS Deaths by Sex, Barbados:1987-2007 Females Males 90 80 70 60 50 40 30 20 10 0 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 Source: 2008 UNGASS Country Report, Barbados There is a claim that HIV is mainly transmitted through heterosexual exposure, as documented in the 2008 UNGASS Report. However, understanding the history of HIV in terms of probability of transmission in men and women, the lack of strong documentation of modes of transmission and the preponderance of males among these reported cases is important before reaching the conclusion that HIV is predominantly transmitted through heterosexual contacts in Barbados. This evidence can be gleaned through the re-examining of the situation through conducting specific surveys. 5. Care and treatment programs The Ladymeade Reference Unit (LRU) is the sole public clinic responsible for the medical care of PLHIV. During the five years of it existence between June 2002 and June 2007, 1 102 PLHIV registered at the facility. Among those, 116 died and 986 are under care with 615 on HAART. Specialists at the LRU manage the majority of PLHIV in Barbados, but a small number of PLHIV is taken care of by physicians in the private sector. To give a perspective on the patient population at the LRU, the profile of 70 persons newly diagnosed with HIV between January 2007 and June 2007 was analyzed and has shown that 54% were males and 46% were females with the majority (83%) of them in the age group 20-49 years-old. The average age was 40.1 years for men and 36.7 years for women. The average CD4 count was 411 for females and 254 for males, thus suggesting that men present themselves at a more advanced stage of the disease than women. This is also translated in more males dying of AIDS than women. Data from the 2008 UNGASS Country Report has shown that 94% of people who started ART are still alive at 12 months after initiating treatment and that 95% of children who need ART and 80% of adults in need are receiving ART in Barbados. This is a success story in terms of coverage of ART and has resulted in a consistent decline in the number of deaths due to AIDS in Barbados. 6. Influence of migration Despite the absence of rigorous documentation of the influence of migration on HIV in Barbados, among newly registered PLHIV at the LRU (January 2007-June 2007) 66% were nationals of Barbados and the remaining 34% were from other Caribbean countries. The question is raised as to whether these non-nationals are traveling to Barbados to look for better care and treatment at 93 HIV in the Caribbean: A Systematic Data Review 2003-2008 the Ladymeade Reference Unit (with its very high standards and modern equipment) or whether they are legal residents in Barbados, thus playing a role in the HIV epidemic in the country. Being a popular tourist destination puts Barbados at a cross roads of sex tourism, but no survey has been conducted to assess the real magnitude of such tourism on the local epidemic. Leaders in the MSM community have acknowledged that there is a network of MSM established through regular parties organized by the local gay community which attract MSM from the Caribbean, the United States and United Kingdom. Again the potential impact of these events on the local epidemic is not determined. 7. Data in specific groups: pregnant women, MSM, and FSW a. HIV prevalence among pregnant women: During the last three years HIV prevalence among pregnant women was 0.47% (8/1718) in 2005, 0.67% (12/1785) in 2006 and 0.26% (4/1558) in 2007. Meanwhile among pregnant women 15-24 years-old HIV prevalence during the last three years was 0.47% (4/853) in 2005, 0.6% (5/838) in 2006 and 0.36% (3/825) in 2007. The important point is that there were 5061 pregnant women attending antenatal clinics (ANC) and who were tested for HIV during the past three years and 2516 i.e. 49.7% were in the age group15- 24 years-old. Meanwhile, a total number of 24 pregnant women were found HIV positive and 12 i.e. 50% of them were 15-24 years-old. During the past three years, in the age group 15-24 years-old, 2 i.e. 17% of the HIV positive pregnant women were in the age group 15-19 years- old and the remaining 10 i.e. 83% of the HIV-positive pregnant women were found in the age group 20-24 years-old. Only 28% (1437/5061) of all pregnant women were in that age group. In 2007 alone, 75% of HIV positive pregnant women were found in the age group 15-24 years-old meanwhile 52.92% of all pregnant women were in that age group and the remaining 25% of the HIV positive pregnant women were 25 years of age or older. Despite the low HIV prevalence rate among pregnant women 15-24 years during the past three years i.e. 0.23% (12/5061), they carry a heavy burden of HIV infection in Barbados compared to the age group 25 years of age and above. Understanding that HIV infections among young people reflect new infections, this observation leads to the conclusion that new HIV infections are occurring in Barbados on an ongoing basis and prevention programs are not achieving the required impact. b. Sex workers and men who have sex with men The 2008 UNAGASS Country Report indicates that no seroprevalence study has been conducted among these two population groups but during 2007 85% of MSM and 73% of sex workers were tested for HIV and know their result. However only 37% of female sex workers (FSW) reject myths surrounding HIV transmission and know HIV preventive measures. 80% of FSW reported having used a condom during last sexual encounter with a client. Initiatives for ‘beach boys’, who are often seen to be sexually involved with tourists, are underway, but no study has been conducted among this group to assess their vulnerability to HIV infection in Barbados. c. Men’s Life Style Study 94 HIV in the Caribbean: A Systematic Data Review 2003-2008 This study was conducted among 500 men (400 heterosexuals and 100 homosexuals) in 2007 focusing on the assessment of the level of risk behavior in men over 15 in Barbados. It includes an identification of socio-cultural factors contributing to risk behavior to understand met and unmet needs of males including the MSM community. Preliminary results have shown that: - 65.7% of men found it acceptable that all women carry condoms, but only 4.1% found it acceptable that only men should carry condoms. - Only 16.5% of men reported having a doctor that they see on a regular basis, 15% never see a doctor and 68.5% of men see a doctor only when something is very wrong. - 36% of males had been intoxicated between one and countless times during the 12 months preceding the survey especially during holiday/vacation and weekend revelry. Among these, 25% reported engaging in unprotected sexual intercourse at least once during the past 12 months. - 47% of all males reported having multiple sex partners - Among the heterosexual men only 46% used a condom during last sexual intercourse with a non regular sex partner - Among MSM 62% have two or more partners and 65% reported using a condom at last anal sex Other behavioural markers among men are summarized in the table below. The findings show that the majority of heterosexual and homosexual men have had an HIV test and found out the results. However, the percentage of men tested during the past 12 months was below 50%. The percentage of MSM reporting an STI episode was 18%, more than double that among heterosexual men. The most striking finding is the relationship between one night stands and STI infection among MSM. Behavioural Markers Heterosexuals MSM Total Ever taken an HIV test 57% 73% 61% Find out the results 76% 85% 78% HIV test in last 12 months 30% 47% 34% STI in last 12 months 7% 18% 10% STI contact: one night stand 29% 63% 48% STI contact: spouse/regular partner 29% 13% 20% 8. Co-infection STI/HIV, TB/HIV and HepB/HIV The 2008 UNGASS Country Report indicates that 100% of the estimated number of patients with HIV and TB were managed adequately based on national standards and policies. However, no information exists on other co-infections such as STI-HIV or Hepatitis B or Hepatitis C and HIV. Newly diagnosed cases of HIV Despite the lack of information on the route of transmission of HIV among these cases, data show that the majority of cases occur in the over 24 age group, that MTCT of HIV is low and also that cases of HIV among those under 25 is very low. a. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months Sex and Age Group Total Females15-24 3 (6.40%) Females >24 14 (30.0%) Males15-24 2 (4.25%) Males>24 27 (57%) Children<15 1 (2.12%) Total 47 b. Reported New Cases of STI in Barbados, 2007 95 HIV in the Caribbean: A Systematic Data Review 2003-2008 Reported cases of STIs show that in 2007 there were 205 cases of trichomoniasis, 154 cases of syphilis, 99 cases of gonorrhea, and 53 cases of chlamydia. All cases of trichomoniasis were reported among female patients. The cases of syphilis were diagnosed among many population groups (people applying for jobs, pregnant women, outpatients, patients at the psychiatric hospital, and STI patients) without any age specification. Among the cases of gonorrhea there were 48.5% females and 51.5% males. The essential point regarding age distribution is that the majority of all cases of gonorrhea were reported in the 15-24 age group 48.5%) with cases among females counting for 62.55 of all infections in that age bracket. b.1. Infections due to N. Gonorrhea Age Male Female Total <15 years-old 0 1 1 (1%) 15-24 years-old 18 30 48 (48.5%) > 25 years-old 12 6 18 (18%) Unknown 21 11 32 (32%) Total 51 (51.51%) 48 (48.48%) 99 The situation of infection with chlamydia is similar to cases of gonorrhea with the majority of the infections occurring among the 15-24 age group and females counting for 67.4% of all infections in that age bracket. b.2. Infections due to Chlamydia Trachomatis Age Male Female Total <15 years-old 0 0 0 (0%) 15-24 years-old 14 29 43 (81%) > 25 years-old 5 5 10 (18.9%) Total 19 (36%) 34 (64%) 53 Newly diagnosed cases of cervical cancer: cases diagnosed during the last 6 months A total number of 9 cases of cervical cancer were reported during the last six months of 2007. These cases have occurred among women aged 45 and older. 6 cases were squamous cell carcinoma, 2 cases were undifferentiated carcinoma and one case was adenocarcinoma. The HPV vaccine has not yet been introduced, but the negotiation and sensitization process is underway to consider the advantage of an HPV vaccine in Barbados. 9. Data on human resources issues National authorities have identified human resources issues as critical to effectively respond to HIV. The strengthening of skills and capacities in monitoring and evaluation and surveillance are underway with the support of UNAIDS and the CDC-GAP. Beyond the formal process, efforts are also initiated to continue to support the ongoing mobilization of civil society organizations to ensure they continue to play their role in the national response to HIV. The multisectoral approach is being promoted and line ministries are carrying out their plans of action as part of the national strategic plan. 10. Data on stigma and discrimination 96 HIV in the Caribbean: A Systematic Data Review 2003-2008 Information on stigma and discrimination is mostly anecdotal; however the National HIV/AIDS Commission has initiated several interventions intended to reduce stigma and discrimination. These include: - The establishment of a Unit for investigating discrimination against PLHIV, - The development of a discrimination registry to record and investigate all forms of discrimination against PLHIV - Encouraging public debate on decriminalization of homosexuality and sex work with the objective of changing social norms related to stigma and discrimination - The development of a human rights based mass media campaign under the theme “Embrace tolerance, protect Human Rightsâ€?. 11. Assessment and recommendations for a programmatic response to the HIV epidemic: new strategies and new priorities National priorities should include rapid expansion of research for action programs to be carried out and implemented among the following population groups: 1. Men who have sex with men 2. Female sex workers 3. Male sex workers and ‘beach boys’ 4. Patients with sexually transmitted infections For these priorities to be addressed and impact achieved in reversing the spread of HIV, more national experts will be needed in the area of research, monitoring and evaluation and surveillance. Social scientists will be needed to transform findings of research, monitoring and surveillance into behavioral modification programs. Bibliography 1. Government of Barbados. National AIDS Programme. UNGASS Country Progress Report. Barbados. February 2008. 2. UNICEF/UNAIDS/WHO. Children and AIDS: Second Stocktaking Report. 2008. 3. Final Technical Report on the Baseline Study on HIV/STI Prevention among Sex workers in Barbados, Ministry of Health, 2007 4. HIV Surveillance Report, January-June 2007, Ministry of Health, Barbados. March 2008 5. National Monitoring and Evaluation Framework and Operational Plan for HIV prevention and Control. March, 2008 6. Draft Report: The Barbados Men’s Life Style Study (BMLS). 2007 97 HIV in the Caribbean: A Systematic Data Review 2003-2008 BELIZE Belize formerly known as British Honduras is the only English speaking Caribbean country situated in Central America. In 2007, its population was estimated at 314 3000 inhabitants constituted by different ethnic groups including the Garifuna a mix of Africans, Arawak and Carib. From the 2000 census, in Belize many languages are spoken: Chinese, Creole, English, Garifuna, German, Hindi, Maya Ketchi, Maya Mopan, Maya Yucateco, and Spanish. English remains the official language. The country is divided into six administrative and health districts: Belize, Cayo, Corozal, Orange Walk, Stann Creek and Toledo. Belize is a member of CARICOM. 1. Summary of National Strategic Plan: The National AIDS Commission (NAC) the coordinating body for the national response to HIV is under the responsibility of the office of the Prime Minister. Under the leadership of the NAC, a multisectoral National Strategic Plan 2006-2011 was developed as a result of a significant national consultation process which brought together all national stakeholders to achieve this end product. Line Ministries included in the planning process were the Ministries of Health, Education, Public Service, Human Development and Tourism. Other key partners included in the process were PLHIV, civil society organizations, labor and professional associations, private sector representatives and development partners including UNAIDS and its co-sponsors e.g. PAHO/WHO, UNICEF, ILO. After the NSP was finalized a nationwide effort was undertaken to promote the socialization of the NSP and engage partners to develop detailed plans according to strategic areas of their mandate. A National Information, Education and Communication Strategy is completed and is being implemented. The Ministry of Health has developed a plan of action to integrate HIV/STI/TB into primary health care system and a plan of action was developed to scale-up interventions in the health sector to achieve Universal Access targets. The NAC is developing a framework for monitoring and evaluation and harmonization of indicators and measurement tools according to international agreed-up indicators in the UNGASS reporting process. The NAC effort includes also the development of a resource mobilization plan to ensure that resources are made available to support the implementation of the NSP. 2. Data Collection Procedures ands surveillance systems The National Health Information and Surveillance Unit (NHISU) has been in charge of HIV/AIDS and STI surveillance and reporting. For HIV/AIDS that approach is mainly laboratory based information systems which do not capture essential demographics and behavioral information key for the monitoring of a lifestyle disease such as HIV. Therefore for many years HIV and AIDS data published by the NHISU included only the minimum information i.e. residence, age and sex. However, in 2005, the national surveillance unit has embarked on a major change by introducing the second generation surveillance. The MOH has dedicated significant efforts in re-structuring of the HIV surveillance system in Belize so that key behavioral and impact indicators are monitored and reported on regular basis. By establishing a more comprehensive monitoring and evaluation system, it is expected that the NHISU will be further strengthened to enhance case reporting, patient tracking and carry out regular surveys among most at risk populations as well as the general population. 3. Prevention efforts: past and present, successful and unsuccessful Several prevention programs were carried out by national agencies as well as the non- governmental sectors and efforts are underway to establish condom social marketing programs, continue mass media campaigns, peer education programs, health and family life education and 98 HIV in the Caribbean: A Systematic Data Review 2003-2008 establishment of non-traditional condom distribution outlets. However, as reported in the 2008 UNGASS Country Report, the most at risk populations such as MSM and FSW have not been reached by these prevention programs and if the impact of programs among young people is measured by the level of their knowledge of prevention measures and rejection of myths, that was 26% in 2007 a relatively very low level of knowledge among young people. Blood safety is assured by screening of HIV antibodies in all donated blood units and PMTCT of HIV is a major prevention program which is ongoing and national health authorities reported a 78% coverage for 2007, however it is difficult to ascertain if this is a coverage rate among HIV+ pregnant women seen in the antenatal services or a true coverage rate i.e. calculated using as denominator the estimated total HIV+ pregnant women in 2007. UNAIDS/UNICEF/WHO estimate that in 2007 the PMTCT coverage is between 24% and 64%. Belize should scale- up strategic interventions to achieve 80% PMTCT coverage rate by 2010 if it has to achieve the Universal Access goal as defined by UNICEF. 4. Graphs with Trends re epidemiological status From 1986 when the first case of HIV was reported to September 2007 a cumulative total number of 4 131 cases of HIV were reported as well as a cumulative number of 805 cases of AIDS and 701 deaths due to AIDS. The geographic distribution of these cases of HIV shows that 82.6% of them are diagnosed in the district of Belize followed by Stann Creek (9.5%), Cayo (3.8%), Corozal (2%), Orange Walk (1.8%) and Toledo (0.2%). In 2005 and 2006 a total number of 434 and 443 cases of HIV were reported respectively. Among the reported cases of HIV in 2006 only 3.8% (17) were under 15 years of age. Among cases older than 15 years of age, 56% (240) were males while 44% (186) were females. The male to female sex ratio was 1.3:1 but unfortunately the information on the mode of transmission of HIV is absent making the interpretation of data limited in terms of dynamics of HIV in Belize conducive to appropriate subsequent public health actions. The remaining consideration to achieve an understanding of the magnitude of HIV epidemic in Belize is to use estimates developed by national authorities in collaboration with UNAIDS/WHO. These indicate that with 2.1% of its adult population living with HIV, Belize is the most HIV- affected country in Central America (UNAIDS/WHO 2008). Graph 1 Adult HIV Prevalence Rate in Central America. UNAIDS/WHO 2007 BEL 2.10% PAN 1.00% GUA 0.80% Country ELS 0.80% HON 0.70% COR 0.40% NIC 0.20% 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% Percentage UNAIDS-Report on the Global AIDS Epidemic, 2008 99 HIV in the Caribbean: A Systematic Data Review 2003-2008 BEL: Belize, PAN: Panama, GUA: Guatemala, ELS: El Salvador, HIN: Honduras, COR: Costa Rica, NIC: Nicaragua Among the 10 larger Caribbean Countries, regarding the adult HIV prevalence rate, Belize is the fifth country the most affected by HIV in the Caribbean. Graph 2 Adult HIV Prevelence Rate in the Larger Caribbean Countries UNAIDS/WHO. 2007 BHA 3.00% GUY 2.50% SUR 2.40% HAI 2.20% BEL 2.10% Country JAM 1.60% TNT 1.50% BDO 1.20% DOR 1.10% CUB 0.10% 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% Percent UNAIDS-Report on the Global AIDS Epidemic, 2008 BHA: Bahamas, GUY: Guyana, SUR: Suriname, HAI: Haiti, BEL: Belize, JAM: Jamaica, TNT: Trinidad and Tobago, BDO: Barbados, DOR: Dominican Republic, CUB: Cuba These two observations bring to the conclusion that Belize is among countries with the highest adult HIV prevalence rates in Central America and the Caribbean. 5. Care and Treatment Programs A key recommendation from the 2004 CAREC/PAHO/CDC review of HIV/AIDS care and treatment services in Belize was to decentralize these services and bring them closer to communities. However, the fact remains that treatment services are centralized; a timid decentralization movement has started with the possibility of provision of ART to patients who have received their prescription from the central level and VCT centers being established in several districts: Belize, Cayo and Toledo. In 2007, there were 3600 PLHIV in Belize who needed general clinical management and follow- up, or care, treatment, and support. Graph 3 100 HIV in the Caribbean: A Systematic Data Review 2003-2008 Estim ated Num ber of Adults and Children Living with HIV in the Ten Larger Caribbean Countries. UNAIDS/WHO.2007 HAI 120000 DOR 62000 JAM 27000 TNT 14000 GUY Country 13000 SUR 6800 BHA 6200 CUB 6200 BEL 3600 BDO 2200 0 20000 40000 60000 80000 100000 120000 140000 Num be r of PLHIV UNAIDS-Report on the Global AIDS Epidemic, 2008 BHA: Bahamas, GUY: Guyana, SUR: Suriname, HAI: Haiti, BEL: Belize, JAM: Jamaica, TNT: Trinidad and Tobago, BDO: Barbados, DOR: Dominican Republic, CUB: Cuba There is an agreement signed with PAHO/WHO for the procurement of ARVs and other medications through the PAHO strategic fund and activities included in that agreement are being implemented. In 2007, WHO/UNAIDS/UNICEF reported that 558 people were on ART in Belize among them 493 adults and 65 children. The ART coverage rate was estimated between 24% and 64%. Laboratory services are available and since 2002 CD4 count is used to make a decision re starting ART, but viral load measurement is lacking in the monitoring process of HIV patients. NGO are involved in HIV prevention (e.g. Belize Family Life Association-BFLA) and care activities especially among PLHIV and some income generation activities for PLHIV through the support of local NGO are taking place beyond the traditional counseling and emotional support. However major challenges remain the lack of an adequate patient tracking system, information management and the use of clear standards and norms to manage patients. 6. Influence of migration HIV and AIDS data is reported mainly from laboratory sources; therefore the influence of immigration on the HIV epidemic is not well documented. However, many central HIV/AIDS experts believe that the HIV epidemic in the neighboring Honduras has some influence on the Belizean epidemic and also two common issues are well known in Belize: 1. The country constitutes a transit route for Latin American migrants to the United States of America 2. Seasonal agricultural migrants workers from Central America are working on banana and citrus plantations For these two reasons, a further exploration of the influence of migration on the local epidemic is needed. 7. Data in specific groups: Prisoners and Pregnant Women Among specific population groups, HIV screening among pregnant women through PMTCT programs is ongoing and had a 91% testing coverage rate resulted in an HIV prevalence of 1.54% (61/3955) in 2006 and during the period January to October 2007 the HIV prevalence among pregnant women was 1.95% (54/2766). Overall, HIV prevalence among pregnant women has remained close to 2% during 2006-2007. 101 HIV in the Caribbean: A Systematic Data Review 2003-2008 A seroprevalence survey was conducted in 2004/2005 among the prison population, resulting in an HIV prevalence rate of 4.90%. No surveys were conducted among MSM and FSW but the country is working with the PASCA/USAID network to include Belize in that regional surveillance network which is focusing on conducting regular surveys among the most at risk populations in Central America. 8. Co-infection TB/HIV In Belize Tuberculosis is the most common opportunistic infection. Information available indicates that in 2007 67 people were screened for Tb and HIV and 10 were found positive (15%) and all treated for both conditions based on national standards. The graph below shows that from 1998 to 2002 the prevalence of HIV among TB patients varied between 10% and 20% in Belize. Graph 4 HIV Trends among TB Patients: 1997-2002 80 70 60 50 40 30 20 10 0 1997 1998 1999 2000 2001 2002 Baham as Be lize Guyana Jam aica Surinam e Trinidad & Tobago Source: CAREC/PAHO/WHO. Status and Trends of HIV in the Caribbean.2004 9. Data on Human Resources Data does not exist on Human Resources. However the need for such important information was underlined in the 2008 UNGASS Report. Five challenges were identified and need to be addressed: 1. Development of a Human Resource Development Plan 2. Development of a succession plan for key health providers’ positions 3. Development of expertise in epidemiology, data processing and analysis 4. Development of skills for community based planning and implementation of interventions 5. Development of skills and expertise in Monitoring and Evaluation at all levels 10. Data on Stigma and Discrimination No official data or survey was conducted on stigma and discrimination, but anecdotal reports suggest that the rejection of most at risk populations is common; especially homophobia appears to be very prevalent because of the existing social and religious beliefs. This is an important area which needs more exploration. 102 HIV in the Caribbean: A Systematic Data Review 2003-2008 11. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities. Analyzing the status and trend of HIV in Belize is very challenging because of lack of comprehensive information among general population as well as most at risk population. To address this challenge, it is important for the country to undertake the following actions: 1. Conduct a DHS survey including knowledge, attitude, beliefs and practices and an HIV test 2. Conduct a BSS among most at risk populations: MSM, FSW and migrant workers 3. Introduce a specific HIV/AIDS surveillance system which will provide comprehensive information among reported cases: demographics and modes of transmission of HIV Overall, as demonstrated in the graph below, Belize is the larger Caribbean country which has reported less information on the UNGASS indicators, therefore, there is a need to establish a strong and effective monitoring and evaluation infrastructure which will collect and collate strategic information from both the governmental and non- governmental sectors, analyze it and publish it for use in planning and programming the response to HIV and reporting to UNGASS 2010. Graph 5 Percentage of Indicators Reported by Country Larger Caribbean Island Settings. 2007 CUB 95% HAI 91% DOR 86% JAM 82% Country GUY 82% SUR 73% BHA 64% BDO 59% TNT 50% BEL 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage In conclusion, the magnitude of the HIV epidemic is not well known in Belize, however, there is a clear indication that the HIV epidemic in that country is generalized; therefore the national response should be a true multisectoral response but priority attention should be paid to the most vulnerable groups in terms of research, programs and services to be made available to these groups. That will be the appropriate approach to increase knowledge about the epidemic and to respond effectively to HIV in Belize. Bibliography www.carec.org 2008 Report on the Global AIDS Epidemic. UNAIDS.2008 2008 UNGASS Country Report, Government of Belize. Status and Trends. Analysis of the Caribbean HIV/AIDS Epidemic. 1982-2002. CAREC/PAHO/WHO 103 HIV in the Caribbean: A Systematic Data Review 2003-2008 Report on CAREC/PAHO and CDC Review of HIV/AIDS Care and Treatment Services in Belize. 2004 FRENCH DEPARTMENTS OF THE AMERICAS The total population of the French Departments of the Americas was estimated at 1 018 000 inhabitants. These Departments are constituted by three administrative entities: Guadeloupe with an estimated 408 000 inhabitants, includes also St Martin, Marie Galante, les Saintes and St Barthelemy. French Guiana situated in South America neighbors Suriname and Brazil has an estimated population of 209 000 inhabitants and Martinique which has an estimated 401 000 inhabitants. These administrative divisions correspond to the organization of their health care delivery systems. 1. Summary of National Strategic Plan None of the three French departments has a local strategic plan, because national plans, strategies and policies are developed for the whole French national territory and made available through national health systems to each department and to major NGOs such as AIDES. Existing national policies include universal access to treatment, care and support as well as prevention through health education programs in the general population, young people and most vulnerable population and national surveillance of the HIV epidemic. . 2. Data Collection Procedures and surveillance systems AIDS became a notifiable disease in 1986 and was a key component of the epidemiological surveillance in France. However since the introduction of antiretroviral treatment and the improvement of quality of life of PLHIV, the monitoring of cases of AIDS has become irrelevant for the true status and trend of the epidemic and became much more a marker of lack of early diagnosis of HIV, lack of follow-up of PLHIV and lack of access to treatment. In 2003 a new policy was introduced to make HIV a reportable disease with a clear case definition for reporting purposes. It is important to underline that reporting of cases of HIV was coupled with the molecular epidemiology surveillance at the CNR i.e. viral genotyping. The objective of this new approach was to better describe the population living with HIV, follow-up the trend of the epidemic and collect better information for public health action in the area of prevention of new HIV infections. Reporting cases of HIV or AIDS is initiated by a physician to the surveillance department of the Direction of the health and social security affairs department. The notification of cases starts with the biologist doing the test and finalized by the physician who is managing the patient by including demographic information, clinical and behavioral information as required. Data is collated and analyzed at the surveillance department and published regularly. 3. Prevention efforts: past and present, successful and unsuccessful No BSS or KABP surveys were recently conducted among general population, young people or the most vulnerable populations in the French Departments of the Americas. In 2004 the last KABP survey was conducted in these three Departments to determine HIV knowledge, attitudes, beliefs and practices in the general population has shown that knowledge has increased, early sexual debut was prevalent, stigma and discrimination have decreased but still important, condom use has increased but consistent use of condom was low, among men sex with prostitutes and concomitant sex relationships were common. Prevention programs are initiated locally and target several segments of the population (young people, general population, migrant populations and most at risk populations) using leaflets, TV and pamphlets, etc. But national health authorities agreed that there is a need for more public 104 HIV in the Caribbean: A Systematic Data Review 2003-2008 health approach to prevention in all three Departments to broaden the health care provider’s managed programs and move more toward peer to peer approaches, and community based programming and outreach. All Departments have voluntary, anonymous and unlinked testing centers, but results of that program are not included in national situational analysis because of the complete anonymous aspect of the process and the impact of these interventions cannot be evaluated. However some conclusion could be reached that most-at risk populations (MSM, FSW) and young people are using these services more often than the general population. 4. Graphs with Trends re epidemiological status Notification of Cases of HIV during 2003-2005: Since the introduction of HIV case notification in 2003 to the end of 2005, a total number of 11 270 cases were reported in France. In 2005, 62% of these cases were males and the median age of diagnosis was 37.5 years and 40% of them where non nationals with the majority from Sub-Saharan Africa. Fifty one percent (51%) of the cases were the result of heterosexual contacts, Twenty seven percent (27%) due to homo/bisexual contacts, two percent (2%) due to IDU and for twenty percent (20%) of these cases of HIV the route of transmission was others (MTCT of HIV, blood transfusion) or unknown. Guadeloupe The regional health district of Guadeloupe covers also Les Saintes, St Barthelemy, Marie Galante and St Martin. During the period 2003-2005 a total number of 295 new cases of HIV were reported with a declining trend: 2003:120, 2004:111 and 2005:64. The age group most affected was 40-49 years-old in 2003 (30%) and 2005 (37.5%) and 20-29 years old in 2004 (28.8%) The male to female sex ratio was 1.2:1 in 2003, 0.6:1 in 2004 and 0.7:1 in 2005. The majority of cases were reported among nationals in 2003 but that situation changed when in 2004 and 2005 Haitian migrants represented respectively 47.7% and 42.2% of all reported cases of HIV. In terms of early diagnosis of cases, only 18.3%, 6.3% and 3.1% of the infections were diagnosed during the first six months of exposure to HIV in 2003, 2004 and 2005 respectively. Heterosexual transmission represented 57.5% in 2003, 75.7% in 2004 and 84.4% in 2005. Other modes of transmission include homo/bisexual contacts and IDU in a small percentage. French Guiana 439 cases of HIV were reported in French Guiana during the period 2003-2005 with 156 in 2003, 170 in 2004 and 113 in 2005. The male-to-female sex ratio was 1.2:1 in 2003, 0.9:1 in 2004 and 1.3:1 in 2005. The proportion of nationals among new cases of HIV was low i.e. 20.5% in 2003, 14% in 2004 and 18.5% in 2005, thus, the majority of cases of new HIV were diagnosed among non-nationals. The major route of transmission was heterosexual transmission representing 75.6% in 2003, 75.3% in 2004 and 67.3% in 2005. Only 3.8% in 2003, 5.9% in 2004 and 7.1% in 2005 of the new cases of HIV were diagnosed within six months after exposure. The age group the most affected was the 30-39 years-old in 2003 (35%), the 20-29 years-old in 2004 (31%) and the 40-49 years-old in 2005 (29%) Martinique During the period 2003-2005 a total number of 202 new cases of HIV were reported in Martinique with an increasing trend (2003:61, 2004: 68 and 2005:73). The major route of transmission is heterosexual with 70% in 2003, 76% in 2004 and 74% in 2005. Homo/bisexual transmission was constant during the three years (13%) and transmission through IDU represented a very low percentage. In terms of age group the most affected there is a declining trend i.e. in 2003 the age group the most affected was the 40-49 (39%), in 2004 it was the 30-39 (31%) and in 2005 the most affected age group was the 20-29 years old (29%). The male to female sex ratio among 105 HIV in the Caribbean: A Systematic Data Review 2003-2008 new cases of HIV was 1:1 in 2003, 1.8:1 in 2004 and 1.3:1 in 2005. The diagnosis of HIV among migrant population is declining, since more and more cases of HIV are reported among nationals: 77% in 2003, 82% in 2004 and 86% in 2005. The number of HIV cases diagnosed during six months after exposure was 23% in 2003, 10.3% in 2004 and 32% in 2005. To sum up, 983 cases of HIV were reported by the three French Departments of the Americas with the majority of them from French Guiana (47%) followed by Guadeloupe (31.5%) and Martinique (21.5%). Table 1: Number of Reported Cases of HIV By Year and FDA: 2003-2005 Year/Department Guadeloupe French Guiana Martinique Total 2003 120 156 61 337 2004 111 170 68 349 2005 64 113 73 250 Total 295 439 202 936 Graph 1: Reported Cases of HIV-French Departments of the Americas: 2003-2005 2003 2004 2005 180 160 140 120 100 80 60 40 20 0 Guadel French G Martinique AIDS Situation in the French Departments of the Americas during 2003-2004 During the period 2004-2005 cases of AIDS were reported using the standardized case definition adapted in 1993. In France the annual incidence has continuously declined from 1993 to 2005. However, it remains high in the French Department compared to Metropolitan France with specifically in French Guiana where in 2005 the AIDS incidence rate was 20 per 100 000 population Number of AIDS cases reported by year and Department: 2004-2005 A total number of 228 cases of AIDS were reported by the French Departments of the Americas with the majority of them being reported from French Guiana (51%) followed by Martinique (25%) and Guadeloupe (24%) Table 2: Reported Cases of AIDS in 2004 and 2005 Year/Department Guadeloupe French Guiana Martinique Total 2004 29 73 31 133 2005 26 44 25 95 Total 55 117 56 228 Age Groups most Affected by year and by Department: In Guadeloupe, the age group most affected was the 40-49 for both 2004 and 2005, in Martinique, the 30-39 years-old was the most affected age group in 2004 and for 2005 it was the 40-49 years-old. And in French Guiana the age group most affected was 40-49 years-old in 2004 and 2005. 106 HIV in the Caribbean: A Systematic Data Review 2003-2008 Male-to-Female Sex Ratio by Year and by Department: The male-to-female sex ratio among cases of AIDS in French Guiana was 1.1:1 and 2.4:1 in 2004 and 2005 respectively. In Martinique it remained at 2.1:1 for both 2004 and 2005. In Guadeloupe it was the lowest i.e. 0.8:1 and 0.7:1 in 2004 and 2005 respectively. Mode of Transmission by Year and by Department: Heterosexual transmission was the major route of transmission of HIV among cases of AIDS in Guadeloupe (76% in 2004 and 92% in 2005), transmission through IDU represented 3.4% and 3.8% in 2004 and 2005 respectively and transmission through homo/bisexual contact represented 10% in 2004 and 0.0% in 2005. In Martinique, transmission through heterosexual contacts represented 77% and 76% in 2004 and 2005 respectively and transmission through homo/bisexual contacts represented 16% and 20% in 2004 and 2005 respectively. In French Guiana, the major route of transmission was through heterosexual contacts 78% and 64% in 2004 and 2005 respectively. Transmission through Homo/bisexual contacts represented 1.4% in 2004 and 4.5% in 2005. Percentage of Non- Nationals in Reported cases by Year and by Department: In Guadeloupe during 2004 and 2005, Haitian migrants represented 48% and 42% respectively. Non nationals represented 6.5% of cases of AIDS in 2004 and 12% in 2005 in Martinique. The percentage of nationals and non nationals among cases of AIDS was equally represented at 33% and 34% of all cases of AIDS in 2004 and 2005 respectively in French Guiana. In 2005, among the cases of AIDS the proportion of people who did not know their HIV status before being diagnosed with AIDS was 52% in French Guiana, 38% in Guadeloupe and 32% in Martinique. Opportunistic Infections Diagnosed during Diagnosis of AIDS. In Guadeloupe and Martinique the three common opportunistic infections present during the diagnosis of AIDS were: - Candidiasis of the esophagus was diagnosed in 69% and 35% of the all cases of AIDS in 2004 and in 2005 in Guadeloupe. This same picture was observed in Martinique with 36% and 48% of all cases of AIDS in 2004 and 2005 respectively - PCP was diagnosed in 16% and 24% of all cases of AIDS in Martinique during the period 2004-2005 and in Guadeloupe that percentage was 10% and 12% in 2004 and 2005 respectively - Cerebral Toxoplasmosis was diagnosed in 10% and 19% of all cases of AIDS in Guadeloupe while in Martinique it was diagnosed among 23% and 16% of all cases in 2004 and 2005 respectively However, in French Guiana, the distribution of opportunistic infections present during the diagnosis of AIDS were Histoplasmosis among 23% and 32% of all cases in 2004 and 2005 respectively, followed by Pulmonary Tuberculosis among 18% and 21% of all cases in 2004 and 2005 respectively. At the third place is either Candidiasis of the esophagus or PCP 5. Care and treatment programs Care and treatment services are organized in the “Center of Information and Care for the Human Immune Deficiencyâ€? (i.e. Centre d’Information et de Soins de l’Immunodéficience Humaine (CISIH)). Data from each Department is entered in a computer programme DMI-2 for analysis and publication, but other sources are also used to report data. The CISIH are providing care and treatment to an important number of PLHIV e.g. 1400 in Guadeloupe in 2006, 564 in Martinique in 2004 and 655 in French Guiana. During the follow-up process patients undergo standard protocols such as CD4 count, viral load testing, height and weight, viral genotyping, screening for common opportunistic infections such as HepB, HepC, HTLV, tuberculosis, toxoplasmosis, etc. 107 HIV in the Caribbean: A Systematic Data Review 2003-2008 Treatment services are integrated in the national treatment services organized on ambulatory and hospital basis and carried-out by teams of professionals including physicians, pharmacists, social workers, psychologists, treatment counselors and the daycare team. Overall the impact of this approach has been the decline in deaths due to AIDS in the FDAs. For example, in Martinique, the number of days of hospitalization of PLHVI has declined from 4442 in 1995 to 2758 in 2004. 6. Influence of migration: If the impact of migration on HIV profile is declining in Martinique, it remains significant in Guadeloupe and French Guiana. These two departments are points of migration of the Haitian population looking for economic opportunities. However in the case of French Guiana, the HIV epidemic in neighboring countries i.e. Suriname and Brazil may have some influence on the HIV epidemiological profile in that department. 7. Data in specific groups: MSM, FSW, Bisexual, pregnant women, DU (injection and non Injection), etc. Anonymous and unlinked testing is done but results cannot be related to any population group. But seroprevalence surveys among most vulnerable groups or general populations are not routinely done. However in French Guiana in 2003, the HIV prevalence among pregnant women was 1.2% with 3.5% among Haitian migrants and 1% on among nationals. In 2006, the HIV prevalence among pregnant women was 1% in St Martin. 8. Co-infection TB/HIV: During 2004 and 2005 a total of 5 cases of extra-pulmonary were reported among PLHVI and 14 cases of Pulmonary Tuberculosis. The only Department where TB has been an important marker of HIV infection during the period 2004-2005 is French Guiana. Maybe is this situation related to the influence of the Haitian migration in that Department where TB is a common condition among PLHIV? 9. Data on Human Resources Issues: There are enough medical professionals and laboratory scientists to attend the need of PLHIV. However, national authorities have expressed the need for more public health approach to respond effectively to HIV in the French Departments of the America. Therefore, there is a need for a cadre of specialists including behavioral change communication specialists, sociologists and anthropologists to blend medical and social sciences and address jointly HIV issues in the FDAs. 10. Issues Surrounding Stigma and Discrimination: Overall, stigma and discrimination is limiting the effectiveness of the responses to HIV in the Three Departments. Despite being part of France, their geographic environment is very important in terms of the level of discrimination and stigma against PLWH. National authorities admit that same prevailing behaviors and attitudes towards PLHIV and most vulnerable groups in the English speaking Caribbean are found in these Departments. 11. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities: • The response to HIV is based on a medical approach; there is a need to broaden that approach and to include more involvement of other sciences and to move toward broader public health approach. • Specific programs should be developed to target the most vulnerable population groups. Programs should be organized with a strong active monitoring and evaluation component in terms of coverage, outcome and impact. • The three Departments should embrace the UNGASS reporting process as have done all the neighboring countries and islands of the English speaking Caribbean. • National authorities in the three departments should work closely with country of origin of migrant populations to ensure strategies and approaches which have achieved impact are exported and adapted to the migrant populations in the French Departments. 108 HIV in the Caribbean: A Systematic Data Review 2003-2008 • It will be important to work closely with neighboring islands and countries such as Haiti, Brazil, Suriname and the Dominican Republic to exchange knowledge, educational materials, best practices and experiences in terms of treatment protocols and prevention strategies. Bibliography 1. Bulletin d’alerte et de surveillance Antilles Guyane. Année 2008, No 2. Institut de Veille sanitaire. CIRE Antilles Guyane 2. Rapport d’Activité CISIH, 2006. Point de prise en Charge du VIH en Guyana. Octobre 2007 3. Rapport d’Activité CISIH. 2004. Centre d’Information et Soins de l’Immunodéficience Humaines de Martinique 4. Rapport d’Activité CISIH. 2006. Centre d’Information et Soins de l’Immunodéficience Humaines de Guadeloupe d’Activité CISIH. 2006. Centre d’Information et Soins de l’Immunodéficience Humaines de Guadeloupe. 5. La sante observée en Martinique. www.ors-martinique.org 6. Inserm. Institut National de la Sante et de la recherche médicale. BEH 7-8/19 Février 2008 109 HIV in the Caribbean: A Systematic Data Review 2003-2008 HAITI WORLD BANK HIV/AIDS SYNTHESIS UPDATE: HAITI INTRODUCTION Haiti is the poorest country in the Western Hemisphere and one of the poorest in the world (UNDP, 2006). Not surprisingly, it has the worst health statistics in the Americas, with a life expectancy less than 52 years. The per-capita health expenditure is just 8 dollars per year, and there is only one physician for every 10,000 people (World Bank, 2004). Decades of political instability have contributed to worsening economic conditions, and at least 65% of Haitians live in extreme poverty. For Haitians, the history of the HIV/AIDS epidemic represents stigma, discrimination, and racism, as Haitians were initially associated with the epidemic and at times blamed for it. This helped contribute to devastating economic, social, and psychological consequences and national stigmatization, which was one factor (along with the ongoing political, social and economic disruption in the country) in decimatie the tourist industry in this island nation. Despite enduring ongoing political difficulties and limited economic resources, however, Haiti has actually mounted a relatively successful response to the HIV/AIDS epidemic. Haiti is one of several countries in the world with a declining HIV prevalence; the percentage of Haitian adults living with HIV dropped from 6.2% to 3.1% between 1993 and 2003 (UNAIDS Epidemic Update 2006), partly due to changes in surveillance methodology. In 2006, a population-based survey (DHS+) of Haitian adults showed an HIV prevalence of 2.2% (Cayemittes M, Placide M, Mariko S, Barrère B, Sévère B, & Canez A, 2007). The decline in prevalence is probably due to a 110 HIV in the Caribbean: A Systematic Data Review 2003-2008 combination of the role of mortality in an early epidemic and to behavior change, including increased condom use for commercial and other casual sex, and partner reduction. For the past five years, Haiti has been in the process of scaling-up antiretroviral therapy (ART) nationwide, with one-year treatment outcomes that rival those of the U.S. (Severe, Leger, Charles, Noel, Bonhomme, Bois, George, Kenel-Pierre, Wright, Gulick, Johnson, Pape & Fitzgerald, 2005). EPIDEMIOLOGY The Early Phaseof the Epidemic In 1980, physicians in the United States began reporting cases of opportunistic infections among otherwise healthy young homosexual men in a pattern that had never been previously observed. In 1981, the Centers for Disease Control and Prevention (CDC) started a national surveillance program for these diseases in the U.S. (MMWR, 1981). Cases were described among recipients of blood transfusions, intravenous drug users, hemophiliacs, and heterosexual partners of AIDS patients. Shortly thereafter, the CDC reported 34 cases of the newly described syndrome among Haitians residing in the U.S. (MMWR, 1982) and 11 cases of Kaposi’s sarcoma were reported among previously healthy young people in Haiti (Liautaud, Laroche, Duvivier & Pean-Guichard, 1983). The previously described risk factors of homosexuality, intravenous drug abuse, and use of blood products were rarely identified among HIV-positive Haitians in the U.S. (Moskowitz, Kory, Chan, Haverkos, Conley & Hensley, 1983; Jaffe, Bregman & Selik, 1983; Pitchenik, Fischl, Dickinson, Becker, Fournier, O’Connell Colton, & Spira, 1983). Consequently, the CDC inferred that Haitians as a group were at increased risk, and HIV/AIDS became known as the “4H Diseaseâ€?, affecting homosexuals, heroin addicts, hemophiliacs, and Haitians. By February 1983, 1000 cases of HIV/AIDS had been reported in the U.S. “All but 61 of the patients could be classified 111 HIV in the Caribbean: A Systematic Data Review 2003-2008 into one or more of the following groups: homosexual or bisexual men, intravenous drug abusers, Haitian natives, or patients with hemophilia (Jaffe et al., 1983).â€? The association between Haitians and HIV/AIDS rapidly spread though the media. Haitians were depicted as the principal cause of the epidemic in the U.S., drawing upon images of voodoo, “boat peopleâ€?, and poverty. The effects on tourism were immediate and devastating. The Haitian Bureau of Tourism estimated a decline from 75,000 visitors during the winter of 1981- 1982 to fewer than 10,000 by the following year (Farmer, 1992). Haiti’s economy never recovered. In 1985, the CDC finally removed Haitians from the risk group category for HIV/AIDS (CDC, 1985), but this action was not widely publicized, and some people continue to associate AIDS with Haiti, though probably less so than in earlier years. Risk Factors for HIV in Haiti In 1983, the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) published the first case series on HIV/AIDS in a developing country. Using CDC criteria, a total of 61 cases of AIDS were diagnosed retrospectively from June 1979 to October 1982 (Pape et al., 1983). These cases were similar to those seen in the U.S., except there were more cases of tuberculosis (TB) and fewer cases of pneumocystis pneumonia and atypical mycobacteria. Mean survival after diagnosis was also much lower among those in the GHESKIO cohort (less than six months versus over a year in the US). In several studies that followed, GHESKIO researchers determined that homo/bisexual intercourse was the most common risk factor for HIV/AIDS among Haitians. Eighty-five percent of patients were male, and 80% lived in Port-au-Prince, most in the suburb of Carrefour, a flourishing center of male and female prostitution (Pape et al., 1983). Over the next three years, however, there was a dramatic shift in the transmission pattern, as the disease was spread from 112 HIV in the Caribbean: A Systematic Data Review 2003-2008 males to their female partners. The proportion of cases attributed to homo/bisexuality plummeted from 50% in 1983 to only 1% in 1987 (Pape & Johnson 1988). Since 1985, the dominant mode of transmission has been heterosexual intercourse; the blood supply was protected early in the epidemic and intravenous drug use is rare in Haiti (Pape et al., 1990; Deschamps et al. 1996). As heterosexual contact became the predominant route of transmission, more women became infected. In 1983, HIV was five times more common among males than females. With each passing year, an increasing proportion of cases have been female. By 1985, the male:female ratio had dropped from 5:1 to 3:1, and then to 2.3:1 in 1987, and 1.6:1 in 1990. By 2000, an equal number of men and women were infected. From that time, the balance shifted. In 2006, the prevalence among adults was 2.3% for women and 2.0% for men (IHE/GHESKIO, 2006). Among the most recent 1000 patients to test positive for HIV at the GHESKIO Center (diagnosed from March 4 to June 30, 2008), 584 patients were women (58%). Poverty and gender inequality are reported to make Haitian women vulnerable to infection with HIV and other sexually transmitted infections (STIs) (Fitzgerald, Behets, Caliendo, Roberfroid, Lucet, Fitzgerald & Kuykens, 2000; Farmer, 1992; Farmer, 1996; Farmer, 1999). Nearly one-third of women attending prenatal clinics in one rural town reported having entered a sexual relationship out of economic necessity. This doubled the risk of syphilis and increased the risk of acquiring HIV by six-fold (Fitzgerald et al., 2000). In an urban slum, illiteracy and low socio-economic status were associated with positive syphilis tests among pregnant women. A positive HIV test was associated with unemployment in their partner (Behets, Desormeaux, Joseph, Adrien, Coicou, Dallabetta, Hamilton, Moeng, Davis, Cohen & Boulos, 1995). In rural Haiti, in one study in the 1990s HIV was found to be associated with the professions of sexual partners, not the lifetime number of partners (2.7 partners among HIV- positive women and 2.4 among HIV-negative women). A history of sexual contact with soldiers or truck drivers was strongly associated with a diagnosis of HIV disease, as men with these professions are able to provide some measure of economic security (Farmer, 1999), and their 113 HIV in the Caribbean: A Systematic Data Review 2003-2008 transient lifestyle allows greater access to sex workers. Another study conducted at the same site in rural Haiti demonstrated the importance of economic stability. The risk of acquiring an STI quadrupled for women working as domestic servants while working as a market vendor (hence having personal income) cut the risk in half (Smith-Fawzi, Lambert, Singler, Koenig, Leandre, Nevil, Bertrand, Claude, Bertrand, Salazar, Louissant, Joanis & Farmer, 2003). Female sex workers (FSWs) and their clients are also at high risk of HIV infection. A recent Haitian study indicated an HIV prevalence of 10% among FSWs (CCISD-CECI 2005). Another recent study found that the prevalence of HIV among clients of FSWs was 7.2% in the cities of Gonaives and St. Marc (Couture, Soto, Akom & Labbe, 2008). HIV Prevalence in Haiti The Caribbean region has the second highest HIV prevalence in the world, after sub- Saharan Africa. Haiti bears the largest share of disease in the region, followed by its neighbor the Dominican Republic. Detailed studies have been conducted at regular intervals in Haiti to estimate HIV prevalence. Pregnant women have been systematically studied when they present for prenatal care at multiple sites around the country. In addition, a national population-based study of nearly 10,000 Haitian households (Cayemittes, 2007) was conducted in 2005-2006 and also assessed HIV prevalence. After it was introduced into the population, the HIV virus spread rapidly in Haiti. By 1986, 8.4% of healthy women receiving prenatal care in the urban slum of Cite Soleil were found to be HIV-positive. The prevalence increased to 9.9% in 1987, and 10.5% in 1989. Women appeared to acquire infection soon after becoming sexually active, as suggested by the high seropositivity rates observed in pregnant women 14 to 19 years of age (Boulos, Halsey, Holt, Ruff, Brutus, Quinn, Adrien & Boulos, 1990). Throughout the 1980s and 1990s, HIV prevalence remained high in Haiti. Two studies conducted at GHESKIO in Port-au-Prince showed that between 1986 and 1992, prevalence increased from 6% to 8% (Pape, Johnson, Stanback, Pamphile, Boncy, 114 HIV in the Caribbean: A Systematic Data Review 2003-2008 Deschamps,Verdier, Beaulieu, Blattner, & Liautaud, 1990), and in the rural areas it increased from 2% to 4% (Pape, Deschamps, Verdier, Jean, Desvarieux, Taverne, Gelin, Hyppolite, Denize, Mellon, Liautaud & Johnson, 1992). The highest rates were found in sex workers on the street (from 53% to 72% positive), patients hospitalized with TB (54% positive), patients referred from other clinics for HIV testing (50% positive), and patients with other STIs (24%). In 1993 and 1996, sentinel surveillance surveys were conducted by the Ministry of Health (MoH), l’Institut Haitien de l’Enfance (IHE), and GHESKIO, to determine the prevalence of HIV, syphilis, and hepatitis B among pregnant women seeking prenatal care in each of Haiti’s medical departments. In 1993, HIV prevalence was 6.2% among pregnant women. In 1996, it remained elevated at 5.9%. At the end of the 1990s, however, HIV prevalence began dropping. In the sentinel survey conducted in 2000, prevalence among pregnant women was down to 4.5%, and by 2004, it had decreased to 3.1% (UNAIDS, 2007). This decrease in prevalence was confirmed in 2005 by a population-based survey of 9,998 households with adults aged 15 to 49, which demonstrated a prevalence of 2.2% among Haitian adults (Cayemittes, 2007). Table 1 provides a break-down by age group. However, the most recently conducted survey among pregnant women found a prevalence of 4.4% in the year 2006. These results remain under discussion by epidemiologists and HIV experts in Haiti. Table 1: Percentage of Positive HIV Tests by Age Group* Age Group Female Gender Male Gender 15 to 19 0.9 0.5 20 to 24 2.3 1.7 25 to 29 3.5 3.3 30 to 34 4.1 3.3 35 to 39 2.2 2.9 40 to 44 3.1 3.7 45 to 49 1.6 2.4 Total ages 15 to 49 2.3 2.2 *Cayemittes et al, 2007 115 HIV in the Caribbean: A Systematic Data Review 2003-2008 Two groups of researchers developed mathematical models to explain the reasons for the decline in Haiti’s HIV prevalence. Hallet et al. (Hallet, Aberle-Grasse, Bello, Boulos, Cayemittes, Cheluget, Chipeta, Dorrington, Dube, Ekra et al., 2006) concluded that the decrease in prevalence was probably due to less risky sexual behaviors. Gaillard et al. (Gaillard, Boulos, Cayemittes, Eustache, Van Onacker, Duval, Louissant & Thimote, 2006) meanwhile attributed the decline in HIV prevalence largely to the more rapid progression from acquisition of HIV infection to death and the (early) interventions to secure the blood supply. And Gaillard et al. also found increases in abstinence, fidelity, and condom use. HIV PREVENTION EFFORTS Nationwide HIV Prevention Strategies Especially considering the political and economic upheavals over the past two decades in Haiti, HIV/AIDS prevention efforts have had rather remarkable success. The sale of condoms has dramatically increased, the prevalence of syphilis has declined, and most importantly, the prevalence of HIV among adults has dropped by perhaps over 50% in the last decade. Though it is theoretically simple for behavioral changes to occur with improved education and availability of condoms, it is presumably difficult to change behaviors in the midst of desperate poverty, political instability, and gender inequality (though behavior change and associated HIV decline have also been reported in other areas suffering from political and economic chaos, such as Zimbabwe). GHESKIO was the first group in Haiti to directly address the epidemic. GHESKIO was created by a group of Haitian health care professionals in 1982 with three main objectives: operational research, patient care, and training of community leaders and medical personnel for the treatment of HIV/AIDS, TB, and other communicable illnesses. In the early years of the epidemic, GHESKIO researchers found that blood transfusions were an important mode of HIV 116 HIV in the Caribbean: A Systematic Data Review 2003-2008 transmission. In 1985, nearly 4% of all blood donors were HIV-infected, and 40% of HIV-positive Haitian women had a history of receiving a transfusion (Pape, 1985). At this time, the Haitian Red Cross and the Public Blood Bank were both responsible for collecting and distributing blood, but the blood bank was buying blood from impoverished patients. In 1986, in response to data linking HIV transmission and blood transfusions, the Haitian MoH closed the Public Blood Bank, established the Red Cross as the only organization authorized to collect blood and provide transfusions, and instituted mandatory behavioural and laboratory screening of all blood products for HIV and other transmissible infections. Since these controls were instituted many years ago, blood transfusion has not been an important mode of HIV transmission in Haiti (suggesting that claims for the recent HIV decline being due to cleaning the blood supply are probably questionable). Nationwide prevention strategies were otherwise limited until the fall of the Duvalier regime in December 1986. In 1987, AIDS was declared to be a priority disease in Haiti, and the first National AIDS Commission was formed. In 1988, the commission was expanded to include representatives of the press, the clergy, and several governmental departments. An AIDS Coordination Bureau was also created within the MoH to coordinate the action of all non- governmental organizations (NGOs) and spearhead the fight against HIV/AIDS. However, due to political upheaval and frequent changes in government, many potentially decisive actions were short-lived. Nationwide prevention campaigns continued during periods of political strife due to the efforts of a network of NGOs that have worked to augment the governmental response when it is weakened by political instability. They have implemented awareness campaigns, prevention strategies, youth education efforts, and emergency hotline services, and provided social support and medical care for those with HIV/AIDS. Efforts have been particularly focused on safer sexual practices and behavior changes. In the early years of the epidemic, patients were found to be resistant to changing their behaviors when only safer sex messages were provided. In the mid 1980s, clinicians at GHESKIO 117 HIV in the Caribbean: A Systematic Data Review 2003-2008 convinced a mere 10% of the men and 7% of the women with AIDS to discontinue unprotected intercourse. In 1991, they found that discordant couples (one partner infected) had as much unprotected intercourse as concordant couples (both partners infected), regardless of the gender of the infected partner, and that pregnancy rates were similar in the HIV-positive and HIV- negative partners of male AIDS patients (12% and 14%, respectively) (Deschamps, Pape, Hafner & Johnson, 1996). This strongly suggested that the idea of an asymptomatic partner spreading HIV was not entirely understood, perhaps partly due to Haitian cultural beliefs (Farmer, 1992). Initially HIV was considered to be a disease that was “supernaturalâ€?, targeted to the afflicted individual, and therefore not transmissible to uninfected partners. However, as time progressed, education and counseling strategies led to increasingly beneficial results. In 1996, Deschamps et al. found that counseling increased the proportion of discordant couples that were using safer sexual practices to 45 percent and that condom use was clearly associated with a marked reduction in the incidence of HIV infection (Deschamps et al., 1996). In 1999 and 2003, Knowledge and Behavioral Surveillance Surveys (BSS) were conducted among young adults (15 to 24 years old) in Port-au-Prince. The proportion of respondents with excellent knowledge of HIV/AIDS increased significantly by 2003, to over 50% in nearly all age and gender groups. Three out of four Haitians surveyed were able to cite three main methods for avoiding the sexual transmission of HIV infection (sexual abstinence, a monogamous relationship with one uninfected partner, and consistent condom use) (Cayemittes et al., 2007). And in these BSS surveys, the proportion of males ages 15-19 and 20-24 reporting sexual contacts with occasional partners fell from 50% and 60% in 1999 to 12% and 20% in 2003, respectively. Among females of the same age groups this reported behavior dropped from 31% and 52%, respectively, in 1999 to only 2% for both age groups in 2003. Condom use has also increased among some people in the general population. The percentage of males in the 2003 BSS who had used condoms at last sexual contact increased to 52% among the 15 to 19 year olds and 63% among 20 to 24 year olds (Family Health 118 HIV in the Caribbean: A Systematic Data Review 2003-2008 International [FHI], 1999; FHI, 2003). In 2001, a national survey found that only 14% of adult women and 26% of adult men had used a condom the last time they had intercourse with someone other than their regular partner (Cayemittes et al., 2001). In 2005, a similar survey revealed that a somewhat higher proportion (26% of women and 42% of men) had used a condom in this situation (Cayemittes et al., 2007). Among young females, 32% of those in the 15 to 19 year old age group, and 24% of those in the 20 to 24 year old age group had used a condom with last intercourse with a non-regular partner. These percentages were 33 and 53%, respectively, for males in these young age groups (Cayemittes et al. 2007). Ongoing prevention efforts will be critical to further increase condom use and other safer sexual practices. Particular efforts must be focused in rural areas, where HIV prevalence may not have decreased as significantly and safer sexual behaviors do not appear to be improving. Only 16% of women and 31% of men in rural areas reported using a condom with their last episode of sexual intercourse (Cayemittes et al., 2007). Prevention efforts also must continue for youth, in particular young girls. Only 28% of sexually active women from ages 15 to 24 reported using a condom during the last time they had intercourse with a non-regular partner (Cayemittes et al., 2007). Additional outreach will also be important among female sex workers (FSWs) and their clients, particularly outside of Port-au-Prince. A recently conducted study demonstrated that 90% of sex workers in Port-au-Prince used a condom at last sexual contact, but a study of clients of FSWs in two medium-sized cities found that only 59% reported always using a condom with FSWs; 45% did so with their casual partners, and 33% with their regular partners. Forty percent of these clients had had more than 10 partners in the prior three months, but only 17% had previously been tested for HIV. The prevalence of HIV, previous or active syphilis, and HSV-2 was 7.2%, 13.4%, and 22%, respectively, among these clients (Couture 2008). These men likely act as bridge population, facilitating the spread of HIV and other STIs throughout the general population. These findings emphasize the need for further prevention efforts for high-risk subgroups. 119 HIV in the Caribbean: A Systematic Data Review 2003-2008 Haiti’s National Strategic Plan Haiti has had four national strategic plans for HIV prevention and treatment, covering the periods from 1988-1992, 1996-2000, 2002-2006, and 2008-2012. These plans have focused on reducing risk factors and vulnerability to HIV, reducing the impact of the virus, promoting the defense of human rights, and constructing plans to treat HIV and conduct surveillance of the impact of the epidemic. For the 2008-2012 National Strategic Plan, four principal axes of intervention have been identified: (1) Improving prevention strategies to reduce the actual number of new HIV/AIDS cases; (2) Reducing the impact of the virus and dampening the effect of HIV/AIDS on families and individuals; (3) Promoting and defending human rights by providing a legal environment effectively supportive of human rights issues within the context of the HIV/AIDS epidemic; and (4) Establishing a system of continuous funding and developing sustainable, progressive interventions. The most recent national plan is a general strategic framework designed to direct the Haitian answer to the fight against HIV/AIDS through all official institutions and civil society. The Haitian government reaffirms that no sector, ministry, or organization alone is sufficient to address the epidemic. All ministries and decentralized organizations are obligated to use it as a reference to develop strategic plans and subsequently coordinate with operational partners to maximize program efficiency and effectiveness. Prior to the plan of 2002-2006, there was no framework of reference to address HIV/AIDS on a national operational level, and no legislation existed to defend the rights of affected patients. The relationship between HIV/AIDS and poverty had not been clearly established for policy makers to develop an understanding of the impact of the epidemic on the country’s socioeconomic development. The plan of 2002-2006 has been updated in the plan of 2008-2012, with revisions to address the appropriation of funds and the feasibility of emerging, previously un- registered interventions such as ART therapy. 120 HIV in the Caribbean: A Systematic Data Review 2003-2008 The plan of 2008-2012 states that Haitian national health policy is based on equity, social justice, and solidarity through efficiency and citizen participation in order to improve the health and socioeconomic status of its citizens. Furthermore, it says that the government wishes to guarantee access to a minimum package of care, including preventive and curative services. Through the National Strategic Plan, the MoH hopes to reform the public health sector by not only addressing the restoration of the country’s health condition but also by acting on the determinants of health. Ideally, issues such as drinkable water and behavioral change education would be targeted to those at risk. In the past, the MoH has lacked the financial means and structure to implement programs efficiently, and currently, the services offered fall short of facing the epidemic, mainly because they are too specific and lack collaboration with different sectors. The idea of “multisectorialityâ€? was promoted in the plan of 2002-2006, but will need to be further emphasized in coming years. The MoH states that the plan of 2008-2012 must not only reinforce current programs but also strengthen partnerships and improve their means of obtaining financial support. Guiding principles include universality, equity, quality, solidarity, and determination of care. The government states that all individuals in Haiti should be granted access to all necessary interventions without reference to sexual preference, social and religious memberships, or residence. By addressing the broader social conditions that promote the epidemic, the Haitian government also hopes to address the fight against poverty. The plan of 2008-2012 emphasizes the fourth axis of intervention described above, which will protect the country from an inopportune withdrawal of international financial assistance. There are four differentiated sources of funds, including a national budget supplied by special taxes specifically for HIV/AIDS initiatives. The government will also call for public participation such as fundraising at churches and cultural activities. Committees will be specifically designated to head these efforts, but ultimately, the plan states that it is the government’s responsibility to generate sufficient resources to guarantee interventions. 121 HIV in the Caribbean: A Systematic Data Review 2003-2008 Levels of management have been delineated in order to improve the capacity to mobilize resources and manage them efficiently. These levels are: (1) Decision and mobilization of resources; (2) Organizational coordination and follow-up of implementation; and (3) Execution of interventions. Different structures have been proposed to operate at each level. The Prime Minister will direct certain commissions, and others will be headed by appointed secretaries. Evaluation will operate on both a vertical and horizontal level, because sectoral units will be created in each ministry and organization to decentralize and reinforce head offices. These units will not replace usual services but will exert functions of analysis and support. Follow-up and evaluation will be emphasized throughout the four years of the plan, and specific health indicators will be monitored. These indicators will include the number of patients on ART therapy and the amount of country funds used towards interventions such as prevention activities, anti-TB initiatives, and educational interventions for AIDS orphans. The evaluation process will include monthly data collection at the level of the sites of service delivery. Data will be made available to each sector through electronic management, and an active system will be put in place for the circulation of reports. Public diffusion of relevant information will contribute to national and international awareness of the country’s efforts to fight the epidemic. Ultimately, a final evaluation will be carried out at the end of 2011. STI Prevalence and the Syndromic Treatment Approach Over the past twenty years, the network of Haitian NGOs working with the government on HIV prevention efforts has also focused on decreasing the prevalence and complications from other STIs. Studies conducted in Port-au-Prince in the 1990s suggested that a genital ulcer increased the risk of HIV transmission by nearly seven times, and a positive syphilis test nearly tripled the risk (Deschamps et al., 1996). Although these findings were confirmed by some other studies conducted in resource-poor settings (Stamm, Handsfield, Rompalo, Ashley, Roberts & 122 HIV in the Caribbean: A Systematic Data Review 2003-2008 Corey, 1988; Keet, Lee, Van Griensven, Lange, Nahmias & Coutinho, 1990), most randomized trials examining the effect of STI treatment on HIV transmission have failed to show an association (Gray and Wawer 2008 Lancet, Potts et al Science 2008). Laboratory tests were too expensive and technically demanding for widespread use, so algorithms were developed for the diagnosis and treatment of STIs based on symptoms rather than test results. From 1992 to 1994, studies were conducted to determine the type of infection responsible for each presenting genital symptom (such as urethral discharge). Patients were then treated for the most likely infections to cause the presenting symptoms, with the goal of preventing disease-related complications and stopping further disease transmission. Throughout the late 1990s, the MoH, GHESKIO, and other local organizations trained over a thousand health care providers from around the country in this strategy of syndromic management for the diagnosis and treatment of STIs. Initially, STI prevalence was high in Haiti. In 1994, 47% of pregnant women in a Port-au- Prince slum had at least one STI: 35% had trichomoniasis; 11% had syphilis; 10% had chlamydia; and 4% had gonorrhea (Behets et al., 1995). Among women seeking prenatal care at GHESKIO, 48% had at least one STI. In the medium-sized town of Deschapelles in 1996, Fitzgerald et al. found the 37% of pregnant women had an STD: 25% had trichomoniasis; 7% had syphilis; 11% had chlamydia; and 2% had gonorrhea (Fitzgerald et al, 2000). From 1999 to 2001, at the PIH women’s health clinic in rural Haiti, the prevalence of trichomoniasis was 13%, chlamydia was 5%, syphilis was 4%, and gonorrhea was 1% (Smith-Fawzi et al, 2003). As national prevention campaigns resulted in safer sexual practices and as algorithms for STI treatment were expanded nationwide, the prevalence of STIs in Haiti declined. In national prevalence studies (conducted along with HIV testing), syphilis prevalence peaked at 7.6% in 1993, and then dropped to 3.5% by the year 2003 (See Figure 1). Though national prevalence studies have not been conducted for other STIs, it is assmed that they have probably declined in 123 HIV in the Caribbean: A Systematic Data Review 2003-2008 parallel with HIV and syphilis. However, ongoing efforts will be critical, particularly among sex workers. A recent Haitian study found a prevalence of 10% for HIV and 18% for syphilis among FSWs (CCISD-CECI 2005). Among clients of FSWs, the prevalence of HIV, previous or active syphilis, and HSV-2 was 7.2%, 13.4%, and 22%, respectively, in the cities of Gonaives and St. Marc (Couture, Soto, Akom & Labbe, 2008). Figure 1: National HIV and Syphilis Seroprevalencein Haiti (1993 – 2003) 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 7.6% 6.1% 5.6% 6.0% 6.2% 3.5% 4.0% 6.0% 4.5% 3.1% 2.0% 0.0% 1993 1996 2000 2003 HIV SYPHILIS MOH, IHE, GHESKIO Prevention of Mother-to-Child Transmission As increasing numbers of women became infected with HIV/AIDS, the virus spread to their children through vertical transmission. A study published in 1990 found that 443 of 4588 pregnant women (9.7%) living in an urban slum were HIV-positive (Halsey, Boulos, Holt, Ruff, Brutus, Kissinger, Quinn, Coberly, Adrien, & Boulos, 1990). The estimated rate of mother-to-child transmission was 25%. Mortality among HIV-infected children was also high. Infants born to HIV-positive mothers were more likely to be premature, of low birth weight, and malnourished. By 124 HIV in the Caribbean: A Systematic Data Review 2003-2008 12 months of age, 23% of infants born to HIV-positive mothers had died, compared with 11% of those who were HIV-negative; by 24 months, respective mortality rates were 31% and 14%. Approximately 260,000 infants are born annually in Haiti (Ministry of Health and Population, 2005). Almost 80% of these births take place outside of a health care setting (Institut Haitien de l’Enfance, 1999). An estimated 6,400 of these pregnancies occur in HIV-positive women. Until mother-to-child transmission (PMTCT) became available in 1999, up to 27% of pregnancies in HIV-infected women resulted in vertical transmission of HIV (Jean, Verdier, Pape, Reed, Johnson, & Wright, 1999). In the late 1990s, PIH, the MoH, and GHESKIO developed programs to provide PMTCT services to pregnant women. Simple regimens of zidovudine and nevirapine were implemented to decrease mother-to-child HIV transmission. In addition to targeted interventions for PMTCT, they also addressed the broader mandates of family planning, treatment of co-existing infections, and primary obstetrical and pediatric care. Pregnant women were offered HIV and syphilis testing, reproductive health services, treatment for STIs, screening and treatment for TB, and HIV care. The MoH has also worked with a network of NGOs to develop national guidelines for Haiti, which are regularly updated. Initially, the MoH recommended the use of zidovudine, starting at 36 weeks gestation for mothers, and for the infants’ first week of life. Due to concerns about the development of drug resistance, single-dose nevirapine was used only for women who presented too late for zidovudine treatment. In the last five years, now that triple drug therapy with ART has been shown to be more effective than zidovudine or nevirapine, its use is being scaled-up in pregnant women. In addition to ART, pregnant women receive ferrous sulfate, folic acid, and tetanus toxoid. Infants are given formula (if feasible and with maternal consent), cotrimoxazole prophylaxis, and early testing for HIV, with immediate ART for infants who test positive. All HIV-related services are provided free-of-charge. No metion of other (important) aspects of PMTCT? Ie, what about exclusive breast feeding? (The WHO recommedatoin….) Is anyone promoting that (incl warning of the dangers of mixed feeding practices) in Haiti?? Someone must be… And JHIESKO has done great work (and 125 HIV in the Caribbean: A Systematic Data Review 2003-2008 published research findings) on the importance of providing family planning access to women, especially those who are HIV pos; this should be mentioned too… The provision of PMTCT has led to dramatic increases in the number of pregnant women accepting voluntary counseling and testing (VCT), and dramatically lowered the rate of vertical transmission of HIV (Behforouz, Farmer & Mukherjee, 2004). However, much remains to be done – by the end of the year 2007, only about 20% of HIV-positive women (975 out of an estimated 5,200) received PMTCT in Haiti. This is largely because most women do not receive prenatal care, and deliver at home without medical assistance. In a population-based survey of nearly 10,000 respondents, fewer than 20% of women who had been pregnant in the prior two years reporting having undergone counseling and testing for HIV during pregnancy (Cayemittes et al., 2007) (See Table 2). Table 2: Percentage of Women Pregnant Receiving Prenatal Care** Age group Received HIV Number of women in Counseled, tested, counseling the study who were and received test results pregnant in the prior two years 15 to 19 34.6 19.8 245 20 to 24 33.0 18.1 582 25 to 29 38.6 23.6 586 30 to 39 31.8 18.3 734 40 to 49 29.6 15.6 171 *Cayemittes et al., 2007 – surveyed women who had been pregnant in the prior two years HIV/AIDS TREATMENT The Natural History of HIV/AIDS in the Pre-HAART Era In the pre-HAART era, HIV-infected patients died more rapidly in Haiti compared to those in more developed settings. Studies from the U.S. demonstrated that the average time from 126 HIV in the Caribbean: A Systematic Data Review 2003-2008 acquisition of HIV infection to AIDS and death was 10 and 12 years, respectively. GHESKIO followed 42 patients with documented dates of HIV seroconversion from 1985 to 1997 and found that the median time from sero-conversion to first HIV symptoms was 3 years, time to AIDS diagnosis was 5.2 years, and time to death was 7.4 years. This was attributed to multiple factors, including poor nutritional status and high rates of concomitant infections such as TB and diarrheal disease, which occur more frequently in less developed settings such as Haiti (Deschamps, Fitzgerald, Pape & Johnson, 2000). HIV and Tuberculosis The TB burden in Haiti is one of the highest in the Western Hemisphere, with a prevalence of 405 per 100,000 people (WHO 2007). Eighty percent of the adult population is infected with Mycobacteria tuberculosis as evidenced by a positive skin test to purified protein derivative. As in many other resource-poor countries, HIV/AIDS has exacerbated the TB epidemic. Up to 10% of HIV-positive patients develop active TB each year. In the past four years, 7275 HIV-positive patients have been treated for TB (6869 adults and 406 children). Treatment outcomes are excellent, even among those with AIDS and TB. At the GHESKIO clinic, 80% of patients with AIDS and active TB complete TB therapy. Mortality on TB treatment is 12%; the majority of patients who die are diagnosed with TB within three months after ART is initiated. Many of these cases may result from activation of sub-clinical TB that is not recognized at the time of ART initiation. It is therefore critical to rule out TB at the time of ART initiation, even among asymptomatic patients. Until recently, it was felt that multidrug-resistant (MDR)-TB rates were low in Haiti. However, in 2002 a cross-sectional study of MDR-TB prevalence at an HIV voluntary testing and counseling center in Port-au-Prince found that MDR-TB was documented in 16 (6%) of the 281 patients with primary TB. Of the 115 patients who were HIV-positive with primary TB, 11 (10%) 127 HIV in the Caribbean: A Systematic Data Review 2003-2008 had MDR-TB. Of those with recurrent TB, 10 (20%) of 49 patients had MDR-TB (Joseph P et al., 2006. For the past decade, PIH had been the only organization treating MDR-TB in Haiti, serving as the national referral center for all cases. Treatment outcomes have been outstanding, equal or superior to those of industrialized nations. GHESKIO and the MoH have recently opened up a second MDR-TB treatment program at a public hospital in Haiti. The Advent of AIDS Treatment in Haiti Haiti is the site of one of the first and most widely celebrated AIDS treatment programs in a resource-poor setting (Farmer, Leandre, Mukherjee, Claude, Nevil, Smith-Fawzi, Koenig, Castro, Becerra, Sachs, Attaran & Kim, 2001). In 1998, PIH used their successful community- based TB treatment model to provide directly observed ART. The community health workers (accompagnateurs) created the structural backbone of the program, linking the clinic with the villages, which are scattered throughout the countryside. Patients were selected on the basis of their clinical status, with the sickest patients treated first. The care component included an uninterrupted supply of ART with limited laboratory infrastructure; CD4 cell counts and viral loads were not available in rural Haiti at the time (Farmer et al., 2001). The clinical response to therapy was favorable in 59 of the first 60 patients, and viral load was undetectable in 86% of those in whom it was tested (Farmer et al, 2001; Koenig, Leandre, & Farmer, 2004). This treatment model has since been duplicated around the world. The Impact of External Funding In 2003, Haiti received the first disbursement of a 5-year, USD 67 million grant from the newly formed Global Fund for AIDS, TB, and Malaria (Global Fund) for the development of a Haiti-wide program to expand HIV testing, care, and treatment. Prior to this, ART was only 128 HIV in the Caribbean: A Systematic Data Review 2003-2008 available in Haiti on a limited basis, due to the high cost and the large number of patients in need. With the release of the Global Fund monies, the widespread use of ART in Haiti finally became feasible. In 2004, additional funding became available through PEPFAR (President’s Emergency Plan for AIDS Relief), the largest commitment ever made by any nation for an international health initiative dedicated to one disease. As a recipient country, Haiti receives USD 40 million per year, which is distributed through the CDC and United States Agency for International Development (USAID) to bolster the ongoing expansion of HIV-related prevention and treatment services throughout the country. PEPFAR has supported efforts to improve PMTCT, increase safe sexual behaviours, expand access to HIV care, and scale-up ART through the MoH and a network of NGOs. They have also provided financing for mobile HIV counselling and testing clinics, provider training programs, and hospital renovations. In addition, PEPFAR has provided funding to the MoH to improve laboratory infrastructure and counselling, testing, and treatment services. With funding from the Global Fund and PEPFAR, treatment scale-up has progressed throughout the country. ART is provided in accordance with the guidelines of the WHO (WHO, 2006) and the MoH, based on the clinical stage of disease and CD4 cell count. First-line ART regimens include zidovudine, lamivudine, and efavirenz or nevirapine. Stavudine is used in place of zidovudine in patients with anemia. For patients who fail first-line treatment, tenofovir, abacavir, and lopinavir/ritonavir are available, though most patients (>97 percent) have remained on first- line therapy (Severe et al., 2005; Mukherjee et al., 2006). With support from the Global Fund and PEPFAR, the MoH, PIH, GHESKIO, and several other NGOs have been working to expand HIV services across the country. In 2006, 166,000 (86%) of the 193,000 Haitians tested for HIV were in the PIH-GHESKIO-MoH network. Of these patients, 44,145 (27%) were pregnant women. Within the GHESKIO network, 8,955 patients (8.9%) tested positive for HIV and in the PIH network, 2,987 (4.6%) tested positive. By the end of 129 HIV in the Caribbean: A Systematic Data Review 2003-2008 the year 2007, over 300,000 people had been tested for HIV through Haiti’s PEPFAR program, over 75,000 had been enrolled in HIV care, and nearly 16,000 had been initiated on ART (see Tables 3 and 4). As of December 2007, 13,586 patients were alive and on ART, out of a total of 27,738 (49%) in need of treatment (UNGASS Report 2008). Is it worth at least noting, in passing, the “enigmaâ€? (or whatever the right word is?) that the vast majority of foreign assistance heatlh-related funding in Haiti now (ie, from PEFPAR) is for HIV, even though only 2% of adults are HIV pos, and many more people are dying of other (simpler to treat/cure) diseases??...) Table 3: Cumulative Number of Haitians Tested for HIV, PEPFAR 2004 to 2007* Adults 2005 2006 2007 Number of Females Tested 80,216 138,333 198,922 Percentage of Females 9.48% 8.31% 7.56% Testing HIV- Positive Number of Males Tested 39,233 72,305 118,499 Percentage of Males Testing 13.16% 10.39% 8.46% HIV-Positive Total Number of Adults 119,449 210,638 317,421 Tested Total Percentage of Adults 10.69% 9.02% 7.90% Testing HIV-Positive *PEPFAR Report Haiti 2008 Table 4: Cumulative Number of Patients Treated with ART, PEPFAR 2004 to 2007* Adults 2005 2006 2007 Cumulative Number of 5019 8842 14,788 Adults on ART Cumulative Number of 348 929 810 Children on ART Cumulative Total Number of 5367 9771 15,598 People on ART *PEPFAR Report Haiti 2008 Treatment results have been outstanding. At GHESKIO, the first 1004 patients had ART treatment outcomes that rival those in the U.S. Among adults and adolescents, the median 3 increase in CD4 cell count was 163 cells/mm from baseline to 12 months, and viral load was 130 HIV in the Caribbean: A Systematic Data Review 2003-2008 undetectable in 76 of 100 patients who were followed for 48 to 56 weeks (Severe et al., 2005). Eighty-seven percent of adults and adolescents were alive after one year, as compared to a mere 30% prior to the provision of ART (See Figure 2). Outcomes were also outstanding among children. In another GHESKIO study, 236 children who were treated with ART, 80% of the children were alive and under care after 24 months of follow up. Figure 2: Kaplan Meier Estimate of survival in the first 910 HIV infected adults and adolescents treated with HAART at GHESKIO compared to survival of 99 historical controls diagnosed with AIDS before HAART was available. There are currently 125 HIV testing centers in Haiti, and 127 sites that offer testing for syphilis, as compared with just 23 centers testing for these two diseases in 2003. GHESKIO, PIH, and the MoH have also built a network of over 30 public and private sites throughout Haiti with the capacity to provide comprehensive HIV care, including ART. GHESKIO continues to provide ongoing training for health care workers in counseling, in the management of TB, in the treatment of opportunistic infections, in the use of ART, and in the provision of PMTCT. In the year 2006 alone, GHESKIO trained 630 laboratory technicians, 258 social workers, 2186 nurses, 785 physicians, 39 pharmacists, and 6478 community leaders (GHESKIO report to PEPFAR, 2006). PIH has worked in collaboration with the MoH to revitalize a network of clinic-hospital 131 HIV in the Caribbean: A Systematic Data Review 2003-2008 complexes in the rural Haiti, and their community-based directly observed ART model has been reproduced at each site. Early Mortality on Antiretroviral Therapy Mortality remains high within the first three to six months after ART initiation, and it does not appear to be decreasing with subsequent treatment cohorts, though all HIV-related care is provided free of charge. At GHESKIO, six-month mortality was approximately 12% among patients initiating ART in 2003, 2004, 2005, 2006, and 2007 (unpublished data). In the cohort of patients initiating ART in 2003 and 2004, predictors of mortality included: body weight in the bottom quartile for gender (HR 3.3; 95% CI: 2.9 to 3.7; p-value < 0.0001); AIDS-defining illness (HR 2.1; 95% CI: 1.7 to 2.5; p-value < 0.0001); and CD4 cell count < 50 cells/mm3 (HR 1.6; 95% CI: 1.1 to 2.1; p-value 0.04) (Severe et al., 2005). Patients continue to present late. In a study conducted by PIH in rural Haiti, factors associated with late presentation included male sex, older age, belief of the patient that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to care, requirement to pay for medication in the past, and a history of a negative experience in a local hospital (Louis C, Ivers L, Smith M, Freedberg K, & Castro A, 2007). Treatment Models 132 HIV in the Caribbean: A Systematic Data Review 2003-2008 GHESKIO has developed an integrated health care program to test and treat for HIV, other STIs, and TB, as these diseases share overlapping risk factors (Peck, Fitzgerald, Liautaud, Deschamps, Verdier, Beaulieu, Grand Pierre, Joseph, Severe, Noel, Wright, Johnson & Pape, 2003). All patients who present to care at GHESKIO are provided with voluntary counseling and testing for HIV, screening for syphilis and other STIs, screening and treatment for TB, counseling and family planning services, nutritional support, and comprehensive HIV treatment, including ART. The GHESKIO ART model requires 1.5 physicians and 2.5 nurses to care for every 1000 patients on ART. Haiti has approximately 2000 doctors, and most of them are concentrated in urban areas. Therefore, this model may be feasible in urban centers. For example, it is estimated that there are approximately 60,000 HIV-infected people living in Port-au-Prince. If that of them required ART, then 45 physicians and 75 nurses would be needed to provide care using the GHESKIO model. However, in rural areas, where there are fewer physicians and nurses, other strategies must be employed. Models of ART using assistant medical officers, community health workers, and a limited number of physicians and nurses must be developed (Koenig S, Riviere C, Leger P, Severe P, Atwood S, Fitzgerald D, Pape J & Schackman B, 2008). In rural Haiti, PIH employs a model of directly observed treatment for ART and TB medications using community health workers, which decreases the reliance on other health professionals. PIH has worked in collaboration with the MoH to revitalize a network of clinic- hospital complexes in the rural Haiti, and their community-based directly observed ART model has been reproduced at each site. After health center improvements, an approximately ten-fold increase in ambulatory visits has occurred within 3 months of expansion. One site (Walton, Farmer, Lambert, Leandre, Koenig, & Mukherjee, 2004) tracked the numerous health improvements that followed. In the first fourteen months of the ART rollout, general medical visits increased by ten-fold, TB diagnoses increased by twenty times, prenatal services were added, 133 HIV in the Caribbean: A Systematic Data Review 2003-2008 vaccination access expanded, a small inpatient unit was built, and staff morale and community participation improved. Over time, the services provided at each site are expanded, with the goal of providing comprehensive care, including general medical and women’s health services, pediatrics, surgical treatment, nutritional support, economic development, and primary and secondary education. GAPS AND CHALLENGES Though the treatment of HIV has dramatically improved in Haiti over the past five years, many challenges remain. There is an urgent need to increase the number of pregnant women with access to prenatal care and broaden coverage of PMTCT across the country. It is critical to reinforce prevention activities, including safer sexual behaviors such as partner reduction and consistent condom use with casual partners, the management of STIs, and improved education and gender equality for women, as well as possible consideration of male circumcision for HIV prevention and male RH (as some groups like GHIESKO, FOSREF and PSI have entertained in recent years). It is essential to scale-up access to HIV care and the provision of ART so that universal access is provided across the country, while ensuring strict compliance with standards in the administration of care. Services must be consolidated as they are expanded, to preserve human resources and decrease overhead costs. For example, resources could be saved if the same providers prescribed both ART and TB medication in the same clinic visit. There is also a need to improve the level of nutrition among those with HIV and the general population by developing agriculture, improving access to nutrition, and training nutritionists. Services must also be expanded for orphans and other vulnerable children. Reinforcement and harmonization of the monitoring and evaluation plan will also be important, to enable better monitoring of HIV/AIDS activities and outcomes. CONCLUSIONS 134 HIV in the Caribbean: A Systematic Data Review 2003-2008 Haiti has mounted a generally successful response to the HIV/AIDS epidemic in spite of ongoing political difficulties and limited resources. It is one of several (and a growing number of) countries in the world with declining HIV prevalence, and access to comprehensive HIV/AIDS care is improving across the country. Though international funding has played a major role in Haiti’s programmatic successes, these later advances would not have been possible without the strong foundations that were already in place before external funds wereincreased. Haiti has high-level political commitment and the MoH has worked with a network of internationally recognized NGOs that were firmly established and already providing prevention and treatment services for HIV/AIDS at the time that international funding became more available. Haiti’s HIV/AIDS program has demonstrated that treatment outcomes rivaling those of developed countries can be attained even under adverse conditions in deeply impoverished settings. It is anticipated that with ongoing support from the Global Fund and PEPFAR, access to comprehensive HIV/AIDS care will continue to improve. In order to maximize the public health benefits of this funding, it is imperative that the public health infrastructure continues to be strengthened under the guidance of the MoH. As ART is scaled-up across the country, it is critical that adherence and quality of care are monitored. The TB program must also be strengthened to adequately address the HIV/TB epidemic, including the prevention and treatment of MDR-TB. Furthermore, human resources must be augmented with innovative delivery models, such as the training of nurses to work as physicians’ assistants, and the expansion of a network of community health workers to improve community-based care. Women’s economic and educational opportunities must be improved, and adjuvant social services (nutritional supplementation and transportation subsidies) will be critical to enable the most vulnerable patients to access HIV/AIDS and TB care. 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Moskowitz LB, Kory P, Chan JC, Haverkos HW, Conley FK, Hensley GT. Unusual causes of death in Haitians residing in Miami. High prevalence of opportunistic infections. JAMA 1983:250(9):1187-91. Mukherjee JS, Ivers L, Leandre F, Farmer P, Behforouz H. Antiretroviral therapy in resource-poor settings. Decreasing barriers to access and promoting adherence. J Aquir Immune Defic Syndr. 2006;43 Suppl 1:S123-6. Pape JW, Liautaud B, Thomas F, Mathurin JR, St Amand MM, Boncy M, Pean V, Pamphile M, LaRoche A, Johnson WD. Characteristics of the acquired immunodeficiency syndrome (AIDS) in Haiti. N Engl J Med. 1983;309(16):945-50. 141 HIV in the Caribbean: A Systematic Data Review 2003-2008 Pape JW, Liautaud B, Thomas F, Mathurin JR, St Amand MM, Boncy M, Pean V, Pamphile M, Laroche A, Dehovitz J, Johnson W. The acquired immunodeficiency syndrome in Haiti. Ann Intern Med. 1985;103(5):674-678. Pape JW. Outcome of Offspring of HIV-infected pregnant women in Haiti. 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Lancet. 1993;342:268-272, Pape JW. AIDS in Haiti: 1980-1996. 2000. In: The Caribbean AIDS Epidemic. Edited by Howe G and Cobley C., 226-242. Kingston: University of the West Indies Press. 142 HIV in the Caribbean: A Systematic Data Review 2003-2008 Peck R, Fitzgerald DW, Liautaud B, Deschamps MM, Verdier RI, Beaulieu ME, Grand Pierre R, Joseph P, Severe P, Noel F, Wright P, Johnson WD, Pape JW. The feasibility, demand, and effect of integrating primary care services with HIV voluntary counseling and testing: evaluation of a 15-year experience in Haiti, 1985-2000. J Acquir Immune Defic Syndr. 2003;33(4):470-475. PEPFAR Report 2008. Access at www.mesi.ht on July 1, 2008. Pitchenik AE, Fischl MA, Dickinson GM, Becker DM, Fournier AM, O’Connell MT, Colton RM, Spira TJ. Opportunistic infections and Kaposi’s sarcoma among Haitians: evidence of a new acquired immunodeficiency state. Ann Intern Med. 1983;98(3):277-84. President’s Emergency Plan for AIDS Relief (PEPFAR). GHESKIO report, 2006. Severe P, Leger P, Charles M, Noel F, Bonhomme G, Bois G, George E, Kenel-Pierre S, Wright PF, Gulick R, Johnson WD, Pape JW, Fitzgerald DW. Antiretroviral therapy in a thousand patients with AIDS in Haiti. N Engl J Med. 2005;353(22):2325-34. Smith-Fawzi MC, Lambert W, Singler JM, Koenig SP, Leandre F, Nevil P, Bertrand D, Claude MS, Bertrand J, Salazar JJ, Louissant M, Joanis L, Farmer PE. Prevalence and risk factors of STDs in rural Haiti: implications for policy and programming in resource-poor settings. Int J STD AIDS. 2003;14(12):848-853. Stamm WE, Handsfield HH, Rompalo AM, Ashley RL, Roberts PL, Corey L. The association between genital ulcer disease and acquisition of HIV infection in homosexual men. JAMA. 1988;260(10):1429-1433. 143 HIV in the Caribbean: A Systematic Data Review 2003-2008 UNAIDS Epidemic Update: Geneva, Switzerland: UNAIDS, (2006). Accessed April 12, 2007 at: http://www.unaids.org/en/HIV_data/epi2006 UNGASS Report 2008. Rapport National de Suivi de la Déclaration d’Engagement sur le VIH/SIDA (UNGASS). Programme National de Lutte contre le VIH/SIDA. Accessed July 2, 2008 at: http://data.unaids.org/pub/Report/2008/haiti_2008_country_rpogress_report_fr.pdf United Nations Development Index (2006). Accessed April 12, 2008 at: http://hdr.undp.org/statistics/data/country_fact_sheets/cys_js_HTI.html Viera J, Frank E, Spira TJ, Landesman SH. Acquired immune deficiency in previously healthy Haitian immigrants. N Engl J Med 1983; 308:125-129. Walton DA, Farmer PE, Lambert W, Leandre F, Koenig SP, Mukherjee JS. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy. 25(2):137-158. World Bank. Haiti at a Glance 2004. (2004). Accessed April 12, 2007 at: http://devdata.worldbank.org/external/CPProfile.asp?SelectedCountry=HTI&CCODE=HIT &CNAME=&TYPE=CP World Health Organization. Antiretroviral Therapy for HIV Infection in Adults and Adolescents in Resource-Limited Settings: Toward Universal Access. Recommendations for a Public Health Approach. 2006, Geneva: World Health Organization. World Health Organization; Core health indicators, 2007. Accessed at http://www.who.int/whosis/database/ June 10, 2007. 144 HIV in the Caribbean: A Systematic Data Review 2003-2008 Trans-Caribbean HIV/AIDS Research Initiative (TCHARI) The countries of the Caribbean have joined together with HIV/AIDS organizations within the region and the Office of AIDS Research of the National Institutes of Health to form the Trans- Caribbean HIV/AIDS Research Initiative to expand the collaborative research network in the region, with the following goals: Æ’ To develop a better understanding of the nature of the Caribbean HIV epidemic, and the pattern of HIV-associated infections such as human papillomavirus (HPV) and multi-drug- resistant tuberculosis (MDR-TB). Æ’ To improve therapeutic approaches to effectively treat HIV and associated infections among HIV-infected people in the region, particularly HIV-associated TB. Æ’ To determine the causes of the high early mortality among AIDS patients in the first six months on ART, and develop interventions to lower mortality Æ’ To develop strategies to improve medication adherence for patients on ART, particularly among adolescents Æ’ To develop and test vaccines to prevent HIV infection Æ’ To better understand the nature and context of high-risk sexual behaviors and the development of prevention interventions to address them. • To develop strategies to prevent transmission of HIV from mother to child. TCHARI is an independent, inclusive, diverse, cross-disciplinary, multicultural group of Caribbean-based HIV/AIDS researchers. Through partnering, networking, and collaborative activities, TCHARI strives to become a catalyst for social change in support of the enhanced public health of the Caribbean. TCHARI objectives are: (1) To contribute to defining a Caribbean HIV/AIDS research agenda; (2) To facilitate, promote, and foster collaboration among Caribbean HIV/AIDS researchers, including the training and mentoring of new investigators; (3) To disseminate research protocols and findings within the Caribbean region internationally; and (4) To develop a Caribbean HIV/AIDS Research Information Repository. Toward these ends, TCHARI has established the following five thematic working groups to identify research priorities for the region and to identify potential areas of collaboration: Therapeutics and Epidemiology; Vaccines; Behavioral, Social Sciences, and Prevention; Molecular Epidemiology; and Prevention of Mother-to-Child Transmission. Multiple studies have been proposed, and a study on the long-term outcomes and cost of ART in the TCHARI countries is underway. Haiti: Overall Context of the Epidemic Though Haiti has the highest HIV prevalence outside of sub-Saharan Africa, it is one of the few countries in the world with a declining HIV prevalence. With the help of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria, Haiti has dramatically improved access to HIV care and treatment across the country. Since 2005, 407,961 people have been tested for HIV through the PEPFAR program in Haiti, including 118,019 women tested during pregnancy. As of September 2008, 93,715 people were in HIV care and 21,509 had been treated with ART, a dramatic increase 2001, when fewer than 300 patients were on ART. 145 HIV in the Caribbean: A Systematic Data Review 2003-2008 Haiti is now moving toward universal treatment for HIV/AIDS. Due to human resource shortages and the need for community-based treatment in rural areas, novel strategies of care have been developed, with nurses working alongside doctors to provide ART and TB services and community health workers providing directly observed treatment and serving as a powerful link to the health centers in rural areas. As ART is scaled up, Haiti is planning a nationwide strategy to monitor adherence, mortality, and retention in care across clinics, to maximize treatment outcomes and quality of care. Though Haiti has faced political turmoil, devastating hurricanes, food shortages, and crippling poverty, they have produced HIV/AIDS treatment outcomes that rival those of industrialized nations. Haiti’s success is indisputable, but significant challenges remain. HIV prevention through safer sexual practices must be reinforced, particularly among the young. In addition, services for mother-to-child prevention must be expanded across the country. Vertical transmission continues because most deliveries occur at home, without the services of formal healthcare providers. Though over 80% of Haitians are aware that the virus can be passed from mother-to-child, fewer than half of men and women across all age, income, and education categories are aware that transmission can be decreased with medication. With education and formal health services, however, the provision of prevention strategies is high – in the GHESKIO network of 22 clinics, over 90% of pregnant women receive treatment to decrease mother-to-child transmission of HIV. Due to these challenges, researchers in Haiti have elected to focus on improving prevention and treatment strategies for HIV/AIDS, and to limit epidemiology studies to the prevalence and risk factors of HIV and other sexually transmitted infections among pregnant women and the general public. Extensive studies in the 1990’s demonstrated that HIV is spread through heterosexual contact in Haiti, so no further studies on the contribution of other modes of transmission in recently acquired infections (blood transfusions, homosexual relations, and intravenous drug use) are felt to be warranted. HIV Prevalence: Seroprevalence Surveys of Pregnant Women and the EMMUS Population-Based Study EMMUS-IV Study: In 2005-2006, Haiti conducted a study at the population level to estimate socio-economic status, access to sanitation, and demographic variables of households with women aged 15 to 49 years, children of less than 5 years, and men aged 15 to 59 years. For the first time, a seroprevalence study, called EMMUS-IV (Enquete Mortalite, Morbidite et Utilisation des Services), was also conducted to estimate the prevalence of HIV/AIDS at the national level. Between October 2005 and June 2006, 9,998 households participated in the study (99.6% of those surveyed). In these households, there were 10,757 females aged 15 to 49. Men were included in every other household – 4,958 men from ages 15 to 59 were enrolled. The results show that Haiti is a young population. Sixty percent of the population is less than 24 years of age. The majority of the population (62%) lives in rural areas. Fifty-two percent are female and 48% are male. Among females, 32% are single, 59% are in long-term unions. Among males, 47% are single and 45% are in long-term unions. Ninety-six percent of participants accepted HIV testing. The EMMUS-IV study found that 2.2% of people aged 15 to 49 were HIV positive (2.3% among females and 2.0% among males). Among females, the prevalence increased with age up to the range of 30-34 years where it peaked at 4.1%. Among males, the prevalence peaked at 4.4% 146 HIV in the Caribbean: A Systematic Data Review 2003-2008 among males aged 40-44 years. Positive HIV status was associated with the lifetime number of sexual partners. For example, females that had at least five lifetime sexual partners were six times more likely to be HIV-infected than those with only one partner (8.0% compared with 1.3%). Knowledge of HIV/AIDS was also tested during the EMMUS-IV study. Virtually all Haitian adults had heard of HIV/AIDS, but only 32% of females and 41% of males had complete knowledge of the disease, as measured by reporting that one could reduce the risk of acquiring the virus by using condoms and limiting sexual activity to one uninfected partner, and by knowing the ways that HIV/AIDS cannot be transmitted (by sharing meals or through the supernatural), and that one who appears in good health can have HIV/AIDS. Knowledge was significantly lower among males and females who had never been to school, who live in rural areas, and who are in the bottom economic quintile. The survey also evaluated sexual behaviours among Haitians. They found that 29% of sexually active females and 62% of males had high-risk intercourse, defined as sexual intercourse with a non-cohabitating or extra-marital partner, in the prior 12 months. Twenty six percent of females and 42% of males stated that they had used a condom with the last act of high-risk sexual intercourse. Among the young (ages 15 to 24), 15% of females and 43% of males were sexually active before the age of 15. Fifty-five percent of sexually active young females and 95% of young males had high-risk intercourse in the prior 12 months. Twenty-nine percent of young females and 43% of males had used a condom with the last act of high-risk sexual intercourse. Sero-prevalence of Pregnant Women: Sentinal surveys are also conducted regularly among pregnant women in Haiti. One objective of these studies is to compare the prevalence of HIV over time. This can be done at nine sites, which have been included in all of the studies. These studies have found that HIV prevalence was similar from 1996 to 2000 (5.96% and 5.10%), but it dropped significantly from 1996 to 2004 (from 5.96% to 3.44%) and from 1996 to 2007 (from 5.96% to 3.96%). However, it slightly increased from 2004 to 2007 (from 3.44% to 3.96%). Logistic regression was done to analyze the results observed between 1996 and 2007 at these nine sites. Logistic regression was also done from 2004 to 2007 at the level of the 17 sites included in the 2007 study, after adjusting for confounding factors (age, income, zone of residence, syphilis co-infection). There was no statistically significant difference detected between the HIV prevalence in 2004 and 2007 after controlling for these variables. Among the women tested in the 2007 study, 43.3% were younger than 25 years of age, 17% had never been to school, and 54% lived in rural areas. Seventy-five percent were in a long-term union with co-habitation. The median prevalence among the study sites was 3.3%. HIV prevalence was higher in women who were older than 25 years of age, and among those living in urban, compared with rural areas (5.9% versus 2.7%). The 2007 survey also measured the prevalence of syphilis, hepatitis B, and hepatitis C. The prevalence of syphilis was 3.6% (95% CI: 2.99 – 4.32%) across the sites, varying from 1.8% to 7.0%. The median prevalence of syphilis among the sites was 3.8%, and was higher in urban compared with rural areas (4.2% versus 3.2%). Little change was noted in the prevalence of syphilis from 1996 to 2000 (6.14% to 5.52%) – but it dropped significantly from 1996 to 2007 (6.14% to 3.9%). The prevalence of hepatitis B (antibody positive) was 4.8% (95% CI: 3.62% – 5.84%), varying from 1.0 to 8.3% across the sites. The prevalence of hepatitis C was 1.5% (95% CI: 0.03% - 0.56%), varying from 0% to 11.3%. 147 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table 1: Prevalence of HIV by Gender and Characteristics* Females Males Total – Male and Female Age Group (Years) 15 to 19 0.9 0.1 0.5 20 to 24 2.3 1.1 1.7 25 to 29 3.5 3.0 3.3 30 to 34 4.1 2.4 3.3 35 to 38 2.2 3.7 2.9 40 to 44 3.1 4.4 3.7 45 to 49 1.6 3.3 2.4 Total ages 15 to 49 2.3 2.0 2.2 Education Level None 2.3 3.3 2.6 Primary 2.6 2.0 2.3 Secondary or More 2.1 1.6 1.8 Area of Residence Port-au-Prince 2.5 1.3 2.0 Other City 2.9 2.4 2.7 Town 2.7 1.8 2.3 Rural 2.0 2.1 2.0 Department Port-au-Prince 2.5 1.3 2.0 West (Outside of P- 2.4 2.4 2.4 au-P) Southeast 1.7 1.1 1.4 North 2.6 3.3 2.9 Northeast 3.4 2.0 2.7 Artibonite 1.8 2.5 2.1 Central 1.4 1.8 1.6 South 2.9 1.5 2.2 Grande-Anse 1.7 1.5 1.6 Northwest 2.3 1.7 2.0 Nippes 3.8 2.2 3.0 Economic Status - Quintiles Poorest Quintile 2.4 1.7 2.1 Second Quintile 0.9 2.8 1.8 Third Quintile 2.4 2.4 2.4 Fourth Quintile 3.7 2.3 3.1 Wealthiest Quintile 1.9 0.9 1.5 Marital Status Single 0.7 0.5 0.6 Long-Term Union 3.1 3.5 3.3 Divorced or 3.5 4.3 3.8 Separated Widowed or 2.6 2.5 2.6 Widower Type of Union Male has Multiple 4.2 2.4 3.8 Partners 148 HIV in the Caribbean: A Systematic Data Review 2003-2008 Monogamous 2.7 3.7 3.1 Not Currently in 1.3 0.8 1.1 Long-Term Union Number of Sexual Partners in the Last Year 0 2.6 1.1 2.0 1 2.8 2.5 2.7 2 9.2 2.2 2.8 3+ * 1.8 2.1 Lifetime Sexual Partners 1 1.3 0.6 1.2 2 2.8 0.1 2.2 3-4 5.4 1.1 3.4 5-9 8.0 2.1 2.9 10+ * 3.8 3.9 Age at First Sexual Intercourse <16 3.3 1.8 2.4 16-17 3.1 2.8 3.0 18-19 2.1 2.4 2.2 20+ 2.6 3.8 3.0 Type of Sexual Relationships in Past Year Extramarital/Non- 3.0 1.9 2.3 cohabitating Partner Monogamous 2.9 3.2 3.0 Activity/Cohabiting Partner Not Sexually Active 2.6 1.1 2.0 * EMMUS-IV Haiti 2005-2006 Table 2: Knowledge of HIV/AIDS Prevention Strategies** FEMALES Age Condoms Monogamy with Abstinence Uninfected Partner 15-19 83 91 83 20-24 87 94 85 25-29 85 94 83 30-39 85 94 87 40-49 82 93 83 MALES Age Condoms Monogamy with Abstinence Uninfected Partner 15-19 92 95 86 20-24 91 93 86 25-29 94 97 87 30-39 94 95 89 40-49 90 97 89 149 HIV in the Caribbean: A Systematic Data Review 2003-2008 **EMMUS-IV 2005-2006 Table 3: Knowledge of Mother-to-Child Transmission by Characteristic**: FEMALES MALES HIV can be Risk of vertical HIV can be Risk of vertical Characteristic vertically transmission vertically transmission transmitted can be reduced transmitted can be reduced with medication with medication Ages 15-19 80 38 88 28 20-24 83 39 87 39 25-29 83 40 90 33 30-39 83 33 89 27 40-49 82 28 91 27 Marital Status Single 80 39 88 33 In long-term union 83 35 90 28 Divorced/Separated/ 82 31 87 29 Widowed Pregnancy Status Currently Pregnant 85 35 n/a n/a Not pregnant/unsure 82 36 n/a n/a Urban vs. Rural Port-au-Prince 82 49 86 40 Other City 83 36 88 36 Town 83 43 87 38 Rural 82 30 90 25 Education Level None 77 25 92 17 Primary 84 32 89 25 Secondary or More 82 46 88 40 Economic Status - Quintile Poorest Quintile 77 27 91 18 Second Quintile 81 27 92 23 Third Quintile 83 32 91 30 Fourth Quintile 85 36 85 31 Wealthiest Quintile 82 49 87 45 **EMMUS-IV 2005-2006 Table 4: Number of Pregnant Women Receiving Prenatal Care in Haiti* 150 HIV in the Caribbean: A Systematic Data Review 2003-2008 Category 2005 2006 2007 2008 (Sept 30) Number of Pregnant Women Tested 54,651 80,471 106,147 118,019 for HIV per Year Number of Pregnant Women Testing 1834 2616 3438 4367 HIV Positive Percentage of Pregnant Women 3.36 3.25 3.24 3.70 Testing Positive for HIV Pregnant Women Enrolled in HIV/AIDS 1760 2498 2691 4036 Care Number of Pregnant Women Tested 45,311 69,813 90,593 99,717 for Syphilis Number of Pregnant Women Testing 2388 3264 3708 4391 Positive for Syphilis Percentage of Pregnant Women 5.27 4.68 4.09 4.40 Testing Positive for Syphilis *PEPFAR Report 2008 Table 5: Percentage of Women Receiving Prenatal Care in Haiti** Age Group Received HIV Counseled, tested, Number of counseling and received test women in the results study who were pregnant in the prior two years 15 to 19 34.6 19.8 245 20 to 24 33.0 18.1 582 25 to 29 38.6 23.6 586 30 to 39 31.8 18.3 734 40 to 49 29.6 15.6 171 **EMMUS-IV 2005-2006 Table 6: Number of Haitians Tested for HIV through PEPFAR* Adults 2005 2006 2007 2008 (Sept 30) Number of Females Tested 80,216 138,492 198,922 254,913 (Cumulative) Number of Females Testing HIV 7603 11,491 15,047 15,932 Positive (Cumulative) Percentage of Females Testing HIV- 9.48 8.30 7.56 6.25 Positive (Cumulative) Number of Males Tested (Cumulative) 39,233 72,356 118,499 153,048 Number of Males Testing Positive for 5164 7511 10,021 10,275 HIV (Cumulative) Percentage of Males Testing HIV- 13.16 10.39 8.46 6.71 Positive (Cumulative) 151 HIV in the Caribbean: A Systematic Data Review 2003-2008 Total Number of Adults Tested 119,449 210,638 317,421 407,961 (Cumulative) Total Number of Adults Tested Positive 12,767 19,002 25,068 26,207 for HIV (Cumulative) Total Percentage of Adults Testing 10.69 9.02 7.90 6.42 HIV-Positive (Cumulative) *PEPFAR Report Haiti 2008 Table 7: Cumulative Number of Patients Initiated on ART, PEFPAR* Adults 2005 2006 2007 2008 (Sept 30) Cumulative Number of Adults on ART 5019 8842 14,788 20,452 Cumulative Number of Children on 348 929 1010 1057 ART Cumulative Total Number of People on 5367 9771 15,798 21,509 ART *PEPFAR Report Haiti 2008 Table 8: Cumulative Number of Adults Alive and on ART, PEFPAR* Adults 2006 2007 2008 (Sept 30) Cumulative Number of Males Alive and 3953 5443 7143 on ART Cumulative Number of Females Alive 5119 7206 9767 and on ART Cumulative Total Number of People 9072 12,649 16,910 Alive and on ART *PEPFAR Report Haiti 2008 Table 9: Cumulative Number of People in Clinical Care for HIV/AIDS PEPFAR* Adults 2005 2006 2007 2008 (Sept 30) Cumulative Number of Males in Clinical 15,476 21,321 28,425 34,706 Care for HIV/AIDS Cumulative Number of Females in 20,511 28,987 40,161 50,205 Clinical Care for HIV/AIDS Cumulative Number of Pregnant 1760 2498 2691 4036 152 HIV in the Caribbean: A Systematic Data Review 2003-2008 Women in Clinical Care for HIV/AIDS Cumulative Number of Children in 2374 3073 4018 4768 Clinical Care for HIV/AIDS Cumulative Number of Adults Living 239 4779 5678 7289 with HIV/AIDS Treated for TB Cumulative Number of Children Living 17 255 383 455 with HIV/AIDS Treated for TB Cumulative Number of People Living 256 5034 6061 7744 with HIV/AIDS Treated for TB Patients Newly Enrolled in Care for 7336 13,900 19,376 17,802 HIV/AIDS Patients Newly Enrolled on ART 1587 4096 6776 5724 Cumulative Number of People in 40,121 55,879 75,295 93,715 Clinical Care for HIV/AIDS *PEPFAR Report Haiti 2008 153 HIV in the Caribbean: A Systematic Data Review 2003-2008 JAMAICA Jamaica has a well established, comprehensive National HIV Program that has slowed the HIV epidemic and mitigated its impact. Adult HIV prevalence has been stable at approximately 1.5% since 1996. HIV transmission from mother-to-child has declined from 25% prior to 2000 to less than 8% in 2007. Over 60% of persons with advanced HIV and AIDS are on anti-retroviral (ARV) treatment and mortality due to HIV has declined significantly. A National AIDS Committee (NAC) was established in 1988 to lead the multi-sectoral response. Over 60 national organizations from all sectors of society including governmental agencies, non- governmental organizations (NGO), private sector, community based organizations (CBOs), trade union, church, youth, AIDS support organizations and persons living with HIV (PLHIV). All are members of the NAC and involved in the national HIV response. A National HIV/AIDS Policy was adopted unanimously in Parliament in 2005. The vision of this policy is “To protect the rights of all Jamaicans including those infected with and affected by HIV/AIDS and to create an enabling environment free of stigma and discrimination and providing access to prevention knowledge and skills; treatment care and support and other services.â€? National HIV/AIDS Strategic Plan Since 1988, Jamaica has had a national plan to guide its HIV response. The current National Strategic Plan 2007 – 2012 was developed following extensive country wide consultations with stakeholders and representatives of civil society. The goal of the plan is “to reduce the transmission of new HIV infections while mitigating the impact of HIV/AIDS on the people of Jamaica within a sustained, effective multi-sectoral infrastructure and soliciting the necessary commitment to support the national response to HIV and AIDS.â€? The guiding principles of the plan include political leadership and commitment, good governance, transparency and accountability, multi-sectoral approach and partnership, participation of PLHIV, equity, evidenced based interventions, participation of target populations in the design of programs and the (International Labour Organization) principles on HIV/AIDS in the world of work. The National Strategic plan 2007 - 2012 commits Jamaica to achieving universal access to HIV prevention, treatment and care. The plan covers four priority areas that are critical to achieving universal access namely: prevention, treatment and care, enabling environment, and empowerment and governance. The prevention component examines how underlying factors influence risk-taking or safe sex behaviour, identifies strategies considered to be effective in changing or sustaining behaviour and addresses how to replicate and scale up successful strategies. Persons most at risk, including sex workers, men who have sex with men (MSM) and youth, are targeted. The key to prevention efforts is for individuals to have the right to control their sexuality and exercise the responsibility to protect themselves and others from infection. The treatment and care component of the national plan aims at identifying all persons living with HIV and bringing them into care including ARV therapy. The need to improve adherence to ARV medication and laboratory facilities to better monitor patients as well as the quality of care are recognized. The national plan commits to promoting an enabling environment and human rights as a priority area. Several factors in the Jamaican environment are identified as barriers to achieving universal access and which need to be addressed through policy, programs and legislation. The final component of the national plan is devoted to improving empowerment and governance. This priority area calls for increased commitment from politicians and civic leaders. 154 HIV in the Caribbean: A Systematic Data Review 2003-2008 The concept of “three onesâ€? advocated by UNAIDS is supported and reflected in the plan. The national response to HIV is led by the National HIV/STI Program located within the Ministry of Health and supported by the NAC, which is responsible for coordinating the multi-sectoral response. The need to strengthen the system of monitoring and evaluation of the HIV response is recognized. The national strategic plan 2007-2012 embraces a number of critical cross-cutting strategies that aim to: • Decrease stigma and discrimination, resulting in increased acceptability and uptake of services • Strengthen the multi-sectoral response and improve the capacity of all stakeholders, resulting in increased quantity and quality of services and • Are evidence-based and comply with local, regional and international guidelines to inform the national response. Specific target indicators are set for achieving universal access to HIV prevention, treatment and care. The monitoring and evaluation (M & E) plan specifies 30 core indicators including indicators of universal access. The total cost of Jamaica’s national HIV strategic plan 2007 – 2012 is US$201.2 million. Jamaica was recently accorded a US$44 million grant over 5-years by the Global Fund (Round 7) as well as a US$10 million loan over 4-years by the World Bank. However, a considerable gap remains with respect to resources to fully implement the national HIV plan. In addition a strategic HIV plan for the education sector is being finalized that will also need to be funded. The conceptual model of the National HIV/IADS Strategic Plan 2007-2012 is illustrated in Diagram 1. 155 HIV in the Caribbean: A Systematic Data Review 2003-2008 Diagram 1: Conceptual model of the National HIV Strategic Plan 2007-2012 Monitoring and Evaluation The Jamaica National HIV/STI Program’s monitoring and evaluation (M&E) system is described in two documents: the M&E Plan (Document A) and the M&E Operations Manual (Document B). Together, these documents guide the implementation of specific M&E activities in a standardized, uniform manner so that program strategies can both gather information for day-to-day management, as well as provide information to parish, regional and national efforts. These documents also formalize procedures to ensure program transparency and preserve institutional memory. The M&E Plan is a fundamental follow-on document to the National Strategic Plan 2007-2012 (NSP). It builds on the NSP’s description of the program objectives and the interventions to further describe the M&E procedures implemented to determine whether or not those objectives are met. The objectives of the Jamaica National HIV/STI Program M&E Plan are: • To track the implementation of the National HIV/STI Program activities and establish whether the programme objectives have been achieved; • To increase the understanding of trends in HIV/AIDS prevalence and explain the changes over time to allow for appropriate response to the epidemic; and • To strengthen the capacity of the National HIV/STI Program, regions, parishes and NGOs and civil society organizations to collect and use HIV/AIDS data. 156 HIV in the Caribbean: A Systematic Data Review 2003-2008 The M&E Plan includes key characteristics of a sound and comprehensive M&E system for a National HIV Program as outlined by UNAIDS. The M&E Plan first describes the relationship between the programme’s expected outputs, outcomes, objectives and goals. It then describes the data and information required to illustrate this relationship (i.e., the indicators). Next, the M&E Plan details the necessary data sources, data collection systems, and information flow maps. In this way, the M&E Plan explains how a program will measure its achievements and provide for accountability to the stakeholder and donor communities. The M&E Operations Manual (Document B) complements the M&E Plan by clearly detailing how each piece of the M&E system functions. Whereas the M&E Plan describes the overall M&E system and components, the M&E Operations Manual provides specific national guidance on procedures, protocols, policies, roles, responsibilities, timelines and other implementation factors described in the M&E Plan. It also details the value of programme information for decision- making at the local, national and donor levels. The M&E Operations Manual is intended to be used by stakeholders at all levels that contribute to or participate in the national M&E system to ensure high quality data is reported and resulting information is received in a timely manner at all levels of programme implementation (i.e., facility, local, national and international levels). Logical Framework for the National HIV Strategic Plan The table below (Figure 1) gives a logical framework for the National HIV Strategic Plan and provides a summary of the goal, purpose, objectives and indicators for each of the National HIV/STI Program priority areas. This logical framework provides the foundation for the program’s monitoring and evaluation system. This is followed by Diagram 2 which outlines the conceptual model for the HIV monitoring and evaluation system in Jamaica. This diagram illustrates the various components of the system and how they are interrelated to provide information for programs. Figure 1: Logical Framework for National HIV Strategic Plan 2007-2012 with National Focus Indicators Prevention Treatment Care Enabling Empowerment & Support Environment & Governance & Human Rights GOAL To reduce the To mitigate the To protect To achieve a transmission of new impact of fundamental sustained, HIV infections HIV/AIDS on the human rights effective multi- Indicators people of and empower sectoral Jamaica the Jamaican infrastructure • Percentage of men & people to make and commitment women aged 15-24 healthy choices to support the who are HIV infected Indicators National • Percentage of SW • % of adults or Response to HIV who are HIV infected children with Indicators and AIDS • Percentage of MSM HIV known to • Percentage of who are HIV infected be on people 15-49 treatment 12 years Indicators months after expressing • National initiation of accepting Composite antiretroviral attitudes Policy Index therapy towards • Domestic and people with international HIV/AIDS AIDS spending 157 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention Treatment Care Enabling Empowerment & Support Environment & Governance & Human Rights by categories and financing sources PURPOSE To achieve universal To achieve To decrease Integration of access to prevention universal access stigma and HIV programs services, focusing on to high quality discrimination into existing most-at-risk comprehensive toward people human and populations treatment, care with HIV/AIDS social and support in development an environment programs Indicators Indicators that is non- • Number of individuals discriminatory • Number and reached through TCI percent age Indicators and supports disaggregated by adherence of reported • National vulnerable groups cases of HIV- Composite (e.g. youth, MSM, related Policy Index SW, prisoners, etc.) Indicators discrimination • Number of people • % of people by receiving trained to provide age, sex and redress by prevention services at-risk group setting by client and service who received area HIV testing in the last 12 months & know their results • % of women, men & children with advanced HIV infection who are receiving antiretroviral combination therapy according to national guidelines OBJECTIVES P1. To increase quality T1. To increase E1. To G1. To build of prevention services access to HIV systematically capacity and P2. To increase testing among identify and commitment of accurate information of priority report acts of health sector to ways to prevent HIV populations discrimination recognize their and dispel myths T2. To prevent E2. To role and provide Mother to Child improve public high-quality P3. To identify Transmission of awareness of services for all communities and HIV HIV and AIDS people populations most at- 158 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention Treatment Care Enabling Empowerment & Support Environment & Governance & Human Rights risk T3. To improve E3. To G2. To build P4. To increase access access to and strengthen capacity and to targeted, age- quality of ARV community commitment of appropriate HIV treatment advocacy other sectors prevention services for T4. To increase against stigma G3. To develop youth adherence to and one monitoring treatment and discrimination and evaluation P5. To strengthen prevention efforts for care E4. To reduce framework SW and others T5. To Improve stigma in all G4. To improve engaging in care and support sectors procurement and transactional sex for Orphans and E5. To reduce financial P6. To strengthen Vulnerable stigma and management prevention efforts for Children (OVC) discrimination systems MSM T6. To improve in the health G5. To access and use sector implement a P7. To strengthen prevention efforts for of Home Based E6. To sustainability tourism workers Care empower youth plan T7. To improve to address G6. To assure P8. To strengthen infection control stigma and multi-sectoral prevention efforts for and access to discrimination commitment to inmates in correctional facilities (PEP) for E7. To National accidentally empower Strategic Plan exposed Health PLWHA in the G7. To assure Care Workers context of strong T8. To reducing governance and strengthen stigma and accountability prevention discrimination efforts for and seeking PLWHA treatment and care T9. To improve the management E8. To of TB, especially advocate for in the HIV legislation that infected protects human rights E9. To advocate for non- discrimination among management and employees of the insurance sub- sector 159 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention Treatment Care Enabling Empowerment & Support Environment & Governance & Human Rights OBJECTIVES P9. To increase T10. To Indicators Indicators (continued) prevention strengthen the • Number and • Number of interventions in the management of percentage of persons labour sector directed STI, including reported trained by at reducing stigma & syphilis cases of HIV- client and discrimination T11. To improve related service area P10. To strengthen the diagnostic discrimination • Number of prevention efforts for capacity of the receiving individuals persons within the laboratory redress by trained in uniformed services services setting strategic P11. To strengthen T12. To • Number of information HFLE program in the strengthen and persons (M&E and/or education sector (early institutionalize trained by surveillance childhood to tertiary) the training client and and/or HMIS) P12. To strengthen the programme service area • Number of capacity of the sectors • Number of NGOs in the national Indicators policy makers providing response to conduct attending HIV/AIDS prevention • % of most-at- risk populations sensitization prevention or interventions workshops on treatment, care (youth, MSM, P13. To reduce SW) who HIV/AIDS/STI and support transmission from received HIV • Number of services PLWHA to their testing in the individuals according to partners and secondary last 12 months trained in national infections & know the strategic guidelines/ P14. To improve results information standards prevention • % of women, (M&E and/or • Percentage of interventions for drug men & children surveillance schools that abusers with advanced and/or HMIS) provided life P15. To increase the HIV infection skills-based use of mass media in who are HIV/AIDS prevention efforts receiving education in antiretroviral the last P16. To identify combination academic year cultural influentials/gatekeepers therapy • Number of who can positively shift according to policy makers existing risky cultural national attending norms guidelines sensitization • % of infants workshops on P17. To strengthen born to HIV- HIV/AIDS/STI prevention efforts for vulnerable adolescents infected Indicators mothers who are HIV- • % of young people infected (15-24) or at risk groups who both • % of PLWHA correctly identify on ART ways of preventing reporting at sexual transmission least 90% of HIV and reject adherence by 160 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention Treatment Care Enabling Empowerment & Support Environment & Governance & Human Rights of HIV and reject pill count major misconceptions • Current school • % of young adults, 15 attendance to 19 years old, who among orphans have never had sex and non- • % of young men & orphans, aged women aged 15-24 10-14 reporting condom use • Number of the last time they had persons trained sex with a non- to provide regular partner treatment • % of SW reporting services by condom use with their client and most recent client service area • % of men reporting • Proportion of using a condom the confirmed TB last time they had cases tested anal sex with a male for HIV partner • Incidence of • Number of people congenital trained to provide syphilis prevention services to persons most at risk 161 HIV in the Caribbean: A Systematic Data Review 2003-2008 Diagram 2 National HIV Program Monitoring & Evaluation System Conceptual Model Goals of the Jamaica National HIV/STI Program 1. Reduce incidence of HIV 2. Improve quality of life for infected NATIONAL HIV/STI M&E SYSTEM Data Sources Inform Indicators Provide program monitoring data Population-Based Program Monitoring Data Surveillance HATS Sentinel Surveillance Hospital Data (HMSR, MRCA, (ANC/STI) PAS) Behavioural Surveillance Health Center Data (MCSR; (KABP) Combined Immunizations and HIV Interventions 2nd Generation Surveillance Mental health databases) • Prevention (MSM & SW) Health Facility Assessment • Care, Treatment & Support Workplace Survey • Enabling Environment & Human MICS Rights Impact • Empowerment & Governance Indicators Outcome Provide funding for Program Output Indicators and implement Indicators Stakeholders at national, Submitted to and regional & parish level analyzed by • Private sector • Public Sector NHP M&E Unit • Civil Society • M&E Director • M&E Officer • Biostatistician Disseminated to: • Database Develop Manager s • Data Entry Information Products Staff • Quarterly epidemic update • UNGASS report • UNICEF report card • Annual Reports • Donor reports 162 HIV in the Caribbean: A Systematic Data Review 2003-2008 The monitoring and evaluation system conceptual diagram illustrates how information is generated from special surveys and program monitoring data. These data inform specific indicators which provide information to local program units, parishes, regional managers, the national program and policy makers. The information is presented through various publications and reports on a regular basis. Many of these reports are also made available to the media and to the public. The M&E system benefits every contributor and stakeholder by providing information on various levels to improve programs and policies around HIV/AIDS. HIV/AIDS Data Collection System The National HIV/STI Program has multiple data sources and collection systems in place and under development. The M&E Plan and M&E Operations Manual document the harmonization of these data sources and collection systems to reduce duplicate reporting and improve data quality. The relationships between key data collection mechanisms of the M&E information system are outlined in Diagram 3. 163 HIV in the Caribbean: A Systematic Data Review 2003-2008 Diagram 3: National HIV Program M&E Database Management System Manual data inputs HIV Surveillance Computerized System ARV Treatment Treatment Indicators* * Detailed indicators available RAPID Test RAPID Test Indicators* New database needed Tuberculosis TB Indicators* New, Needs to be tested, migrate data HATS DBMS Need to accommodate HIV variables HIV/AIDS Indicators* Stakeholders Other STI DBMS STI/Syphilis Indicators* (Components, RHA, Line Ministries, NGOs) Laboratory Information Performance Indicators Stakeholder System LIS Indicators* related to implementations Reports / activities by stakeholders Budget Allocation by Budget / Blood Bank HIV/AIDS/STI Stakeholder Accounts Blood Donors Indicators* Monitoring and Expenditure by Stakeholder / Finance High Risk Groups Evaluation Indicators* Database Surveys Population Groups Low Risk Groups Management BCC Indicators* Indicators KABP System Inventory ARV, Test kits, RHS Indicators* Other Policy Indicators RHS Quality assurance indicators Post Exp. Prophylaxis PEP indicators* Condoms Condoms distribution Indicators distribution / HMSR Hospital Indicators* availability MCSR Database VCT Indicators* Hospital Case Abstracts Hospital Indicators* Management report / Indicator Sets PAS MTCT indicators* -UNGASS -CRIS -CHRC PIOJ / STATIN Population Census -National Indicators There are currently 8 key routine and 2 non-routine data sources within the National HIV/STI Program. Additional data sources and means of harmonizing existing databases are planned. These data sources and the indicators which they inform are discussed in the following sections. HIV Sentinel Surveillance of ANC and STI Clinic Attendees HIV Sentinel surveillance involves testing 15-49 year old persons who attend ANC or STI clinics, typically between April and September of that year. This information was collected annually between 1990 and 2005 and is now collected every 2 years. 164 HIV in the Caribbean: A Systematic Data Review 2003-2008 At the health centre level, a rapid test is applied or in some cases, the blood specimen is sent to a testing site within the parish. Positive rapid tests are then sent for testing at a regional laboratory or the National Public Health Laboratory. HIV/AIDS Tracking System (HATS) The HIV/AIDS Tracking System (HATS) is an ongoing HIV surveillance system based on confidential case reporting, which includes demographic information, mode of transmission, risk factors, and stage of infection. HIV and AIDS case reporting is a legal requirement under the Public Health Act. The M&E Unit receives case reports from health services, public and private, on newly diagnosed HIV/AIDS cases. These are usually submitted by the physician or the contact investigator. In addition, the surveillance officer based at the National HIV/STI Program actively visits hospitals, private practitioners, hospices, death registries, among others, to identify and complete HIV/AIDS case reports. These case reports are entered into the HATS database, which is routinely searched for double entries and revised periodically based on updates from the surveillance officer or contact investigators. Data are collected and entered in an on-going basis. Standard reports are generated by the NHP M&E Unit quarterly. Health Information System The Jamaican Health Information System in its present form consists of 6 stand-alone databases. The databases are directly managed by the Planning and Evaluation Department of the Ministry of Health and consist of data collected from the following two service delivery levels: Hospitals: • Hospital Monthly Statistical Report (HMSR) database – reports on workload information within the hospital system • Medical Records Case Abstract (MRCA) database – stores patient demographics and information on diagnostic procedures, and discharge diagnoses • Patient Administration System (PAS) – stores patient demographics and information on admission, diagnostic procedures, and discharge Health Centres: • Monthly Clinical Summary Report (MCSR) database – stores aggregate information on services including antenatal, postnatal, child health, Family Planning, etc. • Combined Immunization database stores information on the number of vaccination doses given by parish. • Community Mental Health database - stores information on Mental Health diagnostic categories submitted by parish Mental Health Officers. The Government Health Services includes 24 hospitals and 344 health centres across the 4 administrative regions of the island. Data from these two service delivery levels is aggregated on paper-based forms and sent directly to the Planning and Evaluation Department in the Ministry of Health. All of the above databases, with the exception of the Medical Records Case Abstract (MRCA), report monthly summaries on paper-based forms. The MRCA, however, tracks actual patient information based on the Taxation Registration Number (TRN). Three of the databases are on an older FoxPro based platform and have undergone minimal upgrading over the past five years. The only two databases implemented in more standard MS Access include the Immunization database and the MRCA database. There is a proposal to upgrade all systems under a unified MIS and with online connectivity. Successful implementation 165 HIV in the Caribbean: A Systematic Data Review 2003-2008 of the project is contingent upon timely availability of funding and buy-in from senior management. The MCSR form has been revised to accommodate a few HIV related indicators. However, the form has not yet been implemented through the health system due to the obvious challenges involved in introducing a new form and the need to first have an upgraded MCSR database in place before starting to collect data using the new form. It is more than likely that as a fallback option the M&E unit will have to collect HIV data through other channels so that the NHP program is able to report on output indicators. Data are collected by the facilities in an on-going basis. Quarterly, the data are collated and sent to the regional HIV coordinators who complete the Regional HIV/AIDS Summary Report, which is sent to the M&E Unit at the Ministry of Health. These data sources provide the following program indicators: • Percentage of HIV positive pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT • Percentage of ANC clients that are counselled and tested for HIV • Number of individuals tested for HIV according to guidelines Monitoring and Evaluation Database This database captures all information from stakeholders of the National HIV/STI Program. This information is primarily captured on standardized forms, which are described in the M&E Operations Manual. Some sources of data for this database are: • Regional Quarterly Report and progress report • Contact Investigator Monthly Summary Statistics Form • Laboratory Rapid Test database summary reports • Line Ministries’ reports • Stakeholder and sub-recipient reports, including Parish AIDS Associations • Internal program reports • Special Investigation Form for Congenital Syphilis, Ophthalmia Neonatorum and Paediatric HIV • Monthly STI Summary Report The program indicators provided by the M&E Database include: • Number of persons trained to provide services by client and service area • Number of individuals trained in strategic information (M&E and/or surveillance and/or HMIS) • Number of individuals tested for HIV according to guidelines in last 12 months & who know their results • Number of adults and children with HIV known to be on treatment 12 months after initiation of ART • Percentage of HIV positive pregnant women who received a complete course of ARV prophylaxis to reduce the risk of MTCT HIV Rapid test Database: The HIV Rapid Test Database contains information related to all HIV tests that are done using a ‘rapid’ test method. In Jamaica, these tests are preformed by collecting a drop of blood from the client and providing the results to the client during the same visit. The HIV rapid test results are maintained in a database at the regional laboratories. It is a resource for monitoring the implementation of the HIV rapid testing program and can generate aggregate reports on HIV tests done by client group (e.g. ANC attendees, STI clinic attendees, etc.). 166 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV Electronic Register with the HIV/AIDS Treatment and PMTCT Databases: The HIV Electronic Register contains a HIV/AIDS Treatment Database and PMTCT Database that collect treatment-related information on all HIV positive persons at the clinic level. This database captures demographics and clinical data (e.g. CD4 counts, initiation of ART and opportunistic infection prophylaxis). It also provides aggregate reports for the NHP M&E Unit. The program indicators provided from this data source include: • Percentage of adults and children with advance HIV infection who are receiving antiretroviral combination therapy according to national guidelines • Number of adults and children with HIV known to be on treatment 12 months after initiation of ART • Percentage of HIV positive pregnant women who received a complete course of ARV prophylaxis to reduce the risk of MTCT Country Response Information System: CRIS CRIS is a software application developed in 2002 by UNAIDS to assist with UNGASS reporting by countries. The NHP M&E Unit uses this repository for UNGASS and national indicators. National Blood and Transfusion Services and Public Health Lab Databases The National Blood Transfusion Service (NBTS) and National Public Health Laboratory (NPHL) collect information on blood safety and HIV related testing. A laboratory information system is being implemented to facilitate electronic storage of data and better monitoring. On a quarterly basis, the NBTS and NPHL provide the M&E Unit with the number of HIV tests conducted by risk category including: ANC, STI clients, outreach efforts, and hospitalizations. This information can be disaggregated by health region, sex, and age. These sources provide the following program indicators: • HIV prevalence among 15-49 year olds • Percentage of donated blood units screened for HIV in a quality assured manner • Number of individuals receiving CD4 tests in the public sector according to national guidelines. Other Routine Data Sources There are several other routine data sources that are at various stages of development. Many of these data sources are outside of the health sector, but provide valuable information for the HIV program. Examples of these initiatives include: HIV-related Discrimination Reporting and Redress System database: The HIV-related Discrimination Reporting and Redress System is being developed and will capture all reported cases of HIV-related discrimination. It will include follow-up information on the redress process. National Health Fund (NHF) Database One of the functions of the National Health Fund (NHF) is to provide assistance to persons to purchase designated prescription drugs. Access to such services is tracked in a NHF database. Persons with advanced HIV and AIDS are registered with the NHF and receive the NHF card when they are being placed on ARV treatment. This was designed as a means for tracking 167 HIV in the Caribbean: A Systematic Data Review 2003-2008 access to ARVs and adherence of persons living with HIV who are on treatment. However, the system has failed to meet the expectations of the national program to facilitate early identification of persons who fail to collect their ARV medication on time. Non-routine Data Sources National Knowledge, Attitudes, Behaviour and Practices (KABP) Surveys The National HIV/STI Programme conducts National Knowledge, Attitudes, Behaviour and Practices (KABP) population-based surveys every 3-4 years in order to obtain information and track trends on the knowledge and practices related to the prevention and transmission of HIV and other STD. These surveys have provided national level measures of outcome indicators and have focused on partner reduction, consistent use of condoms in regular and non-regular partnerships, delay of sexual activity among young persons, myths and appropriate practices regarding STI/HIV/AIDS, knowledge and awareness of STI, and condom accessibility. The surveys have been conducted by a private local contractor implemented under a sub-contract agreement on a competitive basis. The last KABP was conducted in 2008 and the next one is schedule to be implemented in 2011. The sampling methodology is by clusters, using Enumeration Districts (EDs). The EDs are selected with probability proportionate to their size (measured in terms of the number of dwellings per ED). An equal number of dwellings are selected from each ED using a systematic sampling with a random start. For purpose of selection of the EDs, all EDs of the population census (after grouping them where necessary such that no ED contains less than 80 dwellings) are grouped into 234 strata (also called sampling regions) of equal size (again measured in terms of the number of dwellings. Every stratum contains approximately 25,000 dwellings and the EDs are selected from each sampling region with probability proportionate to its size. The “paired selectionâ€? design has been adopted for the sample. It is a stratified multi-staged sample with quota control for gender. The target groups are male and female 15-24 years, and 25-49 years. Data is collected in confidential face to face interviews by trained interviewers. The rural/urban composition of this sample is generally representative of the country. The program indicators provided from this source include: • Percentage of persons by sex and age groups who reported using a condom at last sex with a non-regular partner • Percentage of young adults, 15 to 19 years old, who have never had sex • Percentage of young women and men aged 15-24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission • Percentage of young women and men aged 15-24 who have had sexual intercourse before age 15 • Percentage of persons 15-49 years old who can access a condom almost immediately (less than 5 minutes) Surveillance of Persons Most at Risk and Youth, These surveys provide national level measures of outcome indicators and prevalence rates in persons most at risk such as MSM and SW. They focus on use of condoms with regular and non-regular partners, myths and appropriate practices with regards to STI/HIV, exposure to 168 HIV in the Caribbean: A Systematic Data Review 2003-2008 interventions, and other high risk behaviours such as substance abuse. Biological samples are also collected for HIV testing and in some instances STI testing. The most recent SW study was done in 2005 and there is another one scheduled for 2008. A survey of MSM was completed in 2007. These studies will be conducted every two to three years, depending on availability of funding. Surveys have also been conducted among prison inmates. The youth data are collected through the Healthy Lifestyles surveys that focus on school-based and population-based samples of 10-15 year olds and 15-19 year olds. Biological samples are not collected among the youth. Healthy Lifestyles data were collected in 2005 for the 10-15 year old survey and in 2006 for the 15-19 year old survey. National program indicators provided by these surveys include: MSM: • Percentage of MSM who received HIV testing in the last 12 months and who know the results • Percentage of MSM who are HIV infected • Percentage of MSM reporting using a condom the last time they had anal sex with a male partner SW: • Percentage of SW who received HIV testing in the last 12 months and who know the results • Percentage of SW who are HIV infected • Percentage of SW reporting using a condom at last sex act with client (paying partner) Youth: • Percentage of people by sex and age groups who reported using a condom at last sex with a non-regular partner • Percentage of young adults, 15 to 19 years old, who have never had sex The HIV/AIDS Epidemic in Jamaica The adult HIV prevalence rate in Jamaica is estimated to be 1.6% (95% Confidence Interval 1.1% - 2.1%) (UNAIDS 2008). An estimated 27,000 persons are living with HIV of whom nearly two thirds are unaware of their HIV status. The HIV prevalence is considerably higher among those most at risk such as CSW (9%) (Gebre et al 2006), MSM (31.8%) (Figueroa et al 2008), persons with STIs (3.6%), crack/cocaine users (4.5%) (de la Hay 2004), and prison inmates (3.3%) (Andrinopoulos et al 2008). Based on sentinel surveillance of women attending antenatal clinics there does not appear to be any significant change in the HIV prevalence in Jamaica over the last decade. HIV prevalence among ANC attendees in the public sector peaked at 2% in 1996 and has been approximately 1.5% since then (Figure 2). In 2007 HIV prevalence among ANC attendees was 1.1% when known HIV cases were excluded. The problem is that a proper count was not kept of the number and percentage of known HIV cases. There are approximately 30,000 ANC attendees in the public sector annually and another 20,000 pregnant women who seek ANC privately. HIV rates are considerably lower among pregnant women in the private sector than in the public sector. Among persons attending public STD clinics HIV prevalence peaked at 7.1% in 1999 and declined to 3.6% in 2007 (Figure 3). 169 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table 1 HIV Prevalence in Jamaica INDICATORS JAMAICA 1.5% (2005), 1.3% (2007) HIV prevalence rate, aged 15-49 (ANC sentinel surveillance) 1.6% (UNAIDS 2007) 9.0% (2005, surveillance of CSW) HIV prevalence rate among CSW HIV prevalence rate among MSM 31.8% (2007 survey of MSM) HIV prevalence rate among STI clinic attendees 3.8% (2004), 4.6% (2005), 3.6% (2007) (STI in public sector sentinel surveillance) HIV prevalence rate among inmates 3.3% (2006 surveillance of inmates) As of December 2007, the cumulative number of persons reported with AIDS or advanced HIV (CD4 count < 350) in Jamaica was 12,520. Reported AIDS Case rates have increased annually to peak in 2005 at 1344 (Figure 4). Reporting of advanced HIV cases began in 2005 in order to take account of those persons with HIV who were being put on antiretroviral treatment prior to developing AIDS. Total reported cases of AIDS and advanced HI V declined somewhat from 1344 in 2005 to 1186 in 2006 and 1104 in 2007. This decline must be viewed cautiously because the actual levels of case ascertainment and reporting are unknown and are likely to be incomplete. A survey conducted in 1994 found that AIDS case reporting tended to be late, with many cases reported at death (Figueroa & Brathwaite 1995). It was estimated that the level of reporting was nearly 80% at the time. A more recent analysis of the HIV/AIDS tracking system found that in the pre-ART era over one third of HIV infected persons were first identified with advanced disease (Losina et al 2007). Although AIDS case reporting appears to have declined somewhat in recent years the National HIV Program has established an HIV testing database and an ARV treatment database, both of which are searched prior to compilation of annual reports. Many unreported cases of AIDS and advanced HIV are identified by reviewing these databases and thereby possibly ensuring a greater case ascertainment overall. The cumulative number of deaths due to AIDS as of 2007 was 6,673 or 53.3% of all reported cases. The annual number of AIDS deaths peaked at 692 in 2002 and declined to 320 in 2007. The significant decrease in deaths is attributable to the public access treatment program, made possible by the Global Fund, in which an average of nearly 100 new cases of AIDS or advanced HI V have been placed on ARV treatment each month since September 2004. Pediatric AIDS cases and deaths have also declined. Pediatric AIDS cases peaked at 83 in 2000 and declined to 33 in 2007 while deaths peaked at 45 in 2002 and declined to 9 in 2007 (Figure 5). These encouraging trends are due to an effective program to prevent HIV transmission from mother to child and a comprehensive treatment program for children with HIV infection (Christie 2004, Christie 2008). Seven percent of all AIDS cases are due to vertical transmission. However, the number of AIDS cases due to vertical transmission has declined considerably in 170 HIV in the Caribbean: A Systematic Data Review 2003-2008 recent years and some of the pediatric cases reported are due to slow progressors that present after 8 years of age (Dunkley et al 2006). In Jamaica, the HIV epidemic is primarily due to sexual transmission (Figure 6) and this is predominantly due to heterosexual spread (Table 2) (Figueroa 2004). Nearly a quarter of all reported cases and 42% of cases among men are classified as being of unknown sexual practice. This is due to the late reporting of many AIDS cases making it difficult to investigate them adequately. In addition, although many male cases are known to be due to sexual transmission, they are not classified as heterosexual unless same sex among men can be ruled out. Given the strong stigma against MSM in Jamaica many men who engage in sex with other men are unwilling to admit it. Therefore, the proportion of men with AIDS classified as homo/bisexual (14%) is likely to be an underestimate of the true proportion of HIV transmission due to MSM. The high HIV prevalence among MSM (31.8%) (Figueroa et al 2008) would also suggest that the proportion of AIDS cases due to MSM is higher than 14%. A more realistic figure may be approximately 20% of men with AIDS in Jamaica are among MSM. AIDS case rates have been consistently higher among men than women in Jamaica (Figure 7). This is likely to be due to two reasons. The sexual behaviour of heterosexual men in Jamaica is more risky than that of women with respect to multiple partners and commercial sex and HIV rates are high among MSM. While AIDS case rates among women appear to have declined marginally from 48.2 per 100,000 in 2005 to 42.6 per 100,000 in 2007 rates among men have increased from 53.3 to 57.4 per 100,000 over the same period. This trend may be due to more women than men practising safer sex and accessing HIV testing as well as the continued high rates of HIV among MSM. Approximately 74% of all reported AIDS cases in Jamaica are in the 20-49 year old age group, and 85% of all reported AIDS cases are individuals between 20 and 60 years old. AIDS case rates among adolescent females are nearly three times higher than among adolescent males (Figure 8). This may be due to age mixing with young females having sexual intercourse, including transactional sex, with older men some of whom are HIIV infected. AIDS case rates are slightly higher among women than men in the age group 20 – 29 years while significantly more men than women are reported with AIDS in the 30 to 60 year old age group. Among persons reported with AIDS approximately 80% of them give a history of having multiple sex partners (i.e. more than 2 sexual contacts in the past year) (Table 3). Nearly half (47.1%) give a history of having another sexually transmitted disease, one quarter reported participating in commercial sex and 8.5% reported using crack/cocaine. Epidemiological studies among STD clinic attendees in Kingston in the early 1990s found independent associations between HIV infection and sex with a prostitute as well as syphilis infection (Figueroa 1994). Injection drug use is not reported in Jamaica. However, 1.1% of AIDS cases reported injecting drug use. This was primarily among Jamaicans with AIDS who used injecting drugs while in North America and were deported to Jamaica. Approximately 20% of all reported AIDS cases in Jamaica give no history of any of the usual risk factors for HIV infection. These are mainly women who have become HIV infected by their male partner or spouse. This emphasises the generalised nature of the HIV epidemic in Jamaica while recognising that HIV is also concentrated among those most at risk. The reported AIDS case rate for Jamaica peaked at 50.7 per 100,000 in 2005 and declined to 41.3 per 100,000 in 2007 (Figure 9). All 14 parishes in Jamaica are affected by the HIV epidemic with the most urbanized parishes having the highest cumulative number of AIDS cases. AIDS case rates are highest in the parish of St James (75.9%) which includes Montego Bay the tourism capital of Jamaica. AIDS case rates are next highest in Kingston (55.3%) and St Catherine ( %). AIDS case rates are relatively high along the North coast where tourism is the major form of economic activity. Over 2 million tourists come to Jamaica each year and sexual encounters 171 HIV in the Caribbean: A Systematic Data Review 2003-2008 between tourists and Jamaicans are not unusual. Jamaica is marketed as a sex tourism destination in certain quarters and some sex workers including beach boys, escorts and ‘rent-a- dreads’ are known to target tourists. Factors driving the HIV Epidemic In Jamaica there are a number of underlying socio-economic and cultural factors that drive the HIV epidemic (Figueroa 2004). Sexual and mating patterns are deeply ingrained in the culture, as are gender roles and expectations associated with sexual practice (Chevannes 1986, 2001, 2002). Most of these behaviours are derived socially, and emerge more spontaneously than by rational choice. Sex begins at an early age with 50% of boys initiating sex by age 15 years and 50% of girls doing so by age 17 years. In fact national population based surveys indicate that the median age of first sex in Jamaica has declined in recent years (Figure 10). Boys are socialised into early sex, which is seen as natural and expected, and ensures that the boy is not labelled a homosexual or mama’s boy (Chevannes 2001, 2002). Traditionally, girls are monitored more closely than boys with respect to sexual behaviour. However, more girls appear to be getting involved with transactional relationships with older men in order to meet basic needs or gain benefits for themselves (Constella/ Hope ref). Although sex begins at an early age, many young people are not adequately prepared for sex and myths remain strong. Only 38% of persons 15 - 24 years of age can correctly identify three ways of preventing sexual transmission of HIV and reject major misconceptions (Duncan & Figueroa 2006, Hope Enterprises 2004). The Jamaica Adolescent Study found that only 30% of boys and 65% of girls used a contraceptive method during their first sexual intercourse (Jackson et al 1999). Among sexually active adolescents 15 – 19 years of age in 2001, 68% of males and 53% of females reported using a contraceptive method at last sex (Hope Enterprises 2002). Among persons aged 15 – 24 years who have had sex with a non-marital, non-cohabiting partner in the past year, 83.5% of males and 66.3% of females report using a condom at last sex with such a partner (Hope Enterprises 2008). While condoms are readily accessible to the general population, it is not always easy for young persons to get condoms because of the negative attitudes of many adults to adolescents having sex and the embarrassment faced by the youth (Gayle et al 2004). The content of the family life and health education in schools is not adequate to prepare young people for sex and many teachers and parents are uncomfortable talking about the subject. Multiple sexual partnerships are common in Jamaica especially among men. The proportion of men aged 15 – 45 years reporting more than one sexual partner in the past 12 months ranges between 49% and 59% in various surveys since 1985 (Figueroa et al 1999, Figueroa et al 2005, Hope Enterprises 2004). Among men aged 15 – 24 years as many as 76.2% report having sexual intercourse with more than one partner in the last 12 months (Hope Enterprises 2008). Despite repeated educational campaigns that include a message to ‘stick to one faithful partner’ there appears to be little change in this sexual practice among men although a significant decline was noticed in multiple partnerships among men in national surveys conducted between 1992/93 and 2000. Masculinity is often viewed by men in terms of how many women or baby mothers they have. It is clear that the practice of men having an ‘outside woman’, that is one outside of his main partnership, is a deeply engrained cultural practice (Chevannes 1986, 2002). It is much more difficult to assess the proportion of women who have multiple sexual relationships because admitting to this is not viewed as socially acceptable and is likely to be under-reported in surveys. National population based KAP surveys indicate that between 11% - 15% of women aged 15 - 45 years report having more than one sexual partner in the past year. Among women aged 15 - 24 years 21.4% reported having sexual intercourse with more than one partner in the last 12 months (Hope Enterprises 2008). However, carefully conducted focus groups suggest that 30% - 40% of women may be having multiple sexual partners in the past year (Chambers & Chevannes 1994). This is a much more realistic estimate given the high rate of men reporting 172 HIV in the Caribbean: A Systematic Data Review 2003-2008 multiple sexual partnerships. This practice is more common among younger than older women. Many women may enter into transactional sexual relations with a man other than their main partner for economic reasons (Chevannes 2001). Condom use increased significantly following educational campaigns and social marketing of condoms in response to the HIV epidemic. The condom market grew from 2.5 million condoms (20% sold) in 1985 to approximately 10 million per year (70% sold) between 1996 and 2004 and 12 million in 2006 (65% sold) (Figure 11) (Hope Enterprises). Since 1992, nearly 75% of men aged 15 – 49 report condom use at last sex with a non-regular sex partner. Among women, the proportion reporting condom use at last sex increased from 37% in 1992 to approximately 60% since 1994 (Figure 12) (Hope Enterprises). Despite repeated educational campaigns promoting consistent condom use approximately one quarter of men and 40% - 50% of women do not use a condom with a non-regular sex partner. Given the gender imbalance between men and women it is difficult for a woman to insist on condom use in a transactional relationship if the man does not wish to do so. There is also a tendency in new relationships, after having sex a few times with a condom, to stop using the condom as a sign of mutual trust in a relationship that appears to be strengthening. This may occur even where the woman may suspect that the man has other sex partners. She may adopt the perspective that she is now the main partner of the man and therefore should not have to use a condom with the expectation that if he does have other sex partners he should be using a condom with them. Many older men are reluctant to use a condom because they never learnt how to use it properly when they were younger or they are concerned that they will lose their erection. Commercial sex appears to have grown and become more diverse in Jamaica in the past two decades. There are now nightclubs with exotic dancers throughout Jamaica including in rural areas. The performance of live sex on stage, known as ‘freaky’ shows, is not unusual. Massage parlors offering sexual massages and escort services are now commonplace and are advertised in the daily newspapers. Many girls and young ladies see their good looks and ability to dance as an asset to be marketed and commercial sex, exotic dancing or sexual massage are all options especially where economic needs cannot be met through other conventional means. Unemployed boys, especially those on the street, also see sex with men who pick them up as an option for survival. There is a considerable demand, primarily from men, for commercial sex and there is a pool of unemployed women (and boys) who can make good money from it. Many female sex workers report that they do not like the trade but it pays better than most other employment that they can do, such as domestic work, and they need the money to look after their children (Figueroa in press). Commercial sex is illegal in Jamaica and periodically the police do make raids and remove sex workers from the street. It is unusual for the police to interfere with night clubs even when it is well known that sex workers are operating on the premises or that live sex is taking place on stage. However, there have been raids on clubs where it is alleged that dancers from other countries are working without work permits. Sex workers travel widely within Jamaica and many also travel abroad. Jamaica has been cited by the United States for not doing enough to prevent human trafficking. This led to the closure of a rural meeting point where club owners and exotic dancers gathered regularly in order to rotate dancers at different work sites. Increased police activity drives commercial sex underground and makes it more difficult to reach the sex workers. The massage parlors, in particular, are difficult for field staff to access. Many sex workers use their cell phones to reach clients. HIV prevalence has remained at 9% among sex workers for nearly two decades. This is the case despite reported condom use among sex worker clients being over 90%. In depth interaction with sex workers reveals that many of them are of low literacy and have limited knowledge, poor condom skills and believe in a variety of myths. While most of then do insist on condom use with clients they often make an exception for regular clients who treat them well. The proportion of men reporting condom use at last sex with a sex worker declined from 77% in 2004 to 65% in 173 HIV in the Caribbean: A Systematic Data Review 2003-2008 2008 (Hope Enterprises 2008). Sex workers also have a tendency not to use condoms with their regular partner or boy friend although he frequently has multiple sex partners. A recent survey using urine samples to test for STIs (Gen Probe) found that 65% of street prostitutes and 40% of sex workers in night clubs had a STI (Figure 13) (Figueroa 2007). Only 4% of persons 15 – 45 years admit to commercial sex in national surveys (Hope Enterprises 2004). However, as many as 20% of persons report giving or receiving money or a gift for sex when a self administered questionnaire is used indicating that transactional sexual relationships are widespread in Jamaica. The high rates of STIs found among both female (30%) and male (24%) patrons of night clubs in Kingston supports this view (Figueroa 2007). The stigma associated with HIV/AIDS and marginalized groups is a critical factor contributing to the continued spread of HIV in Jamaica. The initial association between homosexual men and AIDS, as described in the USA, remains imprinted in the minds of most Jamaicans. This complicates the response to HIV because the stigma against homosexuality is very strong. Although overt discrimination against PLHIV is no longer common HIV related stigma remains strong and very few PLHIV are willing to be open or public with their status. This makes the epidemic virtually invisible in the mind of most persons who do not appreciate that they could be at risk. Heterosexual men are concerned that if they are HIV infected persons may believe that they are really homosexual. However, most HIV infected women are also concerned about revealing their HIV status. The strong stigma associated with HIV and male homosexuality in Jamaica drives the HIV epidemic underground and makes it more difficult for persons at risk to seek services including HIV testing. At the same time it makes it more difficult for HIV program staff to reach those most at risk especially MSM. Among MSM there is also significant denial of risk and failure to face up to the reality of HIV and AIDS within their community. HIV prevalence rates among MSM have been unacceptably high (approximately 30%) for over 15 years. A recent survey of 201 MSM found HIV prevalence to be 31.8% (Figueroa et al 2008). Low socio-economic status, a history of ever being homeless and being a victim of physical violence were significantly associated with HIV status (table 4). Many of these MSM also had another STI (Chamydia 8.5%, syphilis 5.5%, gonorrhea 2.5%). HIV Prevention The prevention component of the National HIV Program has evolved considerably over the past two decades. A safe blood supply was secured when routine HIV testing of all blood donors was introduced in December 1985 the same year a commercial HIV test kit became available. Initial education campaigns focused on explaining what AIDS was, how it was caused by the Human Immunodeficiency Virus (HIV), how HIV was transmitted and how HIV transmission was prevented. Persons were advised to abstain from sex, stick to one faithful partner and use a condom every time. General awareness of HIV and how it was caused was virtually universal by the late 1980s and early 1990s. However, certain myths such as you can tell who has HIV by looking or that mosquitoes can cause HIV remained common. At the same time reported condom use at last sex increased significantly and the condom market grew four-fold with the proportion of persons purchasing condoms increasing from 20% to 70% between 1985 and 1996. Condoms were promoted actively including through social marketing campaigns organized by both the HIV program and the National Family Planning Board. HIV/AIDS was recognized as a sexually transmitted disease and the national program was defined as a HIV/AIDS/STD control program. Considerable resources were invested in strengthening the STD services. STD treatment facilities were expanded to ensure a specialist STD clinic in every parish and syphilis testing was decentralized to facilitate testing with same day results and treatment for all STD and ANC attendees. Treatment of STD using syndromic management was introduced with a major training program for practitioners in both the public and the private sector. Sufficient supplies of STD treatment drugs were ordered and made available. The Ministry of Health increased the number of posts available for contact investigators, trained 174 HIV in the Caribbean: A Systematic Data Review 2003-2008 additional contact investigators locally and employed them. The surveillance and reporting of STD were improved. The public were educated about symptoms of STD and encouraged to seek treatment early and education programs were introduced to persons attending public STD clinics. These measures contributed to a significant decline in infectious syphilis which peaked at 150 cases per 100,000 population in 1987 and declined to below 10 cases per 100,000 since 2000 (Figure 14). Congenital syphilis has also declined significantly over the period from 68 cases in 1994 to 19 cases in 2003 (Figure 15) (Figueroa et al 1996). In the early stages of the epidemic it was recognized that there was a need to involve all sectors of society if HIV was to be effectively controlled. Towards this end the National AIDS Committee (NAC) was established in 1988 with the mandate to mobilize all sectors of society in the fight against HIV/AIDS, to advise the government on policy and to raise funds. Within one year the NAC had over 50 member organizations including government, non-governmental, private sector, professional, trade union, church, youth, women and community organizations. In this period there were three different bishops attending the NAC. The government appointed a prominent businessman as chairman of the NAC and the director of the national HIV/STD program in the Ministry of health was the deputy chairman. Several sub-committees were established and volunteers encouraged and regular public forums held. This model has served the country well. In the early 1990s it was recognized that there needed to be targeted prevention interventions focused on commercial sex workers, MSM and persons attending STD clinics. Two NGOs were contracted to lead these interventions namely ACOSTRAD (sex workers) and JAS (MSM) while Ministry of health staff targeted STD attendees. In fact JAS also targeted sex workers as well as provided hospice care and social support to persons with AIDS. During the early 1990s the importance of working with youth and in low income inner cities was also recognized. This lead to the training and employment of community outreach workers island wide. A number of peer educator programs among youth were also initiated including by the Jamaica Red Cross. Efforts to get the Ministry of Education involved in developing sex education in schools in a meaningful way failed at this time despite offering project funding to support their activities. In contrast, the Ministry of Labour introduced an education program for Jamaicans traveling to North America for seasonal employment as migrant farm workers alongside HIV testing that was required by the USA employers. The Joint Trade Union Confederation and the Jamaica Defense Force were among the first organizations to develop a HIV policy and program. Both were active members of the NAC. Many different approaches were taken to educate the nation about HIV and how to prevent it. Leaders of the national program and the few behaviour change communication (BCC) staff gave numerous talks to different organizations and community groups as well as media interviews. There were regular mass media campaigns promoting prevention messages and condoms and combating common myths. The community outreach workers throughout the island played an important role in reminding persons about HIV, how it spread and how to prevent it especially consistent condom use. It became clear that the outreach workers needed to place more emphasis on doing condom demonstrations and promoting condom use and negotiation skills. Regular debriefing and training sessions with these community outreach workers were essential as was close supervision which was frequently not available. From the outset it was recognized that social norms in relation to sexual behaviour needed to change if the HIV epidemic was to be controlled. Cultural approaches were considered to be essential towards this end, alongside the mass media campaigns and education programs. Music, entertainment and drama were identified as important ways to reach the public. Many popular entertainers including Yellow Man, Shabba Ranks, Buju Banton, Lady Saw, Tony Rebel and more recently Wayne Marshall and others supported the safe sex message or did popular songs promoting condom use. The association “Artists against AIDSâ€? was formed and Buju Banton set up a foundation to raise money for children with AIDS. The Association of Sound Systems, led by Louise ---------, prepared a dub plate of reggae songs and DJs supporting 175 HIV in the Caribbean: A Systematic Data Review 2003-2008 condom use and encouraged their members to play them at dances. For many years concerts were arranged on World AIDS Day in an effort to use music to reach people. Drama has been seen as an important medium to get the message across. The outstanding “edutainmentâ€? group Ashe founded by Joseph Robinson got its start through the HIV program. Over the years Ashe has done hundreds of performances in schools and communities across Jamaica and abroad to educate young people about HIV. Early in the epidemic the renowned playwright Trevor Rhone worked with the program to produce an educational video depicting the story of a migrant farm worker who developed AIDS. The play by Trinidadian Godfrey Sealy “One of my sons is missingâ€? was performed in Jamaica. For several years the annual drama competition facilitated schools performing plays with an AIDS theme. Several playwrights have integrated HIV/AIDS themes into their plays. More recently a play prepared entirely about living with HIV was staged across the island. A number of community drama groups have received support from the program to carry the HIV message. Targeted interventions among vulnerable populations often make use of animators and drama to ensure more effective communication. The annual national debating competition among schools includes a topic on HIV/AIDS. During the first decade or so of the HIV/AIDS response in Jamaica most of the work was conducted by a limited number of professional staff from the Ministry of heath, led by Dr Peter Figueroa who was Principal Medial officer (Epidemiology), and a few NGOs like Jamaica AIDS Support (JAS) and the Jamaica Red Cross. Due to the strong stigma associated with AIDS very few men were willing to be associated with HIV/AIDS control. While Ministers of Health have always supported the national program and been willing to speak on AIDS most of their political colleagues and most civic leaders were unwilling to speak out. Even many health professionals were fearful of being involved in HIV prevention or AIDS care in the first decade of the HIV response in Jamaica. This fear, timidity, ignorance and at times prejudice among many of our leaders limited the scope of the HIV prevention effort and fostered a tendency towards complacency and denial in the population alongside an alarmist or sensationalist manner when dealing with HIV/AIDS matters. Given the hostile environment it was not surprising that very few persons with AIDS would willingly reveal their status to their family or friends and certainly not publicly. Thus the AIDS epidemic was known and feared but remained in many ways invisible and abstract in the sense that it was outside the concrete experience of most people. The prevailing perception was that “HIV infection and AIDS happened to other persons like homosexuals and sex workers and not to a normal person like meâ€?. In any case, many persons who were advised of their risk due to multiple partners or unprotected sex preferred not to know. During the mid to late 1990s the prevailing attitudes began to shift. An important contributor to this was an alliance established by the national program with media managers led by Oliver Clarke of the Gleaner Company. The media generally played a constructive role in educating the Jamaican public and offered the national program an average of 30% discount on the placement of advertisements and media campaigns. Another decisive step was the Government’s decision in 1999 to seek a World Bank loan for HIV/AIDS. The preparatory work took about 18 months and helped to crystallize the Government’s commitment to a strengthened HIV response. Although two thirds of the US$12 million loan over 5 years was for a laboratory information system and infrastructure as well as a modern infectious waste management plant in Kingston, it facilitated a broader HIV response through financial support for five government ministries (Education, Tourism, Labour, National Security and Health) and a range of NGOs including the NAC. The submission of a successful grant to Round 3 of the Global Fund for AIDS, Tuberculosis and Malaria provided the national program with significant resources (US$23 million for 5 years) for HIV treatment and prevention for the first time in July 2004. Prior to the World Bank loan in 2001 and the Global Fund grant the main external funding for the program was from USAID (annual grants of approximately US$1 million since 1988). The national program also benefited from grants from the German (GTZ) and Dutch governments in the initial years as well as the UN agencies and others at different times. 176 HIV in the Caribbean: A Systematic Data Review 2003-2008 In the past five years, with the additional resources, HIV prevention efforts have grown significantly. In addition to general education programs and media campaigns the work among vulnerable groups such as sex workers, MSM, prison inmates and youth as well as vulnerable communities expanded. HIV coordinators and BCC staff were placed in the Health Regions which were also funded to carry out HIV work according to an agreed work plan. Scores of workshops were held to train civil servants and persons from various sectors including members of the vulnerable populations. The Jamaica network of persons living with HIV (JN+) was supported financially and some of their members gave personal testimonies in the training workshops to help put a face on HIV. The national program embarked on a major program to promote voluntary counseling and HIV testing (VCT) using a rapid HIV test. The aim was to provide HIV testing with immediate results to all pregnant women, persons with STDs, persons most at risk and all persons wishing to do a HIV test. A major VCT trainer of trainers program was undertaken in association with JPHIEGO. Within three years thousands of health workers and staff from NGOs and other organizations were trained to provide counseling for persons doing HIV tests. Hospitals were encouraged to offer HIV testing on a voluntary routine opt out basis and fairs were held offering free HIV testing to promote the importance of knowing your HIV status. Another important HIV prevention initiative was the introduction of the PLACE (priorities for local AIDS control efforts) methodology to Jamaica. This method targets sites where persons go to meet new sex partners and introduces HIV prevention at these sites. An initial study was done in Montego Bay (Figueroa et al 2003) and then in Kingston where a randomized controlled trial (RCT) was conducted (Weir et al 2007). An adaptation of the PLACE method has now been rolled out island wide with emphasis on prevention interventions targeted at sites where the risk of HIV is greatest such as CSW street sites, night clubs and bars. Prevention measures are planned at three levels: environmental, group and individual including outreach HIV testing. PLACE outreach staff use a variety of innovative interactive methods to engage persons in risk assessment, improving condom use and negotiation skills including doing condom demonstrations and promoting self efficacy and risk reduction. The Ministry of Education has embarked on a program to introduce Health and Family Life Education in all schools. Workshops have been held with the principals and teachers and the HFLE program is being rolled out. A HIV policy and a HIV strategic plan for the education sector have been prepared. A small HIV unit has been set up in the Ministry and a few HIV staff been placed in the field. However, the policy and HFLE program still fail to come to grips with the realities of sexually active school children and fail to adequately prepare the youth to practice safe sex. The Ministry of Labour is in the process of finalizing legislation making it illegal to discriminate against persons living with HIV. They continue to have an active program educating workers traveling abroad for seasonal work. The Ministry of Tourism has conducted HIV education programs among the workers in hotels and the adjoining communities. The Ministry of National Security has introduced a health program for all prison inmates that includes a medical examination, laboratory tests including HIV and syphilis, ARV treatment and HIV prevention education. From the outset of the epidemic the national program worked hard to reduce the strong stigma associated with HIV. A special program of training health staff was established in 1990 to educate them on HIV/AIDS and encourage appropriate attitudes and behaviour. All reports of discrimination due to HIV were investigated and action taken to educate those involved and help persons affected. Many large employers and the government ministries and agencies were generally open to supporting employees with AIDS. Many small businesses were less receptive and often fired staff they thought to have AIDS. Frequently the program was called in to defuse a situation where members of the work force were protesting against someone with AIDS. There were horror stories of persons with AIDS being thrown out by their families or run out of their 177 HIV in the Caribbean: A Systematic Data Review 2003-2008 communities or children being refused entry to school. Jamaica AIDS Support and the Catholic Church in particular were very supportive in offering support and hospice care. Thankfully this situation has been largely transformed and overt discrimination against PLHIV is now unusual. However, the history of discrimination is sufficiently vivid that persons with HIV are reluctant to disclose their status although most people are now supportive to PLHIV. The reluctance of PLHIV to disclose their status to family, friends, neighbours and coworkers is constraining further progress in combating HIV stigma, normalizing HIV and reducing HIV spread. A major mass media campaign against HIV stigma in 2002 showcased several prominent Jamaicans calling on people to accept PLHIV. However, a critical turning point was the “living positiveâ€? media campaign 2004 in which two courageous persons living with AIDS, Ainsley and Annesha, went public with their stories and their images were used on television and billboards “getting on with lifeâ€?. HIV Treatment One of the tragedies of the HIV epidemic was the premature death of so many persons due to AIDS. At first there was no treatment available. Then treatment became available but it was too expensive for most patients or developing countries to afford. When generic ARV drugs first became available neither the World Bank or the Global Fund supported their purchase initially due to the stance of the major pharmaceutical companies and the United States government. The advocacy of AIDS activists and many developing countries, as well as good sense, resulted in the Doha Declaration that gave countries the right to purchase generic ARV drugs to avoid national public health catastrophes. In Jamaica the first challenge was to establish an effective program to prevent HIV transmission from mother to child during pregnancy and childbirth. A pilot program was established in 2001 – 2002 that showed that it was possible using nevirapine at birth (Harvey et al 2004). However, coverage was limited. During 2003 and 2004 coverage of HIV pregnant women who received ARV drugs was increased to 47% in 2004 (Jamaica UNGASS report 2008) through a collaborative program between the Ministry of Health and the UWI led by Prof. Celia Christie and supported by an Elizabeth Glaser Pediatric AIDS Foundation award (Christie et al 2004, West Indian Med J supplement 2004). Subsequently, coverage was increased to over 85% and HIV transmission from mother to child has been reduced from approximately 25% prior to 2000 to 8% or less in 2007. The Global Fund grant was the decisive factor that enabled Jamaica to establish a public access program for ARV treatment of persons with AIDS and advanced HIV disease. Approximately 50% of the grant was devoted to treatment primarily ARV drugs, laboratory monitoring and training. From September 2004, when the public access program began, approximately 100 persons with AIDS or advanced HIV have been put on treatment monthly. As of 2007 an estimated 60% of persons in need of ARV medication are on treatment. This includes all children living with HIV that have been identified through the program to prevent mother to child transmission. The ARV database reveals that 87.6% of all adults and children on ARV treatment in the public sector were still on treatment after 12 months (Jamaica UNGASS report 2008). Death rates due to AIDS have decreased significantly since the ARV public access program. The challenge is to get more persons at risk to be HIV tested so that persons with HIV who are unaware of their status can be placed on treatment. With ARV treatment the number of persons with HIV getting severe opportunistic infections has decreased significantly. However, precise data are not available. HIV Policy A National HIV/AIDS Policy was accepted unanimously by Parliament in 2004. The purpose of the policy is to: 178 HIV in the Caribbean: A Systematic Data Review 2003-2008 Define the framework for an effective multi-sectoral response to the HIV/AIDS epidemic Outline the role of social institutions and promote the involvement of all sectors of society in the national response Affirm the rights and responsibilities of persons living with HIV, of those interacting with them, of people vulnerable to HIV infection and of health care providers Provide a framework for assistance and cooperation from international, regional and national development partners Delineate the mechanisms for effective implementation and monitoring of the policy. The Government has also developed a number of sector policies. The Ministry of Education developed a policy for HIV/AIDS in schools and a Health and Family Life education policy. The Ministry of Labour developed a workplace policy and the Ministry of Tourism developed a HIV policy for the Tourism sector. All these policies are supported by education and training programs in the different sectors coordinated by a senior person designated a HIV focal point for the respective ministry. Business places are also encouraged to develop HIV workplace policies and programs and they are helped to do so through training and technical assistance. The ILO has also provided support for this process. A Parliamentary Joint Committee on HIV/AIDS was established in 2005 and it invited submissions from interested parties and held public hearings. It produced a comprehensive report with many recommendations. The new Health and Safety legislation prepared by the Ministry of Labour includes a provision against discrimination at the work place due to HIV/AIDS. The national program has set up a committee that includes the National AIDS Committee, the Independent Jamaica Council for Human Rights and the Jamaica Network of Seropositives (JN+) to establish a system for monitoring HIV discrimination. A review of legislation has also been done and recommendations prepared. However, successive governments have made it clear that they are not prepared to repeal the Buggery Act or to decriminalize commercial sex work. Health system strengthening The HIV program has also contributed to strengthening the health sector including the national and regional laboratories, the laboratory information systems, the surveillance and information systems, the national blood transfusion service and selected health centres. A modern infectious waste disposal plant has been established in Kingston for the South East Health Region and a system for the management of infectious waste introduced. A range of modern laboratory equipment including Fax counters and PCR machines have been provided. Hundreds of computers have been provided to the national laboratory, the Ministry, the regions and parishes as well as multi-media and other equipment. The program has ensured a supply of laboratory reagents, testing kits, ARV, STI, TB and OI drugs as well as basic office supplies. Several vehicles have been provided to the ministry and health regions and a revolving fund has been established to help contact investigators and other staff purchase cars. Staff capacity has been strengthened at national, regional and parish levels including the employment of behaviour change communication specialists, community and peer outreach workers, HIV coordinators and administrators. Thousands of staff have been trained in HIV/AIDS prevention and care, HIV testing and counseling, STI, TB, opportunistic infections, surveillance, and other related topics. Many staff have received financial support to attend courses locally and abroad including the Masters in Public Health and Masters in Communication. Capacity to develop and implement communication and behaviour change and health promotion programs at national and regional levels has been strengthened considerably. 179 HIV in the Caribbean: A Systematic Data Review 2003-2008 The capacity to mount an effective sectoral response to the HIV epidemic has been established in several government sectors including education, labour, tourism and national security. A number of NGO and other organizations have been strengthened. Conclusion Jamaica has established a comprehensive HIV control program that has definitely slowed the HIV epidemic. General awareness and knowledge of HIV and how to prevent it is high and there has been significant behavour change with respect to increased condom use especially in relation to sex with non-regular partners and commercial sex. However, the pattern of early initiation of sex, multiple partners and transactional sex has changed little. While adult HIV prevalence has been controlled at approximately 1.5% for the past decade HIV rates are considerably higher among vulnerable groups especially sex workers (9%) and MSM (31.8%). Given the strong stigma associated with homosexuality in Jamaica it has proven challenging to establish HIV prevention programs among MSM. A way must be found to address this challenge more effectively. Stigma associated with HIV remains strong though it is considerably reduced and outright discrimination due to HIV is now unusual. However, discrimination and hostility towards MSM remains strong and impairs an effective response to the epidemic among MSM and nationally. Jamaica’s HIV program has shown definite impact in reducing HIV transmission from mother to child (from 25% prior to 2000 to 8% or less in 2007) and in placing 60% of persons with AIDS or advanced HIV on ARV treatment and significantly reducing mortality due to AIDS. 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West Indian Med J Special Issue on Paediatric and Perinatal HIV/AIDS in Jamaica. 2004; 53 (5); 271-365. 184 HIV in the Caribbean: A Systematic Data Review 2003-2008 Netherlands Antilles NETHERLANDS ANTILLES: BONAIRE, CURACAO, SABA, ST EUSTATIUS AND ST MAARTEN The Netherlands Antilles constitute a political federation of five small islands settings within the Kingdom of the Netherlands: Bonaire, Curacao, Saba, St Eustatius and St Maarten. Bonaire and Curacao are situated close to Venezuela in South America but Saba, St Eustatius and St Maarten are situated in the North close to the Eastern Caribbean States. The federal government is based in Curacao as well as the Governor the representative of the Queen of the Netherlands. The total population of the five Netherlands Antilles was 201 366 in 2006 and was distributed as follows: Curacao with 133 644 inhabitants, St Maarten with 50 000 inhabitants, Bonaire with 14 006 inhabitants, St Eustatius with 2 292 inhabitants and Saba with 1 424 inhabitants. The Netherlands Antilles are considered as a major tourist destination and its economy has become more and more dependent on this source of revenue. During the past two years, the Netherlands Antilles have been going through political changes which will affect the future of the federation. Indeed, there seems to be a consensus to break down that federation giving to Curacao and St Maarten the “status apartâ€? status like Aruba is enjoying and the tiny islands of Bonaire, Saba and St Eustatius will be part of the main Netherlands. These changes have had some implication on the federal response to HIV in terms of joint action. 1. Summary of National Strategic Plan: There is no Strategic Plan for the Netherlands Antilles as an entity but two islands Curacao and St Maarten have developed Strategic Plans with specific strategies corresponding to their epidemiological realities. Curacao: the Strategic Plan 2003-2008 has six priority areas: - Advocacy, research, policy development and legislations - Prevention of HIV/STDs - Care and Support of PLHIV - Prevention of HIV/STI among High Risk groups: Sex Workers, Homosexuals, prisoners and immigrants - Strengthening of response capabilities - Institutional Strengthening St Maarten: the Strategic Plan 2007-2011 has outlined four strategic directions: - Advocacy, Policy Development and Legislation - Reducing the risk and vulnerability to HIV infection - Care and Treatment and Support of PLHIV - Surveillance and Research These two Strategic Plans are being implemented by the Health sector and to some extend the Civil Society Organizations. However, national authorities in Curacao have expressed pessimism regarding the outcome of their Strategic Plan which has not received necessary financial and human resources supports needed for its comprehensive implementation leaving NGOs working individually in their areas of interest without proper guidance or sustained use of strategies included in the Strategic Plan. 2. Data Collection Procedures and surveillance systems 185 HIV in the Caribbean: A Systematic Data Review 2003-2008 There are two institutions involved in the confirmatory testing of HIV: the Analytical Diagnostic Center and the Red Cross Blood Bank Foundation. These two play the essential role in the case identification and case reporting mechanisms in the Netherlands Antilles. HIV-monitoring data is collected among patients under care or treatment by the HIV-treating specialists and the pharmacists at the St Elizabeth Hospital. Demographic data or estimates which serve as denominators are provided by the Central Bureau of Statistics and the analysis of data and publication are done by the Epidemiology and research Unit in the Medical and Public Health Service of Curacao. Here again, as it is the case in Aruba, the national reporting system uses a case definition which does not differentiate between cases of HIV and cases of AIDS and reports HIV/AIDS cases. Key information on modes of transmission among reported cases of HIV/AIDS is generally missing. Despite the attempt to address this issue, national authorities remain convinced that it is difficult in an environment of stigma and discrimination which rejects sex trade and homosexuality to get the true mode of transmission from PLHIV. 3. Prevention efforts: past and present, successful and unsuccessful Blood safety is assured through the screening of all donated units of blood at the Red Cross. Universal precautions are observed and policies are in place to assure adherence to these precautions. Health education and promotion programs are ongoing but not developed based on evidence or guided by data and not evaluated to assess their impact. Policies exist for the legal sex work in all the islands, each female sex workers is screened for a series of conditions including HIV and if the result is positive the sex worker is not allowed to trade sex and have to return back home. The “Campo Alegreâ€? site serves as the area for legal prostitution has a regular population of 150 prostitutes and is equipped by a medical team which provides all necessary programs and services a female sex worker may need to protect her during her legal 3 month stay and work in the Netherlands Antilles. However beyond the legal sex trade, there is an illegal prostitution circuit going on especially in Curacao where small bars or “snacksâ€? have become sites for sex trade which is not controlled by the state or under medical supervision. The ad hoc nature of HIV prevention programs targeting young people and the general population, the lack of prevention programs targeting other most-at-risk populations such as MSM and crack-cocaine users and the illegal prostitution rings bring to the conclusion that prevention programs in the Netherlands Antilles may not be achieving their goals. One area of prevention which appears to work well is the prevention of mother-to-child transmission of HIV. The highest number of infants with HIV was in 1990 when 11 cases of HIV were reported among children in the Netherlands Antilles. However, in recent years the number of reported cases of HIV/AIDS among infants remained low between 0 and 2 cases during the period 2000-2007. Table 1: Number of Cases of HIV Reported Among Infants less than 1 year-old: 2000-2007 Year Number of HIV cases among Infants less than 1 year old 2000 1 2001 2 2002 2 2003 1 2004 0 2005 0 2006 0 2007 1 Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles 186 HIV in the Caribbean: A Systematic Data Review 2003-2008 4. Graphs with Trends re epidemiological status A cumulative total number of 1812 cases of HIV/AIDS were reported by the five islands of Bonaire, Curacao, Saba, St Eustatius and St Marten since the epidemic started in 1985 to the end of 2007. National authorities have underlined the fact that 33% of all cases of HIV/AIDS were reported in the last five years and that is a major cause of concern because the epidemic does not appear of peaking after 22 years of evolution. However, it is important to take into account in that situation the fact that there is an increase in coverage of HIV testing among pregnant women during that period to prevent mother-to-child transmission of HIV which has become a routine component of antennal care services. But certainly the concern of national authorities regarding the increasing trend should not be minimized because of the lack of well-structured prevention programs and targeted interventions among the most-at-risk populations. Graph 1 Reported New Cases of HIV/AIDS by Year in the Netherlands Antilles: 1985-2007 120 113 110 102 106 100 96 88 84 89 92 80 80 78 80 82 83 79 79 71 67 65 60 59 54 46 40 20 9 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Y ear s Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles In total 1184 (65%) of all cases of HIV/AIDS were reported from Curacao, the most populous island followed by St Maarten with 579 cases of HIV/AIDS i.e. 32% of all cases. Overall, males represent 57% of all cases and females 43%, the male to female sex ratio varied between islands with the highest ratio observed in St Eustatius at 2.3:1 and the lowest ratio was observed in St Maarten at 1.2:1. Graph 2 187 HIV in the Caribbean: A Systematic Data Review 2003-2008 Reported Cases of HIV/AIDS by Island and by Sex The Netherlands Antilles:1985-2007 Males Females 683 700 600 501 500 Num ber of 322 400 Cases 257 300 200 100 19 13 4 3 7 3 0 Bonaire Saba StMaarten Islands Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles Regarding the trend in reported cases of HIV/AIDS in the Netherlands Antilles, there is a stable trend in general as well as in Curacao; however the trend in St Maarten is an increasing one, bringing national authorities to conclude that there is a growing HIV epidemic in the Northern island of St Maarten. Graph 3 HIV Incidence per 1000 population-Netherlands Antilles, Curacao and St Maarten:2000-2007 Neth.Ant Curacao StMaarten Linear (StMaarten) 1.2 1 0.8 Rate 0.6 0.4 0.2 0 2000 2001 2002 2003 2004 2005 2006 2007 Years Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles Mean Age at HIV Diagnosis: Overall, it appears that the mean age of diagnosis of HIV is increasing the Netherlands Antilles among both sexes, however the increase is clear for females and not for males where is appears to decline in the past three years 2005-2007. Graph 4 188 HIV in the Caribbean: A Systematic Data Review 2003-2008 Mean Age at HIV Diagnosis: Combined-Males-Females, Netherlands Antilles:1997-2007 Combined Mean Age Mean Age for Males Mean Age for Females 50 45 40 35 30 Age 25 20 15 10 5 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Years Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles From this situation analysis, several conclusions were reached by the national surveillance and research unit which are very important to be included here in this report: 1. the chance to find an HIV + female is three times higher that it is for finding and HIV+ male 2. There are three times as many HIV tests performed among females than males 3. When a male is tested his chances to be found HIV+ are three times higher than in females 4. There is an increase in incidence of cases of HIV is due to the increasing trend of HIV among males in St Maarten 5. Curacao is unable to make a dent in incidence rates of HIV/AIDS in the past 20 years These five points have brought national authorities to conclude that: 1. If as many HIV tests would be performed on males as on females, the HIV + male to female sex ratio might well shift which would imply that a more homosexual transmission is taking place than as assumed up to now. 2. There is a better selection among male subjects for HIV testing. Physicians may refer males for HIV testing when there is a suspicion of HIV infection 3. More research is needed to compile data on the reasons of HIV testing for both sexes to come to the conclusion that the presumption of a predominantly heterosexual transmission of HIV is realistic. 5. Care and treatment programs There are no local standards and norms for treatment, generally, guidelines from the Netherlands and the US-CDC are used to manage HIV/AIDS patients. In the Netherlands Antilles, care and treatment services are organized around three physicians (2 in St Maarten and 1 in Curacao), among them two are working in the public sector and one in the private non- profit sector. It is estimated that between 300 and 400 patients are on ART in the Netherlands Antilles. ARV drugs and laboratory support are covered by different kinds of health insurance; however several times stock-outs have been reported in Curacao, these unfortunate events are reflected in the mortality among patients on ART in Curacao during the period 2001-2004 Graph 5 189 HIV in the Caribbean: A Systematic Data Review 2003-2008 Number of deaths due to AIDS in Curacao:1991-2004 35 32 30 25 24 22 22 21 Number 20 19 15 14 15 12 12 10 10 10 9 8 5 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Years Source: Gerstenbluth and Lourents, epidemiology and research unit, MOH, Netherlands Antilles In Curacao, there is an overall decline in number of reported deaths due to AIDS when the period of the 90’s is compared to the 20’s, however, it also is clear that during the period 2001- 2004, there is a gradual slight increase in reported deaths due to AIDS in Curacao. To prevent such an event in St Maarten, national authorities and physicians have mobilized Civil Society Organizations in the Netherlands to develop a parallel mechanism for a continuous availability of ARV drugs. Preliminary results of the HIV Monitoring Multicentric Study targeting patients on ART in the Netherlands and Curacao have demonstrated that among three groups under survey i.e. PLHIV from Suriname, PLHIV from the Netherlands Antilles (Aruba, other islands) who live in the Netherlands and PLHIV in Curacao, the treatment outcome was worse among the latter group. Several reasons could support that observation: - Lack of compliance - Stock-outs and high cost of ARV drugs - Limited availability of laboratory support - Emerging HIV drug resistance 6. Influence of migration There is no data liking migration and HIV epidemic in the Netherlands Antilles. However, looking at the legal sex trade, the prostitutes are nationals of Colombia, the Dominican Republic and other English speaking Caribbean countries. Beyond that aspect of potential impact of immigration through sex trade on the local HIV epidemic, in the case of St Maarten, it is estimated that 2 984 national of the Dominican Republic are living in St Maarten and also nationals of many English speaking Caribbean are accessing treatment on that island (e.g. Anguilla, Haiti, Jamaica, St Kitts and Nevis, etc.) and the booming tourist expansion in St Maarten is also a factor attracting migrants from other Caribbean countries, 7. Data in specific groups: MSM, FSW, Bisexual, pregnant women, DU (injection and non Injection), etc. Despite the fact the introduction of HIV testing among national cohorts of pregnant women for several years, no attempt is made to put that information together and assess HIV prevalence among pregnant women in the Netherlands Antilles. That is a lost opportunity which has to be 190 HIV in the Caribbean: A Systematic Data Review 2003-2008 rectified because it will provide the Netherlands Antilles with very valuable information on this important population group representing the general population for public health action. In 2007, the National Drug Control Program (FMA) estimated that in Curacao alone there were 1 500 addicted people who were classified as “problematicâ€?. However, there is no policy in place to screen people addicted to substance for HIV antibodies despite the link between these two public health issues. Regarding the MSM there is no specific survey conducted among these most-at-risk population groups. Stigma and discrimination against MSM and the lack of public health approach towards FSW population make it impossible to have an understanding of the impact of HIV among these most-at-risk populations and to build public health programs aimed at reducing the spread of HIV among these populations. Screening programs among FSW who are coming through the legal circuit include testing of HIV antibodies, Tuberculosis (Chest X ray and Mantoux/PPD test) and other STIs, but there is no systematic collation and analysis of that information, rather results of that screening process are used “to allow or not to allowâ€? sex workers to stay and work in the Netherlands Antilles. 8. Co-infection STI/HIV, TB/HIV and HepB/HIV There is no national policy promoting or reinforcing the double screening strategy, therefore information on co-infections is lacking in the Netherlands Antilles. However there is a new project called the HIV Monitoring Project which is a multicentric monitoring of patients on ART in the Netherlands and the Netherlands Antilles and assess biologic and virological parameters among them. That project collected also information on occurrence of opportunistic infections among these patients, thus, it has the potential to provide information on co-infections in the future. a. Sexually Transmitted Infections in St Maarten Existing data on STIs is from St Maarten and is based on two reporting systems. The etiological reporting of data which has shown that during the period 2003-2007 the most common STI was Chlamydia (23 cases) representing 56% of all cases followed by gonorrhea (10 cases) representing 25% of all cases and syphilis (7 cases) representing 19% of all cases. However, understanding the limitations of etiological reporting of STI, national health authorities have introduced the syndromic quarterly reporting of several acute conditions including STI and relying on sentinel physicians reporting system. Through that system during the period April to September 2007, a total number of 119 cases of STIs were reported. 108 cases were genital discharge syndrome, 6 cases of genital ulcer disease and 5 cases of other causes. Females were more affected than males, 66% and 33% respectively. This is not a surprise when it is known the genital discharge syndrome is common among females. But, from national authorities’ perspective, seen the number of reported PID (49 cases) the impact of unsafe abortions have to be taken into consideration in this situation. b. Cervical Cancer in the Netherlands Antilles Data reported here is limited in the sense it is not mentioning the cause of these cases of cervical cancer reported by the histology department in Curacao. Preliminary data from that department has shown that for the period 1999-2003 there were 183 cases of cervical cancer with 67 cases of cervix carcinoma, 83 cases of carcinoma in situ and 33 cases of invasive carcinoma. The majority of these cases occurring in women older than 30 years of age. As demonstrated in the table below, during the period January 2008 and June 2008, there were 28 cases of cervical cancer with 75% being carcinoma in situ and 25% invasive carcinoma. Unfortunately no HIV test was done on the cases of invasive carcinoma to determine if an HIV infection was associated to that condition. 191 HIV in the Caribbean: A Systematic Data Review 2003-2008 Newly Diagnosed Cases of Cervical Cancer: Cases diagnosed during 01-01-08 to 17-06-08 Age Group Types and Total Invasive Carcinoma In Situ Total carcinoma 25-29 years-old 0 2 2 30-34 years-old 0 3 3 35-39 years-old 2 7 9 40-44 years-old 0 5 5 45-49 years-old 2 1 3 50-54 years-old 1 2 3 55-59 years-old 0 0 0 60-64 years-old 2 0 2 65-60 years-old 0 0 0 >70 years-old 0 1 1 Total 7 21 28 Regarding the HPV vaccine, the private sector is promoting it and administering it to people who can afford it, there is no policy in place at national level to introduce HPV vaccine as part of public health intervention. 9. Data on human resources issues The general focus is on the political process between the Netherlands and the five islands. Therefore, the human resources issues will be handled depending on the conclusion of that political process which may be that “status apartâ€? for Curacao and St Maarten and the small islands of Bonaire, Saba and St Eustatius becoming integral parts of the Netherlands. Already in St Maarten there was a need for an epidemiologist identified as critical resource to help with data HIV/AIDS collection and analysis and the establishment of a comprehensive surveillance system. National health authorities on both sides Curacao and St Maarten have identified the lack of human resources to carry –out monitoring and evaluation functions are lacking and that there is a need for a monitoring and evaluation unit to be established. 10. Data on stigma and discrimination issues There is no data on stigma at community level, but anecdotes are that stigma and discrimination exist in the five islands as the rest of the Caribbean. In November 2003 a study was carried out on attitudes of health care providers to homosexuality and HIV in the Netherlands Antilles, using the Index of Attitudes towards Homosexuality 9Hudson and Ricketts, 1980) as well as a question from the International Social Survey Program 1998/1999 relating to attitudes towards homosexuals. In the general practitioners survey, 82% of physicians participated in the survey. Analysis showed that homophobia was inversely associated with age. The highest level of homophobic attitudes was noted in Caribbean born practitioners compared with practitioners of other nationalities. Data in this subgroup revealed that tolerance scores that were among lowest internationally. Stigma against PLHIV was low in Saba with 73% favorable responses. Further analysis of data suggests a lack of knowledge about HIV transmission among health care workers persists. This result was confirmed in another study carried out among preclinical students, where the majority overstated transmission risks. 11. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities The assessment of the programmatic response to HIV of the two islands has shown that in Curacao national authorities have been attending only the medical component of the response (diagnosis and treatment of HIV/AIDS and STI) leaving to NGOs to work on other components: 192 HIV in the Caribbean: A Systematic Data Review 2003-2008 prevention, care and support and advocacy. National authorities admitted that this situation resulted into a fragmentation of the national response and a duplication of efforts in many areas e.g. several NGOs are working with young people without any coordination. The local response to HIV in St Maarten appears to be better organized within the Sector Health Care Affairs where there is a well established program which coordinates the implementation of interventions in the public and private sectors. However, here again the medical component of the response appears to be better organized than the public health components. New strategies, new priorities and adjustments: 1. Care and treatment services should be better organized to prevent stock-outs and be community based oriented by getting PLHIV much more involved in reaching out to each other. 2. Prevention programs should be data driven and their impact be measured accurately and regularly. 3. he number of reported cases of cervical cancer is high compare to the Bahamas and Barbados that is making the HIV screening among these cases a priority. 4. The adherence to the “Three Onesâ€? principles is strongly recommended, public health policies regarding double screening should be designed and promoted, and national health authorities should develop quickly comprehensive monitoring, evaluation and epidemiological surveillance systems which will provide them with strategic information to be used for planning, programming and reporting on progress accomplished or challenges. Bibliography 1. 2008 UNGASS Country Report. The Netherlands and Netherlands Antilles. Reporting Period: January 2006-December 2007. 2. Ben Whiteman. Organization of the federal response to HIV. 2008 3. Gerard van Osch. Personal Communications 2008. 4. Population Services International (PSI). Project among sex workers in St Maarten 5. St Maarten HIV/AIDS Strategic Plan 2007-2011 6. Curacao HIV/AIDS/STDs Strategic Plan 2003-2008 7. Carmen Coronel, MD, pathologist, Report on cervical Cancer 1999-2003, draft Report 2008. 8. Carmen Coronel, MD, pathologist, Report on cervical Cancer January-June 2008. Report 2008. nd rd 9. Physician-based Sentinel Surveillance System. 2 and 3 Quarter of 2007. Sector Health Care Affairs (SHCA) 10. Gerstenbluth & Lourents. Summary of HIV/AIDS Situation in the Netherlands Antilles. Epidemiology and Research. 2008 11. Monitoring of HIV Infection in the Netherlands. Stichting HIV Monitoring. 2007 Report. 193 HIV in the Caribbean: A Systematic Data Review 2003-2008 OECS 194 HIV in the Caribbean: A Systematic Data Review 2003-2008 ANTIGUA AND BARBUDA HIV Overview Complied by Dr Marcus Day 10 June 2008 195 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Table of Contents....................................................................................................................... 196 Antigua and Barbuda Review ................................................................................................... 198 Antigua HIV Overview................................................................................................................ 198 CARE AND TREATMENT........................................................................................................... 199 Treatment, care and support.............................................................................................. 199 Provision of ARV ................................................................................................................ 199 Data Collection and Country Surveillance System ................................................................ 200 Monitoring and Evaluation (M&E ....................................................................................... 200 Testing and Diagnosis sites ............................................................................................... 201 Prevention................................................................................................................................... 201 Condom access and use ................................................................................................... 201 Condom access ................................................................................................................. 201 Condom use at first sexual encounter ............................................................................... 201 Condom use with non-commercial sex partner ................................................................. 202 Condom use with commercial sex partners ....................................................................... 202 Rejection of myths about HIV ............................................................................................ 203 Knowledge of HIV prevention strategies............................................................................ 203 PMTCT............................................................................................................................... 203 VCT .................................................................................................................................... 204 PEP .................................................................................................................................... 205 HIV and OI ......................................................................................................................... 205 Care and Treatment ................................................................................................................... 206 Impact of Caribbean migration on local epidemic ................................................................. 206 Specific transmission groups: ................................................................................................. 206 Female / Heterosexual ....................................................................................................... 206 Discordant couples............................................................................................................. 207 Sex Workers....................................................................................................................... 207 Drug Use ............................................................................................................................ 207 Prisoners ............................................................................................................................ 207 Male-to-male sex................................................................................................................ 207 General risk behaviour .............................................................................................................. 208 Alcohol consumption .......................................................................................................... 208 Use of illegal drugs............................................................................................................. 208 Sexual activity .................................................................................................................... 209 Sexual initiation .................................................................................................................. 209 196 HIV in the Caribbean: A Systematic Data Review 2003-2008 Sex before 15..................................................................................................................... 209 Age-mixing at first sexual encounter.................................................................................. 209 Forced sex at first sexual encounter .................................................................................. 210 Youths sexually active in the last 12 months ..................................................................... 210 Youth with multiple sex partners ........................................................................................ 210 Commercial and transactional sex for those who have had sex in the past 12 months.... 210 Non-regular non-commercial sex partners among adults.................................................. 211 Prevalence of HIV co-infection with STIs, TB and hepatitis .................................................. 211 Self-reported Sexually Transmitted Infections (STIs) ........................................................ 211 Impact of stigma and discrimination ....................................................................................... 212 Stigma and discrimination .................................................................................................. 212 Human Rights .................................................................................................................... 214 Provider Stigma.................................................................................................................. 214 Criminalisation of Sexual Offenses in Antigua and Barbuda ............................................. 214 Human Resource Shortages..................................................................................................... 214 References.................................................................................................................................. 216 197 HIV in the Caribbean: A Systematic Data Review 2003-2008 Antigua and Barbuda Review As part of the National Strategic plan for the expanded response to HIV/AIDS in Antigua and Barbuda, the Government through the Ministry of Health aims to: 1. improve the quality of life for all persons living with HIV/AIDS by providing comprehensive care, treatment and support and to 2. reduce the number of new infections through sustained health promotion campaigns and 24 the prevention of mother to child transmission. The AIDS Secretariat housed within the Ministry of Health is the coordinating body for all the HIV and AIDS efforts in Antigua and Barbuda. A National Strategic Plan for HIV/AIDS was completed in 2001 and approved by Cabinet. It extended from 2002 through to 2005 – there is a new plan in the draft that will be in effect from 2008 – 2012. The National AIDS Programmed has been incorporated into the existing public health infrastructure. Along with primary care services, voluntary counseling and testing is carried out at all the health centers, the private medical offices, and hospital laboratories. In keeping with policy, persons requesting voluntary counseling and testing from public laboratories are not required to contribute to the cost of the testing 25 services. Several policies and procedural manuals have been developed to guide the operations of the NAP and provision has been made for the establishment of the Office of an Ombudsman to deal with issues pertaining to workers rights including those associated with HIV 26 and AIDS. 27 The 2001 (2) – 2005 Strategic plan identifies the following six priority areas for addressing the HIV epidemic: • Education and prevention • Policy and legislation • Treatment, care, and support • Employment and social mobilization • Surveillance, epidemiology, and research • Program coordination and management. And has the following six priority program areas: • Program design, implementation, evaluation, and management • Advocacy, human rights, policy development, and legislation • Provision of treatment and care for PLHIVs • Prevention of HIV among the general population • Prevention of HIV among vulnerable groups (including youth) • Prevention of mother-to-child transmission of HIV and AIDS. Antigua HIV Overview The United Nations Children’s Fund (UNICEF) estimates the HIV and AIDS prevalence rate to be 28 2 percent in Antigua and Barbuda. But this seems high. In fact a review of existing reports show a discrepancy in HIV prevalence rates leading to the conclusion that no one really knows. 24 http://www.ab.gov.ag/gov_v2/government/news/news2005/news_2005dec01_id1.html 25 UNGASS 2005 as reported in Measure Evaluation 2007 26 UNGASS 2008 27 UNGASS 2005 as reported in Measure Evaluation 2007 28 United Nations Children’s Fund (UNICEF). Antigua and Barbuda. Available at 198 HIV in the Caribbean: A Systematic Data Review 2003-2008 Determinants of the epidemic include multiple sexual partners, sex workers, sex tourism, inconsistent condom use and underlying psycho-social and economic factors, which include an increasing migrant labour population; mobility among native Antiguans; interest in high-end 29 commodities which stretch earning power; an economy rooted in tourism; and gender inequalities. The Measure Evaluation HIV and AIDS Service Provision Assessment (HSPA) identified areas for further capacity building, particularly in program implementation monitoring; data management; and tracking ongoing advocacy, rights, and policy developments. Currently, among the 4 facilities that offer care and support services to HIV and AIDS clients, records and client registers are not found consistently across all eligible service units. None had client records/charts observed in all eligible units, although 50 percent had registers with HIV- and AIDS-related client diagnoses observed in some of the eligible service units within the facility. The one facility offering ART had no observed records indicating the number of clients receiving ARV treatment nor did it submit any reports for ART services. This reflects the need for a confidential record-keeping system. Currently a HIV care coordinator could be tracking this information informally because of the fear of exposing sensitive information on individual clients through the routine record-keeping system. While the lack of a formal system may work now, as Antigua and Barbuda scales up its HIV and AIDS programming, a confidential record-keeping system will be required across service delivery units. CARE AND TREATMENT 30 Treatment, care and support In the UNGASS report for 2008 the following challenges were encountered in implementing activities of the NAP 1. Fragmented treatment and care services for PLHIV especially in the areas of monitoring and follow-up care. 2. Breaches in confidentiality regarding disclosure of HIV status. This acts as a deterrent for HIV testing and for treating HIV-positive persons with ARV drugs. 3. Lack of youth-friendly services. 4. Low uptake of HIV testing, with more women than men being tested. 5. Unwillingness of male and female sex workers to attend clinics for VCT services. 6. Lack of knowledge about OVC. 7. Under-use of VCT services by nationals. 8. Limited number of trained staff to provide ART services and a low number of HIV positive clients accessing available services. Provision of ARV The one facility that offers ART services reported no provider trained in prescribing ART, ordering and/or prescribing laboratory tests for monitoring ART, or medical follow-up for ART. There was one trained provider in adherence counseling who reported being trained by CHART. Fifty percent of the 4 facilities providing care and support services (CSS) to HIV and AIDS clients offer http://www.unicef.org/infobycountry/ (accessed November 5, 2006). (as reported in Measure Evaluation 2007. 29 UNGASS 2008 30 UNGASS 2008 199 HIV in the Caribbean: A Systematic Data Review 2003-2008 TB diagnostic or treatment services. None of the facilities had all the first-line TB medicines available. None of the 8 public facilities with an HIV testing system offered protein supplementation along with nutritional rehabilitation services. Thirteen percent offered IV 31 treatment of fungal infections. Data Collection and Country Surveillance System There are 7 service sites across the 4 facilities offering care and support services (CSS) for HIV and AIDS clients. Of the public facilities surveyed that provide CSS, 50 percent were observed to have registers to track HIV and AIDS-related client diagnoses in any eligible outpatient and/or inpatient clinic or unit. However, no individual client records/charts were observed across all 32 eligible units nor was a confidentiality guideline found in any of the facilities Number of blood units collected and screened – 2006 and 2007* 2006 2006 2007 2007 Source of Blood HIV+ Blood HIV+ referral screened screened Blood donor 1014 2 739 2 STI Patients 239 10 157 3 Ante-natal 583 7 467 2 Insurance 1257 42 955 39 33 Source: AIDS Secretariat, Ministry of Health 34 Monitoring and Evaluation (M&E) Findings 1. Lack of a Monitoring and Evaluation System which will provide technical assistance to ministries and agencies to maintain applications of Operational and Procedural manuals; as well as provide quality management of information. 2. Lack of evidence-based information. 3. Absence of progress reports of the NAP. 4. Lack of funds to conduct research associated with vulnerable and at-risk groups including orphans and vulnerable children in the population. Recommendations In Antigua and Barbuda, monitoring and evaluation of the NAP is limited and inadequate as there is no comprehensive M&E system in place. There is therefore an urgent need for technical assistance: 1. To develop a comprehensive M&E system; 2. To train staff in all aspects of monitoring and evaluation such as use of M&E tools; data analysis; understanding indicators and data sources and the use of relevant software.. The tracking of client receipt of pre- and post-test counseling and test results is inconsistent, with only 13 percent of the 8 facilities that offer counseling and testing having observable records 31 Measure Evaluation 2007 32 Measure Evaluation 2007 33 As reported in UNGASS 2008 34 As reported in the UNGASS 2008 200 HIV in the Caribbean: A Systematic Data Review 2003-2008 indicating that clients received pre- and post-test counseling and test results. Fifty percent of the 35 8 facilities submitted any reports for HIV testing services. Testing and Diagnosis sites, shows that among the 8 facilities that have an HIV testing system, 38 percent offer STI services, 25 percent offer TB diagnostic or treatment services, 50 percent offer treatment for opportunistic infections for HIV and AIDS clients, and 25 percent provide palliative care for HIV and AIDS clients. Since malaria is not a widespread problem, only 13 percent of the facilities with an HIV testing system in place offer malaria treatment services. It is also not surprising that most of the VCT sites are located in the parish of St. John’s, as this is where all the laboratories and hospital facilities are situated. A large proportion of the population works and resides in and around St. John’s. Of the 4 facilities (and at 7 sites across these facilities) offering CSS for HIV and AIDS clients, 50 percent had a record system for individual client appointments observed in all relevant program sites of the facility, although they may be present in some (but not all) of the sites in the other facilities. In only 25 percent of the facilities offering CSS were guidelines/protocols for treating opportunistic infections observed in all relevant sites within the facility. Guidelines/Protocols for symptomatic palliative care were observed at all sites in 25 percent of the facilities, and only in 25 percent of the facilities were guidelines/protocols for the care of children and adults living with HIV 36 and AIDS observed in all relevant sites within the facility Prevention 37 Condom access and use Condom access More than 9 out of 10 of all interviewees adults and youth could identify a place where condoms can be obtained. Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. 40% of the adults in Antigua and Barbuda reported being able to obtain condoms within one hour of their home or workplace. Generally, respondents preferred to obtain condoms at shops or pharmacies. There were some common gender differences, for example, in all surveyed countries, more males than females cited ‘shop’ as a preferred place to obtain condoms. 38 Condom use at first sexual encounter About ½ of young males (53%) and 64% of the young females surveyed reported using a condom during their first sexual encounter 35 Measure Evaluation 2007 36 Measure Evaluation 2007 37 CAREC 2007 38 CAREC 2007 201 HIV in the Caribbean: A Systematic Data Review 2003-2008 39 Condom use with non-commercial sex partner Respondents were asked about sex with different partner types and about the frequency of their condom use with each partner type. Consistent condom use is defined here as using a condom “every timeâ€? with the specified partner type. Across all countries, more than half of the respondents reported using a condom the last time they had sex with a non-commercial partner. However this still shows that there are still significant numbers of young people not using condoms in these potentially high-risk partnerships. Condom use at last sex was consistently higher amongst males compared to females (M 73%, F 40%). Among adults condom use was also reported higher among males 64% then females 26%. This highlights an important gap with women almost ¾ of the females engaging in unprotected sex with casual partners. 40 Condom use with commercial sex partners The findings show that Antiguan males had a 94% rate of condom use at last sex with a commercial partner. These results should be interpreted with caution as the denominators are quite small, with 34 males and 1 female reporting having had sex with commercial sex partners in the last 12 months. It is expected that there was strong potential for response bias to questions on illegal activities, such as engagement in commercial sex. Internationally, this indicator is usually calculated for males only, but in this BSS, the question was also posed to female respondents. The results are surprising and interesting, with much lower condom use rates reported by females compared to males. Although the question did not specify if the respondent was the client or the commercial sex worker, the assumption can be made that these young women were more likely the recipients of the money and therefore not in a strong position to negotiate condom use. Consistent condom use among males was 86% These numbers should be interpreted carefully as the denominators are very small, n= 22 reporting having had sex with commercial sex partners in the last 12 months. Prevention activities continued in the following areas: social marketing of condoms; school-based AIDS education for youth; Voluntary Counselling and Testing; programmes for sex workers, MSM and other most-at-risk populations; blood safety; PMTCT; and programmes to ensure safe injections in health care settings; and programmes for men who have sex with men. A mechanism to ensure that PLHIV receive appropriate medical care, home care and supportive 41 palliative care has been developed. The PAHO Health in America report stated that in the period 2003–2005, HIV prevention programmes included a social marketing program on condoms (funded by and operated by Population Services International (PSI)) , school-based AIDS education for youth, programs to ensure safe injections in health care settings, programs for men who have sex with men (funded 39 CAREC 2007 40 CAREC 2007 41 UNGASS 2008 202 HIV in the Caribbean: A Systematic Data Review 2003-2008 by International AIDS Alliance) CD4 count testing every three months, and public education to 42 address the issues of stigma and discrimination. 43 Rejection of myths about HIV Youth Respondents were asked 1. if HIV could be transmitted through mosquito bites 2. if someone can be infected by sharing a meal with an HIV infected person 3. if a healthy-looking person can be infected with HIV. Most young people surveyed, regardless of their gender, knew that a healthy-looking person could have HIV. Similar proportions of respondents rejected myths about HIV transmission via mosquito bites and by sharing a meal with an HIV infected person. Almost all adults interviewed, regardless of gender, knew that a healthy-looking person can be infected with HIV. In Antigua, one-third believed that HIV could be acquired by sitting on a toilet set after someone who is HIV infected and almost half of survey participants had some misconceptions around HIV transmission. 44 Knowledge of HIV prevention strategies The questionnaire had three questions to assess knowledge of HIV prevention methods – abstinence from sex, having one faithful uninfected partner, and consistent condom use. A composite of the three questions was calculated for an indicator on overall knowledge of the “ABCâ€? of HIV prevention methods. Generally, all three prevention methods were identified by many youth respondents. But overall one-quarter or more of these surveyed adults did not identify the three basic ways of reducing the risk of acquiring HIV infection. Of particular note was that, in this sexually active and reproductive age group, condom use was identified by a smaller proportion of respondents. In Antigua the proportion of 15 – 24 females with overall correct knowledge was higher than male counterparts but these findings highlight the fact that 3 in 10 survey participants did not have comprehensive knowledge of the ABCs of HIV prevention. Similarly the proportion of adult females with overall correct knowledge was higher than males. (M 69% vs F 80%) PMTCT Testing of pregnant women is voluntary in Antigua and Barbuda. In 2006 there were 982 patients seen at Antenatal Clinics and 257 were blood screened for HIV and 244 were provided with pre- 45 test counseling. 6 tested positive for HIV 42 Health in the Americas, 2007, Volume II – Countries www.paho.org/HIA/vol2paisesing.htm 43 CAREC 2007 44 CAREC 2007 45 AIDS Secretariat, Ministry of Health as reported in UNGASS 2006 203 HIV in the Caribbean: A Systematic Data Review 2003-2008 Based on these figures we have a prevalence rate of .61% of all patients (n=982) but a rate of 1.03% when looking only at the women tested (n=583) HIV positive women receiving ARV drugs in the PMTCT programme 2006 2007* No. of patients seen at Antenatal Clinics 982 1,072 No. of patients pre-test counselled for HIV 244 187 No. of patients tested for HIV 257 186 No. of patients testing positive for HIV 6 5 No. of patients on ART 5 3 * Jan. – Sep. Source: AIDS Secretariat, Ministry of Health The PAHO Health in America Country report states that PMTCT programme continues in which 99% of pregnant women are tested for HIV and those testing positive receive antiretroviral drugs free of cost. This though is at odds with what was reported in the 2008 UNGASS report. That report states that the testing of pregnant women is voluntary in Antigua and Barbuda. In 2006 there were 982 patients seen at Antenatal Clinics and 583 (59%) were blood screened for HIV while only 244 (25%) were provided with pre-test counseling of. 7 (1.2%) of the 583 tested 46 positive for HIV . HIV-positive mothers are given infant formula and discouraged from breast- feeding. There is a need to strengthen PMTCT services in Antigua and Barbuda. HSPA data show that only 20 percent of the five public facilities surveyed provided all four items of the minimum package of PMTCT (pre- and post-test counselling and HIV testing services, ARV prophylaxis to 47 prevent MTCT, infant feeding counselling, and family planning counselling or referral). The greatest challenge to tracking PMTCT service delivery is in tracking ARV treatment among pregnant women. None of the five facilities offering any PMTCT services could provide records of all items for routine record-keeping for these services. None of the facilities in Antigua and Barbuda offered PMTCT+ services VCT The 2008 UNGASS reports VCT services are available at all community health centres, private medical offices and laboratories of the hospitals in Antigua and Barbuda. Free HIV testing is provided at the public laboratory and is available for all pregnant women and their partners. Standard drug kits for managing STI are provided by the Ministry of Health. Condoms are available free of cost at government health centres, and the AIDS Secretariat. They are sold at pharmacies, supermarkets, places of entertainment, the Antigua Planned Parenthood Association 48 and through PSI/SFH More training is required to address prevention program areas. Antigua and Barbuda scales up its VCT programs and creates a greater demand for counselling and testing, more access (more facilities with an HIV testing system in place) and additional and/or more recent training for providers in pre- and post-test counselling and PMTCT will be required. The availability and supply of STI medicines and other STI services should also grow to meet increased demand. At the time of the HSPA, all facilities offering STI treatment services had all STI medicines available. 46 AIDS Secretariat, Ministry of Health as reported in UNGASS 2006 47 Measure Evaluation 2007 48 UNGASS 2008 204 HIV in the Caribbean: A Systematic Data Review 2003-2008 PEP Although PEP is available at 8 of the 9 public facilities surveyed (all of which were in Antigua), the availability of PEP medicines is very limited. PEP medicines were observed at only 13 percent of the facilities, even though 89 percent reported that the staff has access to PEP. PEP guidelines are available in 63 percent of the facilities where staff prescribes PEP, but only in 13 percent of 49 the facilities are there records for monitoring records/registers of staff receiving PEP HIV and OI Of the 9 public facilities surveyed, 89 percent have an HIV testing system, 33 percent provide STI services, 22 percent offer TB diagnostic or treatment services of any kind, and 11 percent reported offering malaria treatment services. Of the 9 public facilities, 44 percent offer treatment 50 for opportunistic infections for HIV and AIDS clients, and 22 percent offer palliative care. Clinic data showed that in 2001–2003, the three leading sexually transmitted infections were 51 syphilis (195), candidiasis (117), and gonococcal infection (111). Of the nine facilities in Antigua and Barbuda, none report having a TB DOTS strategy or being a part of the national program. 52 Only one of the nine public facilities surveyed reported that it provides ART .This facility did not report having an ART director. Capacity in ART service provision is likely challenged by the relatively limited number of staff and the low number of HIV-positive clients accessing services. For the purposes of this assessment, ART is defined as: prescribing ART; medical follow-up for ART clients; or ordering/prescribing lab tests to monitor ART Of the 4 facilities that reported offering care or support services, all offer treatment for opportunistic infections (such as oral thrush) for HIV and AIDS clients, and 50 percent offer palliative care for HIV and AIDS clients. From the health worker interviews, there are 19 providers who work in the facility that offers ART services. Of those 19, only one provider reported having received training in ART adherence counselling in the last year and that training was done by CHART. None reported having been trained in medical follow-up for ART or ordering and/or prescribing lab tests for monitoring ART in the past year. During the period 2001-2005, there were 16 cases of TB, 5 of which were in HIV-positive 53 persons. Two out of the nine facilities surveyed in 2006 provided TB services, none offered DOTS and one facility indicated that only follow-up treatment was performed. In the absence of additional information on TB and HIV co-infection, it is difficult to report on this indicator. If a patient with malaria were to present themselves to the health system for 49 Measure Evaluation 2007 50 Measure Evaluation 2007 51 Health in the Americas, 2007, Volume II – Countries www.paho.org/HIA/vol2paisesing.htm 52 Measure Evaluation 2007 53 Health in the Americas, 2007, Volume II – Countries www.paho.org/HIA/vol2paisesing.htm 205 HIV in the Caribbean: A Systematic Data Review 2003-2008 care, there is one facility that reported offering malaria treatment services, and it had observed malarial medicines. However, there was no malaria treatment protocols observed in all treatment 54 sites Care and Treatment Antigua and Barbuda is substantially lacking in facilities that provide advanced-level services for HIV and AIDS. This lack of availability is noticeable in all areas except PEP available to staff. Eleven percent of the public facilities reported offering paediatric AIDS care. Only 22 percent of the public facilities offered nutritional rehabilitation services, and none of these offered fortified protein supplementation (FPS). 25 percent of the 8 public facilities with an HIV testing system in place offered nutritional rehabilitation services. None of the facilities offered fortified protein supplementation along with nutritional rehabilitation services. Thirteen percent of the public 55 facilities that have an HIV testing system in place offered IV treatment of fungal infections. Impact of Caribbean migration on local epidemic There is a steady inflow of immigrants and, in 2001, this inflow represented 21.3% of the 56 population. With the creation of the CARICOM Single Market and Economy (CSME) in 1989 to advance integration and promote economic growth in the region, there has been an anticipated increase in the migrant labour. Such population mobility is likely to increase the spread of HIV and burden the HIV and AIDS response and treatment. It has been reported elsewhere that because of high levels of stigma and discrimination, people often seek services outside their own health districts to remain anonymous. It is well known that people travel long distances, even to other countries, for care and treatment of HIV. This underlines the need not only for urgent measures to reduce stigma, but also the importance of having quality services available throughout the region. However from the HSPA, Table 3.2.3a does not indicate this happening in Antigua and Barbuda for ART services. Of the nine facilities sampled, only one reported offering ART service and there none offered services to residents of other countries. However, for PMTCT, only one facility reported that they had provided services to people from other countries in the Caribbean. Mechanisms to track movement of PLHIV around the region are not currently in place. This makes it difficult to assess migration for health services. Specific transmission groups: Men who have sex with men, including bisexual, Female / Heterosexual The AIDS Secretariat recently announced that the number of HIV cases among young females in the country is increasing. According to AIDS Program Manager Janet Weston, available data show that more young girls, some as young as age 14, are being diagnosed with HIV. This was attributed to sexual relationships between young women and older men. The number of HIV cases among men and women ages 25 to 50 is nearly equal, but more men are being diagnosed 54 Measure Evaluation 2007 55 Measure Evaluation 2007 56 UNGASS 2008 206 HIV in the Caribbean: A Systematic Data Review 2003-2008 57 with HIV in the 50 and older age group, the data showed. Discordant couples No information was available on discordant couples Sex Workers The economy depends heavily on tourism for foreign exchange, employment and government revenue. This dependence, coupled with the introduction of casinos and gambling spots, has 58 resulted in the growth of sex work. In 2007 the Minister of Social Affairs in a personal conversation with me estimated that there was about 3000 sex workers from the Dominican Republic in Antigua. Drug Use We are trying to secure a copy of a report cited in Antigua’s UNGASS 2008 report entitled “The Link between Drug Use and HIV/AIDS among Young People in Antigua and Barbuda: A Semi- Qualitative Research Study. 2003â€?. Alcohol use among young people is high with a 60+% lifetime use among 11-14 age group while 59 marijuana and solvent use for the same age group was less the 20%. This shows very early initiation into substance use which is important especially with alcohol’s dis-inhibiting effect. Prisoners In 2005, Antigua and Barbuda’s Ministry of Health, Sports, and Youth Affairs; Her Majesty’s Prison; and CAREC conducted a two day survey on HIV seroprevalence among male inmates in the prison. In addition to determining the HIV prevalence rate, the survey aimed to provide evidence to support the development of expanded, confidential, voluntary counselling and testing; prevention education; and care and treatment for incarcerated HIV positive males. Of 163 male inmates, 100 (61%) participated in the survey. The mean age of the participants was 32 years, with the youngest being 15 years and the oldest 66 years. Three inmates tested positive for HIV 60 for a prevalence rate of 3.0%. 61 Male-to-male sex 57 http://www.medicalnewstoday.com/articles/106044.php 58 UNGASS 2008 59 CICAD, Antigua and Barbuda - National Drug Survey of High School Students, 2007 60 Pan American Health Organization. 2007 Health in the Americas, 2007 61 CAREC 2007 207 HIV in the Caribbean: A Systematic Data Review 2003-2008 The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. The percentage of men who reported sex with men was less than 1%. These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report. 62 General risk behaviour This section is assesses general risk behaviours that may be associated with influencing risk for HIV. Participants were asked about their consumption of alcohol, use of illicit drugs and history of sexually transmitted infections (STIs) in the 12 months preceding their interview. Answers can provide a picture of safe/high risk behaviours that may put respondents at risk for HIV by having unprotected sex. 63 Alcohol consumption Daily alcohol consumption amongst surveyed youths appeared to be low. Overall, male youths were more likely to report alcohol consumption on an every-day basis than young females. There was a notable gender difference for every-day consumption of alcohol by adults with more adult males than adult females reporting alcohol consumption everyday. 6% of the adult male vs 1% of adult females survey participants reported drinking alcohol at least once a week; again there was a gender difference with more males than females reporting this frequency of alcohol consumption. Approximately half of interviewees reported drinking alcohol less than once a week or never. The majority of people interviewed reported drinking alcohol less than once a week or never. 64 Use of illegal drugs Young males were more likely to report using marijuana than female youths Among males, marijuana use in the 30 days preceding the interview was 31% by comparison, marijuana use among females was only 4%. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders Compared to adult females, a higher proportion of adult males reported ever trying marijuana and marijuana-use in the last month. The data indicate that approximately one-third of male interviewees had ever tried marijuana, with a smaller proportion (10%) having used this drug in the month preceding the interview. 62 CAREC 2007 63 CAREC 2007 64 CAREC 2007 208 HIV in the Caribbean: A Systematic Data Review 2003-2008 Very few survey participants reported using crack and cocaine (M 1%, F <1%), ever and in the last month. These results may not be reflective of reality as it is likely to be under-reported due to the illegal nature of the activity. 65 Sexual activity These indicators measure sexual activity among young people. Typically, young people have partnerships that are more often of short duration and perhaps less formal than those of older people. Moreover, they are less likely to live with their sexual partners, and this can often result in one of the partners having additional concurrent partners, thus increasing the risk of infection. Data are presented for indicators around sexual debut (age, age mixing and forced sex) and indicators of recent sexual activity (sexual intercourse, number of partners, commercial sex and sex between men, in the last 12 months). Among adults the findings showed that approximately eight out of ten males and females were sexually active in the last 12 months. 66 Sexual initiation More than half of the youth surveyed reported having ever had sex. More male youths were sexually experienced compared to their female counterparts, For young males, the percent of sexually active respondents was 80% in Antigua and Barbuda and 47% for females 67 Sex before 15 In Antigua 48% of young males vs 5% of young females reported having sex 48%, F 5% All 25% 68 Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. For young women in particular, sex with older men is often risky because young women lack the power in the relationship to negotiate safe sex. It is also an efficient means of spreading HIV infection, 65 CAREC 2007 66 CAREC 2007 67 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 68 CAREC 2007 209 HIV in the Caribbean: A Systematic Data Review 2003-2008 since, for physiological reasons younger women are more likely to become infected. Each sexual act with an infected man carries a higher risk of infection for a young girl, and older men are more likely than younger men to be infected. Age mixing is a term that refers to sexual activity between two partners that are separated by ten or more years in age. For first partner older by 10 years the percentage for all was less then 5%. The proportion whose first sexual partner was between 5 and 10 years older was greater for females 19% vs 6% for males 69 Forced sex at first sexual encounter By gender, female youths (6%) are more likely than young males (5%) to have been forced to have sex during their first sexual intercourse. Even if females are more likely to have reported forced sex, findings show that both genders experienced this form of violence. In addition, with such a sensitive question, respondents may have been unwilling to report being raped due to feelings of fear and/or shame and so these statistics are likely to be under-reported and may represent just the tip of the iceberg. Additionally, the interpretation of this question was physical force, and so does not represent psychological force. 70 Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 62% of the young males and 33% young females were sexually active in the last 12 months. 71 Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 62% of males in Antigua reported having more than one partner while among females 5% reported having more than one partner. The range of non-commercial partners in the last 12 months in Antigua and Barbuda 1 – 20 for males vs 1 - 2 females 72 Commercial and transactional sex for those who have had sex in the past 12 months Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. 12% of the young males vs only 1% of young females reported a engaging in commercial or transactional sex. The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. 69 CAREC 2007 70 CAREC 2007 71 CAREC 2007 72 CAREC 2007 210 HIV in the Caribbean: A Systematic Data Review 2003-2008 When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?" 5% of the males vs 1% of the females reported being paid or receiving gifts. There were no reports of young people giving drugs for sex in Antigua but when asked a similar question of receiving drugs for sex 1% of the males and 3% of the females. It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr Day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. Among adults 8% of the men reported engaging in commercial sex vs less then 1% for females Only 1% of men and women who declared having commercial partners reported receiving money or gifts in exchange for sex in the 12 months preceding the interview. There were negligible reports less than 1% of giving or receiving drugs in exchange for sex. 73 Non-regular non-commercial sex partners among adults Noticeably more adult men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than one non-regular partner in the last 12 months was 24% while among females only 1% reported have non-regular, non commercial sex partner. The number of non-regular, non- commercial partners reported by at least half of surveyed men and women was one, Prevalence of HIV co-infection with STIs, TB and hepatitis 74 Self-reported Sexually Transmitted Infections (STIs) Sexually Transmitted Infections (STIs) are transmitted in the same ways as HIV, and can be prevented by the same safe behaviours being promoted by HIV prevention programmes. Therefore, measures of STI prevalence are a relatively good guide to recent trends in sexual risk behaviour. The surveys assessed self-reported prevalence of genital discharges and ulcers among youths in the 12 months preceding the interview. Among male youths, the reported prevalence rates of 1% for genital discharge while females reported less then 1% while among adults were 7% among males and 3% among females. 73 CAREC 2007 74 CAREC 2007 211 HIV in the Caribbean: A Systematic Data Review 2003-2008 Among male youths, the reported prevalence rates of less then 1% for genital ulcers/sores while no females reported any. This differs little from adults where genital discharge rates among surveyed adult males was less then 1% while females had a rate of 1%> 75 Availability of basic care and support services • Availability of TB medicines at TB service sites and items for sputum test where sputum tests performed. • Inadequate TB services or trained personnel. • In need of recent malaria training. • Sites in need of STI protocols. • Nosocomial infection prevention although practiced in all facilities is not fully available in all sites of facilities. • Low percentage of staff supervised for clinical services in facilities At facilities, there is a lack of protocols and guidelines for opportunistic infections (OI), palliative care, children living with HIV and AIDS, adults living with HIV and AIDS and meningitis 9. Assessment and recommendations for the programmatic response to the HIV/AIDS epidemic. Include thoughts about strategic priorities and resource allocation. Impact of stigma and discrimination “Stigma and discrimination against a person because of their HIV status have reduced the efforts to control the epidemic and are a major cause of the spread of this disease. Stigma can prevent people from negotiating safer sex, taking an HIV test, disclosing their status to their partners or seeking treatment, even when it is available. Discrimination drives the epidemic underground. Many people have been denied their jobs, insurance coverage, work permits and freedom of movement because of their HIV status. Early next year, we will undertake a law, ethics and human rights review in order to review national policy and legislation and address HIV/AIDS 76 stigma and discriminationâ€?. In the Government Policy Statement regarding HIV/AIDS at the Workplace for Antigua and Barbuda, the AIDS Secretariat noted that: “In recognition of the fact that HIV is of a major public health concern with implication for the continuing success of business and the growth and development of our nation, it will be our policy to support an HIV infected employee in a positive and non discriminatory mannerâ€?. It further pointed out that “ No HIV infected employee will be dismissed on the basis of his/her HIV status; HIV testing will not be required as a basis for employment; and every effort will be made to retain an HIV infected employee whose performance is satisfactory for as long as he/she remains well and/or is able to perform his/her 77 duties satisfactorily.â€? 78 Stigma and discrimination The section CAREC BSS uses proxy indicators to assess the level of stigma and discrimination among the target population. Attitudes of the respondents towards people with HIV/AIDS were 75 MEASURE Evaluation 2007 76 http://www.ab.gov.ag/gov_v2/government/news/news2005/news_2005dec01_id1.html 77 http://www.caribbeannetnews.com/2005/04/25/clarifies.shtml 78 CAREC 2007 212 HIV in the Caribbean: A Systematic Data Review 2003-2008 assessed using a series of questions about willingness to have contact with infected people. By the responses gathered from respondents, the majority of surveyed people seemed willing to care for HIV infected relatives. Similarly, more than half of respondents reported being willing to allow asymptomatic HIV infected students and teachers to continue with their school-related activities. It should be noted, however, when this result is considered alongside relatively low experience with HIV positive people, it is possible that this level of willingness was affected by several things. These include the specification in the questions that the person “has HIV but is not sickâ€?, the degree of contact with the HIV infected person was not specified, and respondents may have a desire to appear compassionate to the interviewer (social desirability bias). Questions that specified closer contact with HIV infected people received less favourable answers. In particular, respondents were much less willing to buy food from an HIV infected vendor or shop keeper, indicating a fear of HIV transmission through food. Respondents with accepting attitudes towards persons with HIV/AIDS based on a composite of 5 questions a-e (a) willingness to care for a close male relative who became sick with the AIDS virus (b) willingness to care for a close female relative who became sick with the AIDS virus (c) willingness to buy food from a shopkeeper or food vendor whom they knew was HIV positive (d) thinks a teacher who is HIV infected but not sick should be allowed to continue teaching in school (e) would not want to keep the HIV positive status of a family member a secret. The denominator for individual proportions and the composites is the total number of respondents who have heard of HIV or AIDS The results of this indicator showed that among the youth 96% of the males and 95% of the females interviewed would have discomfort having close contact/associations with people living with HIV infection or AIDS Among adults approximately 7 or more out of 10 respondents were willing to care for HIV infected relatives, to allow asymptomatic teachers and students to conduct their school-related activities, and to allow asymptomatic co-workers to continue working. The figures were lower for willingness to share a meal with an HIV infected person, with approximately 6 out of 10 respondents giving positive responses for this question. Strikingly, 2 or fewer out of 10 respondents reported being willing to buy food from an HIV infected vendor. The trends observed were similar among countries, and between genders in each country. Almost half of respondents reported that they would not want the HIV status of a family member to be kept a secret. The composite indicator for accepting attitudes towards people with HIV infection showed low acceptance of HIV infected people. These low scores were heavily influenced by the low willingness to buy food from an HIV infected shopkeeper or food vendor, which may actually be less a matter of stigma than a reflection that people have fears that HIV can be spread through contact with contaminated food. The results of this indicator showed that most people interviewed (M 8%, F 9% All 8%) would have discomfort having close contact/associations with people living with HIV infection or AIDS 213 HIV in the Caribbean: A Systematic Data Review 2003-2008 Human Rights The Health Hope and HIV Network a local NGO runs a Human Rights Desk, set up to respond to 79 human rights violations against people living with HIV and AIDS in Antigua and Barbuda. Provider Stigma Of 45 health care providers interviewed in public facilities, 51 percent displayed a positive attitude 80 toward PLHIV. Criminalisation of Sexual Offenses in Antigua and Barbuda Sexual intercourse per anum by a male person with a male person or by a male person with a female person as per the Sexual Offences Act of 1995 (Act No. 9) Buggery Article 12 (1) A person who commits buggery is guilty of an offences and is liable on conviction to imprisonment - (a) for life, if committed by an adult on a minor; (b) for fifteen years, if committed by an adult on another adult; (c) for five years, if committed by a minor. (2) In this section "buggery" means sexual intercourse per anum by a male person with a male person or by a male person with a female person. Serious indecency Article 15. (1) "A person who commits an act of serious indecency on or towards another is guilty of an offences and is liable on conviction to imprisonment - (a) for ten years, if committed on or towards a minor under sixteen years of age; (b) for five years, if committed on or towards a person sixteen years of age or more, (2) Subsection (1) does not apply to an act of serious indecency committed in private between – (a) a husband and his wife; or (b) a male person and a female person each of whom is sixteen years of age or more; (3) An act of "serious indecency" is an act, other than sexual intercourse (whether natural or unnatural), by a person involving the use of genital organ for the purpose of arousing or gratifying sexual desire. (This last article is applied also to lesbian acts.) Human Resource Shortages 81 According to a 2001 PAHO report , there was an adequate supply of health personnel, 309 in the public sector and 58 in the private sector. In 1999, there were 10.5 physicians and 33.2 trained nurses per 10,000 population. The specialists among the physicians included two gynecologists, two ophthalmologists, and two pediatricians. The majority of doctors and nurses practice at the general hospital. In addition, Caribbean nationals as well as returning residents supplemented the local health personnel. Staff vacancies were filled by nationals. 79 http://www.antiguasun.com/paper/?as=view&sun=193643128205252008&an=361619099105222008&ac =Local 80 Measure 81 PAHO. 2001. Health Systems and Services Profile of Antigua and Barbuda 214 HIV in the Caribbean: A Systematic Data Review 2003-2008 215 HIV in the Caribbean: A Systematic Data Review 2003-2008 References Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. CICAD, Antigua and Barbuda - National Drug Survey of High School Students, 2007 found at http://www.cicad.oas.org/oid/NEW/en/Caribbean/2007/Antigua%20&%20Barbuda%20School%20 Survey.pdf MEASURE Evaluation 2007. Antigua and Barbuda Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. Pan American Health Organization. 2007 Health in the Americas, 2007, Volume II – Countries found at www.paho.org/HIA/vol2paisesing.htm Pan American Health Organization. 2005. Access to care for people living with th HIV/AIDS. Provisional Agenda Item 4.15 CD46/20 (Eng.): 46th Directing Council, 57 Session of the Regional Committee, 26-30 September. Washington, DC: World Health Organization. Pan American Health Organization. 2003. Scaling up Health Systems to Respond to the Challenges of HIV/AIDS—Latin America and the Caribbean. Washington, DC: World Health Organization. Pan American Health Organization. 2001. Antigua and Barbuda. Available at http://www.paho.org/english/SHA/PRFLANT.htm. Pan American Health Organization. Basic Country Health Profile for the Americas: Antigua and Barbuda. Available at http://www.paho.org/English/DD/AIS/cp_028.htm Pan American Health Organization. 2001. Health Systems and Services Profile for Antigua and Barbuda. http://www.lachsr.org/documents/healthsystemprofileofantiguabarbuda-EN.pdf United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—Antigua and Barbuda 216 HIV in the Caribbean: A Systematic Data Review 2003-2008 COMMONWEALTH OF DOMINICA HIV Overview Complied by Dr Marcus Day 10 June 2008 217 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Table of Contents....................................................................................................................... 218 Commonwealth of Dominica Review ....................................................................................... 220 National Strategic Plan ...................................................................................................... 220 Guiding Principles .............................................................................................................. 220 HIV Overview .............................................................................................................................. 220 CARE AND TREATMENT........................................................................................................... 221 Provision of ARV ................................................................................................................ 221 Data Collection and Country Surveillance System ................................................................ 221 Monitoring and Evaluation (M&E ....................................................................................... 222 Testing and Diagnosis sites ............................................................................................... 223 Testing ............................................................................................................................... 223 HIV Test last 12 months..................................................................................................... 224 Prevention................................................................................................................................... 224 Condoms............................................................................................................................ 224 Condom access ................................................................................................................. 224 Condom use at first sexual encounter ............................................................................... 224 Condom use with non-commercial sex partner ................................................................. 224 Condom use with commercial sex partners ....................................................................... 225 Rejection of myths about HIV ............................................................................................ 225 Knowledge of HIV prevention strategies............................................................................ 225 PMTCT............................................................................................................................... 225 VCT – voluntary? ............................................................................................................... 226 PEP .................................................................................................................................... 226 HIV and OI ......................................................................................................................... 226 Care and Treatment .................................................................................................................. 226 Impact of Caribbean migration on local epidemic ................................................................. 227 Specific transmission groups: ................................................................................................. 227 Female / Heterosexual ....................................................................................................... 227 Discordant couples............................................................................................................. 227 Sex Workers....................................................................................................................... 227 Drug Use ........................................................................................................................... 227 Prisoners ............................................................................................................................ 227 Male-to-male sex................................................................................................................ 228 KAPB with Men who have sex with men............................................................................ 228 218 HIV in the Caribbean: A Systematic Data Review 2003-2008 General risk behaviour .............................................................................................................. 228 Alcohol consumption .......................................................................................................... 228 Sexual initiation .................................................................................................................. 229 Sex before 15..................................................................................................................... 229 Age-mixing at first sexual encounter.................................................................................. 229 Forced sex at first sexual encounter .................................................................................. 229 Youths sexually active in the last 12 months ..................................................................... 230 Youth with multiple sex partners ........................................................................................ 230 Commercial & transactional sex in the past 12 months..................................................... 230 Non-regular non-commercial sex partners among adults.................................................. 231 Prevalence of HIV co-infection with STIs, TB and hepatitis .................................................. 231 Self-reported Sexually Transmitted Infections (STIs) ........................................................ 231 Sexually Transmitted Infection Services and Service-Related Conditions ........................ 232 Impact of stigma and discrimination ....................................................................................... 232 Stigma and discrimination .................................................................................................. 232 Human Rights .................................................................................................................... 233 Provider Stigma.................................................................................................................. 233 Human Resource Shortages..................................................................................................... 233 References.................................................................................................................................. 234 219 HIV in the Caribbean: A Systematic Data Review 2003-2008 Commonwealth of Dominica Review 82 National Strategic Plan The National Response to the HIV/AIDS Epidemic in Dominica is sub-titled ‘Expanding the Response, Reaping the Benefits’. This expanded response is clearly outlined in the National Strategic Plan 2003-2007. Though the Strategic Plan is currently under review (using global tools and technical assistance provided by World Bank and UNAIDS) the guiding principles, goals and purpose have provided the basis for programming over the past five years. This plan consists of six (6) priority areas: 1. Programme Design, Implementation and Evaluation. 2. Advocacy, Human Rights, Policy Development and Legislation. 3. Provision of treatment and care for PLWHA. 4. Prevention of HIV Transmission among the General Population. 5. Prevention of HIV transmission especially among vulnerable groups. 6. Prevention of Mother to Child Transmission. Guiding Principles The life of every individual is precious and valuable. All attempts will be made to preserve the well-being of the individual regardless of his/her health status, sexual persuasion or other personal characteristics. A greater sense of self-esteem and self respect will be fostered among all Dominicans at all times during the expanded response to HIV/AIDS. The scope and intensity of the response to HIV/AIDS will be maintained in keeping with the requirements of the problem. HIV Overview The United Nations Children’s Fund (UNICEF) estimates the HIV and AIDS prevalence rate to be 83 2 percent in Dominica. From the first case of HIV diagnosed in 1987 through the end of 2005, there were 305 persons who tested positive for HIV infection and 148 cases of AIDS were reported to the Surveillance Unit at the Ministry of Health and Social Security in Dominica. Males represent 72 percent of diagnosed HIV cases in Dominica. Except for the 15–19 year old age group, males are diagnosed with HIV and AIDS at higher rates than females in all of the age groups of sexually active Dominicans. The male-to-female ratio for diagnosis is 2.61:1—the highest male to female ratio in the Eastern Caribbean region. Close to 70 percent of all HIV and AIDS cases occur in the 25–44 year-old age group. Less than one percent of all HIV cases and 5 percent of AIDS cases occurred in those 84 under 15 years of age. 85 Since 1987, 120 persons have died from AIDS-related diseases. Men having sex with men were the leading mode of transmission of the disease. 82 UNGASS 2008 83 United nations Children’s Funds. At a Glance, Dominica. As reported in Measure Evalution 2007 84 United nations Children’s Funds. At a Glance, Dominica. As reported in Measure Evalution 2007 85 PAHO 2007 220 HIV in the Caribbean: A Systematic Data Review 2003-2008 CARE AND TREATMENT 86 Provision of ARV The number of PLWH accessing care and treatment is increasing. A total of thirty-nine persons are accessing free antiretroviral treatment out of which twenty-eight are males and 11 females. Prescriptions for antiretroviral therapy are only available from the Clinical Care Coordinator (CCC) in the public health care system. Clients commence antiretroviral therapy based on their CD4 counts and clinical presentation. CD4 count of <350 in an adult and clinical presentation and CD4 count of <24 in a child are the accepted values used to initiate antiretroviral therapy. The Clinical Care team as part of the services being offered provide education and support to patients and or caregivers in order to maintain, and or improve adherence to medication regimens. A variety of antiretroviral drugs are available locally, and drugs are prescribed in various combinations to clients. As a result clients who are infected are able to benefit from both first line and second line medication. These drugs include: Stavudine, Combivir, Neverapine, Efavirenz, Lamudivine Nevirapine, Zidovudine, Kaletra (became available 2005), and in 2006 DDI, Abcavir, and Indinavir became available 87 There is an opportunity to identify scale-up for ART and improve recordkeeping systems. Data Collection and Country Surveillance System • 88 Inconsistent recordkeeping system for client appointments. 86 UNGASS 2008 87 Measure Evaluation 2006 88 Measure Evaluation 2006 221 HIV in the Caribbean: A Systematic Data Review 2003-2008 89 Number of blood units collected and screened – 2006 and 2007 Table 1: Total number of persons testing for HIV within the Government Laboratory for 2006 and 2007 SEX NUMBER (%) OF # testing NUMBER (%) # testing PERSONS positive2006 OF PERSONS positive TESTING FOR TESTING FOR 2007 HIV2006 HIV 2007 Males 490 (20.3%) 8 (57.1%) 372 (18.8%) 12 (85.7%) Females 1899 (78.7%) 6 (42.8%) 1575 (79.8%) 2 (14.2%) Unknown 25 (1%) 0 241 (12.2%) 0 Total 2414(100%) 14 1974 14 Source – Princess Margaret Hospital Laboratory Dominica’s HIV/AIDS prevalence rate stands at 0.75%, with males representing 72% of all diagnosed HIV cases in Dominica In 2006, a total of 2,414 persons were tested at the Government Laboratory at the Princess Margaret Hospital. From this total, 1899 females (78.7%) and 490 males were tested for HIV (Table 1). Sex was not recorded for 25 persons. Among the females testing for HIV in 2006, 1244 (65.5%) were pregnant women. Data from the Government Laboratory suggests that more females were tested for HIV than males. In spite of the greater number of women than men who tested for HIV in 2006, of those who tested positive in that year, 57% were men. However in terms of the number of men who tested for HIV, 1.6% of them tested positive, as compared to 0.3% of women testing positive of all women who tested for HIV in 2006 90 Monitoring and Evaluation (M&E) The National HIV/AIDS Response Programme and the Health Information Unit (HIU) are the key agencies responsible for the functioning of the M&E system. A social worker at the NHRP serves as the Monitoring and Evaluation officer and is responsible for collecting, collating and managing information. This officer works closely with district health teams, private practitioners, the laboratory, the clinical care team, pharmacies, and stakeholders outside the public health system to collect programme monitoring data. Dominica collects information on both national level indicators and donor-based indicators. The HIU is the Management and Information Systems and Surveillance branch of the Ministry of Health (MoH). The Unit has functional monitoring systems in place that monitors and records vital statistics, infectious and communicable diseases and, as such, serves as a critical partner in the development and implementation of the M&E system for HIV/AIDS. Paper-based data collection tools have been developed for use at the primary health care setting, Non-Governmental Organisations and Community Based Organisation to capture information on programmes being implemented. Different types of programme data e.g. VCT and PMTCT are collected on a quarterly basis and stored at the NHRP. This data is then analysed and developed into reports that are distributed to the MoH and relevant donors. Quarterly meetings are held to discuss/share best practices and challenges that are encountered. Information emanating from these reports guides decision making to help improve the services that are being offered. 89 UNGASS 2008 90 UNGASS 2008 222 HIV in the Caribbean: A Systematic Data Review 2003-2008 Overall, data collection is currently reported as both a passive process (sent in by the providers) and an active process (when the M&E officer needs to visit sites to abstract data from sources and records). Periodicity of data collection is largely dependent on the reporting schedules of external donors - for example that of the Global Fund. A Patient Monitoring and Tracking System have been developed to simplify the data collection processes and analysis of key clinical indicators. This system seeks to monitor individual patients from the point of entry into the health care system throughout their lifetime, enabling health care providers to monitor their progress. Dominica has a draft M&E plan that clearly outlines what data needs to be collected, how best to collect it, and how to disseminate and use the results for programme implementation and improvement. The surveillance system is updated every 2 months. The national epidemiologist visits the private and public laboratory to collect the following data: number of individuals tested, and number of HIV-positive clients, their age, address, and date of diagnosis. The epidemiologist enters all confirmed cases and records information into an Excel spreadsheet. The statistician later enters 91 these data into an Access database Testing and Diagnosis sites, - Almost all of the public facilities (15 of 16 surveyed) have an HIV testing system. - Availability of advance care and support services - Good infrastructure for in-patient HIV/AIDS services - There is need for care and treatment services to be scaled-up. - Strong presence of a referral system of home-based care services (HCS) among facilities 92 providing CSS. 93 HIV testing system • Almost all of the public facilities (15 of 16) surveyed have an HIV testing system. • Among facilities with HIV testing systems, only one met all of the requirements for a complete system. • None of the HIV testing system facilities met all of the requirements for counseling or youth-friendly services. • There are three service facilities with a youth-friendly trained counselor. • Overall lack of protocols and policies in place at services sites for informed consent, counseling and youth-friendly services. Testing Testing for HIV is free at the Laboratory once it has been accessed through the government system. HIV is more prevalent among the 15 – 54 age groups. The data reveals that persons from all age groups are accessing HIV testing at the various sampling sites (within the seven Health Districts). However testing is much higher within the female population in the 94 respective age categories 15-19, 20-24 and 25-34 age groups. 91 PAHO 2002 92 UNGASS 2008 93 Measure Evaluation 2006 94 Measure Evaluation 2006 223 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV Test last 12 months Of the respondents ever tested the percentage tested in the past 12 months 95 Dominica, M 49% males vs 56% for females Prevention 96 Condoms Condoms are available at all the hospitals and health centres on the island. The Central Medical stores provide condoms to the district health centres and the hospitals as requested by the pharmacist in that area. According to the “Spot Checkâ€? registry of the NHRP, there were no stock outs of condoms recorded in 2006 97 Condom access More than 9 out of 10 interviewees could identify a place where condoms can be obtained. Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. 79% of the adults surveys in Dominica reported being able to obtain condoms within one hour of their home or workplace 98 Condom use at first sexual encounter Dominican youths, both males (69%) and females (84%) reported the highest levels of condom use at first sex 99 Condom use with non-commercial sex partner Youth Respondents were asked about sex with different partner types and about the frequency of their condom use with each partner type. Consistent condom use is defined here as using a condom “every timeâ€? with the specified partner type. Across all countries, more than half of the respondents reported using a condom the last time they had sex with a non-commercial partner. However this still shows that there are still significant numbers of young people not using condoms in these potentially high-risk partnerships. Condom use at last sex was consistently higher amongst males 83% compared to females 61%. Adult Condom use with a non-regular, non commercial partner in Dominica was reported at 80% for males vs 37% for females. In terms of consistent condom use with casual sex partners, there were similar gender difference. More males than females reported using condoms every time they had sex with non-regular, non- commercial partners in the 12 months preceding the interview. Adult condom use was reported in Dominica amongst males 58% vs 22% for females. 95 CAREC 2007 96 UNGASS 2008 97 CAREC 2007 98 CAREC 2007 99 CAREC 2007 224 HIV in the Caribbean: A Systematic Data Review 2003-2008 100 Condom use with commercial sex partners Young Dominican males had the highest reported condom use rates at last sex with a commercial partner (100%). Consistent condom use with these high-risk partners was also high in Dominica (100%). Adult males had a similarly high use of 85% with an n=26 These results should be interpreted with caution as the denominators are quite small, with 15 young males / 26 adult males and no females reporting having had sex with commercial sex partners in the last 12 months. It is expected that there was strong potential for response bias to questions on illegal activities, such as engagement in commercial sex. 101 Rejection of myths about HIV BSS Respondents were asked 4. if HIV could be transmitted through mosquito bites 5. if someone can be infected by sharing a meal with an HIV infected person 6. if a healthy-looking person can be infected with HIV. Most young people surveyed, regardless of their gender, knew that a healthy-looking person could have HIV. Similar proportions of respondents rejected myths about HIV transmission via mosquito bites and by sharing a meal with an HIV infected person. Likewise almost all adults interviewed, regardless of gender, knew that a healthy-looking person can be infected with HIV. 102 103 Knowledge of HIV prevention strategies PMTCT The purpose of the PMTCT programme is to reduce mother to child transmission of HIV in Dominica through: - Primary prevention of HIV among prospective parents. - Prevention of unwanted pregnancies among HIV infected women. - Prevention of HIV transmission from HIV infected women to their infants. The principles that are being used in the provision of Mother to child transmission in Dominica are based on the following: - The most effective approach to preventing vertically acquired infection in children is through primary prevention among women of childbearing age. - High quality and accessible voluntary counselling and testing services are necessary prerequisites for a successful PMTCT Programme. All testing are accompanied by pre and post-test counselling conducted under conditions that ensure privacy and confidentiality of information. - All HIV infected pregnant women are given access to high quality PMTCT care and services. Once a pregnant woman is found to be HIV positive, care is provided to preserve and improve the 104 health of the woman, as well as to decrease the risk of transmission to the infant. 100 CAREC 2007 101 CAREC 2007 102 CAREC 2007 103 CAREC 2007 104 UNGASS 2008 225 HIV in the Caribbean: A Systematic Data Review 2003-2008 PMTCT sites do not meet all four components; i.e., pre- and post-test counseling and HIV testing services, ARV prophylaxis to prevent MTCT, infant feeding counseling, and family planning counseling or referral. No facility provided ARV therapeutic treatment for HIV+ women and their 105 families or all items of PMTCT+. HIV positive women receiving ARV drugs in the PMTCT programme VCT – voluntary? Among adults who had reported taking an HIV test, it was voluntary for more males than females. 45% of the males in Dominica vs 20% of the females, the implication is that more females had ever had an HIV test compared to males, and 80% of females and more than half of males felt that they had no choice about being tested. PEP • 106 There was a lack of PEP medicines found in health care facilities. HIV and OI • Lack of TB medicines in stock at TB service sites and lack of items in stock for sputum test 107 where sputum tests are performed. • 108 Service sites in need of STI protocols. • 109 Opportunity to increase capacity among providers treating opportunistic infections • At facilities, there is a lack of protocols and guidelines for OI, palliative care, children living 110 with HIV/AIDS, adults living with HIV/AIDS and meningitis. 111 Care and Treatment • Strong presence of a referral system for home-based care services (HCS) among facilities providing CSS. • Good infrastructure for in-patient HIV and AIDS services; although there is opportunity for care and treatment services to be scaled-up. • 112 Availability of advance care and support services • Gaps exist in recent training of health workers in counseling and HIV specific services • Low percentage of staff recently supervised for clinical services in facilities. 105 Measure Evaluation 2006 106 Measure Evaluation 2006 107 Measure Evaluation 2006 108 Measure Evaluation 2006 109 Measure Evaluation 2006 110 Measure Evaluation 2006 111 Measure Evaluation 2006 112 Measure Evaluation 2006 226 HIV in the Caribbean: A Systematic Data Review 2003-2008 Impact of Caribbean migration on local epidemic There are opportunities to address migrants seeking testing, counseling and treatment for 113 HIV/AIDS There are large numbers of Haitian migrants in Dominica where they can more easily blend in because of the common Creole language. Many have settled but many this is a transit point to reach Guadeloupe. Specific transmission groups: Female / Heterosexual The epidemic was largely seen among men in the earlier years, but more recently there have been an increasing proportion of women testing positive. However the number of men testing positive still outnumbers that of women in any given year Discordant couples No data on discordant couples specific to Dominica was found. Sex Workers The NAP in collaboration with COIN conducted a mapping exercise in January 2006 in Dominica to identify the areas in the island where CSWs were concentrated. The findings provided the NAP and the Dominica Planned Parenthood (DPPA) with a baseline to work with this target population. In that same year two professionals attended a training workshop in St. Maarten on HIV/STI prevention strategies for Sex Workers. In 2006, the DPPA in collaboration with the NAP embarked on a series of educational sessions targeting Female Sex Workers (FSWs), which 114 resulted in eleven (11) FSW voluntarily tested for HIV. 115 Drug Use Young males were more likely to report using marijuana than female youths Among males, marijuana use in the 30 days preceding the interview was 17%. By comparison, marijuana use among females was 4%. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders. Compared to females, a higher proportion of adult males reported ever trying marijuana and marijuana-use in the last month. The data indicate that 21% of male interviewees had used marijuana compared to 1% for females. Very few survey participants reported ever using crack and cocaine, (M 4%, F <1%). These results may not be reflective of reality as it is likely to be under-reported due to the illegal nature of the activity. Prisoners 113 Measure Evaluation 2006 114 UNGASS 2008 115 CAREC 2007 227 HIV in the Caribbean: A Systematic Data Review 2003-2008 In May 2005, an HIV Sero-prevalence survey among male inmates was conducted at the National Prison in collaboration with CAREC and the Ministry of Health. The objective of the survey was to determine the HIV prevalence among male inmates, to provide evidence to support the development of expanded voluntary counselling and testing, prevention education, care and treatment for HIV infected and affected persons in the prison. Of the 251 inmates at the time of the study, 191 participated in the survey giving a participation rate of 76 %. The mean age of the participants was 33 years, the youngest being 15 years and the eldest 67 years. The survey 116 revealed that five (5) inmates tested positive for HIV, giving a prevalence of 2.6%. 117 Male-to-male sex The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. In Dominica the proportion of men reporting ever engaging in male-to- male sex was one percent. This is interesting given the fact that 70% of all HIV is found in the male population These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report KAPB with Men who have sex with men The National HIV/AIDS Programme was able to work with this population with the help of a focal point within the group. As a result, in 2004 the NHRP was able to conduct a KAPB study with this group of men who have sex with men. The Findings suggest that men who have sex with men are aware of the means by which HIV is transmitted and the methods and strategies of prevention, however there is a gap between the information they have acquired through 118 educational sessions and what they actually practice. 119 General risk behaviour 120 Alcohol consumption For adults in Dominica 6% of the males vs <1% of the females reporting alcohol consumption everyday For youth – daily drinking was not as common with only 1% of the males and <1% of the females aged 15 – 24 reporting daily drinking. The majority of people interviewed reported drinking alcohol less than once a week or never. 116 UNGASS 2008 117 CAREC 2007 118 UNGASS 2008 119 CAREC 2007 120 CAREC 2007 228 HIV in the Caribbean: A Systematic Data Review 2003-2008 121 Sexual initiation Across all countries, more than half of the people surveyed reported having ever had sex. More male youths were sexually experienced compared to their female counterparts. For young males in Dominica, the percent of sexually active respondents was 81% and 62% for females 122 Sex before 15 In Dominica 36%, of males and 12% of females reported have sex before the age of 15 123 Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. For young women in particular, sex with older men is often risky because young women lack the power in the relationship to negotiate safe sex. It is also an efficient means of spreading HIV infection, since, for physiological reasons younger women are more likely to become infected. Each sexual act with an infected man carries a higher risk of infection for a young girl, and older men are more likely than younger men to be infected. Age mixing is a term that refers to sexual activity between two partners that are separated by ten or more years in age. For first partner older by 10 years the percentage for all was less then 5%.The proportion whose first sexual partner was between 5 and 10 years older was 3% for males and 16% for females as this scenario appeared to be more frequent amongst those surveyed. 124 Forced sex at first sexual encounter By gender, female youths are more likely than young males to have been forced to have sex during their first sexual intercourse. In Dominica 2% of the males and 7% of the females reported being forced to have sex at their first sexual intercourse. Even if females are more likely to have reported forced sex, findings show that both genders experienced this form of violence. In addition, with such a sensitive question, respondents may have been unwilling to report being raped due to feelings of fear and/or shame and so these statistics are likely to be under-reported and may represent just the tip of the iceberg. Additionally, the interpretation of this question was physical force, and so does not represent psychological force (i.e. coercion). 121 CAREC 2007 122 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 123 CAREC 2007 124 CAREC 2007 229 HIV in the Caribbean: A Systematic Data Review 2003-2008 125 Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 63% of the males and 48% females were sexually active in the last 12 months. This indirect measure of secondary abstinence can inform on the impact of education and prevention programmes, which encourage young people to abstain from sex after engaging in early sexual activity. 126 Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 45%, % of males in reported having more than one partner. Among females 16%, reported having more than one partner. The range of non-commercial partners in the last 12 months in Dominica Males 1 – 24 Females 1 - 5 127 Commercial & transactional sex in the past 12 months Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. In Dominica, 5% of males and no females reported this type of exchange. The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?" 3% of males and 1% of females reported this behaviour. There were no reports of young people exchanging drugs for sex A similar question was also asked who received drugs for sex. It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr Day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. In Dominica, 1% of males and 11% of females reported this, This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. The proportion of adult men who reported engaging in commercial sex 9%,vs none for females. No Men who declared having commercial partners reported having received money or gifts in exchange for sex in the 12 months preceding the interview. 125 CAREC 2007 126 CAREC 2007 127 CAREC 2007 230 HIV in the Caribbean: A Systematic Data Review 2003-2008 128 Non-regular non-commercial sex partners among adults Noticeably more men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than one non-regular partner in the last 12 months was 19% while among females1%, The number of non-regular, non-commercial partners reported by at least half of surveyed men and women was one, Prevalence of HIV co-infection with STIs, TB and hepatitis The incidence of tuberculosis did not increase in the period 2001 - 2005 and protocols were 129 developed to facilitate case finding, contact tracing, and treatment regimens. TB Services In addition to providing quality treatment for diagnosed cases of TB, it is advocated that all newly diagnosed HIV-infected persons be screened for TB (and that all newly diagnosed TB patients be screened for HIV). Preventive treatment for TB, using isoniazid (INH) in HIV-infected persons who might not yet have TB but who may have been infected is advocated in some instances, but is not, at present, advocated as a routine intervention. 130 Eleven facilities with 16 service sites offer any TB services . Only 2 of the 11 facilities offer DOTS treatment Nine of 11 facilities report that they perform only follow-up treatment and only 2 of the 11 facilities where TB treatment is offered had an observed TB treatment protocol at all sites, and similarly, 3 of the 11 facilities offering any TB services had all first-line TB medicines available Only 1 facility of the 11 offering any TB services had an observed client register at any site where TB treatment is offered; yet, nine facilities offering any TB services reported that they provide follow-up treatment. Registers would be helpful to any follow-up system for TB. Of the 16 public facilities surveyed, 11 offer any TB diagnostic or treatment services. Nine of the 16 report that they are part of the National DOTS program. Only one had an observed client register and none 131 had a treatment protocol available in all eligible services sites Self-reported Sexually Transmitted Infections (STIs) The number and percentage of positive VDRL blood samples increased each year from 1998 to 132 2001. Sexually Transmitted Infections (STIs) are transmitted in the same ways as HIV, and can be prevented by the same safe behaviours being promoted by HIV prevention programmes. Therefore, measures of STI prevalence are a relatively good guide to recent trends in sexual risk behaviour. 128 CAREC 2007 129 CAREC 2007 130 Measure Evaluation 2006 Table 3.3.3c 131 Measure Evaluation 2006 Table 3.3.3c 132 PAHO 2007 231 HIV in the Caribbean: A Systematic Data Review 2003-2008 The surveys assessed self-reported prevalence of genital discharges and ulcers among youths in the 12 months preceding the interview. Among male youths, the reported prevalence rates of <1%, for genital discharge while females reported 1%, Among male youths, the reported prevalence rates of <1% for genital ulcers/sores while females reported<1%. These low self- reported rates carry a high likelihood of bias and should not be used to represent national STI 133 prevalence. Sexually Transmitted Infection Services and Service-Related Conditions While 13 of the 16 facilities (and 22 STI treatment service sites from among these 13 facilities) offer STI services, an STI treatment protocol was observed in all sites in only one facility (Table 3.3.3f). All STI medicines were available in only one facility. No facility had all the items available for STI services (i.e., observed treatment protocols in all relevant units, STI medicines available, and condoms in any service area or pharmacy). It should be noted that large facilities such as hospitals with multiple service sites may not have all of the items in every site, and hence are penalized by this indicator. In addition, in some facilities one or two people may provide the service at multiple sites and thereby may only have a protocol at one site but not another. The emphasis on STI services appears to be provision of condoms, with 12 of the 13 facilities offering 134 condoms in any service area or pharmacy of the facility. Impact of stigma and discrimination 135 Stigma and discrimination Assessment of the national laws on law, ethics and human rights sought to inform on best practices, and to generate interest in the area of legislative and policy reform to address issues of stigma and discrimination and human rights, geared at reducing the spread of HIV/AIDS. This triggered forums for legal professionals on the topic and general HIV education as it relates to the law. Respondents with accepting attitudes towards persons with HIV/AIDS based on a composite of 5 questions a-e (f) willingness to care for a close male relative who became sick with the AIDS virus (g) willingness to care for a close female relative who became sick with the AIDS virus (h) willingness to buy food from a shopkeeper or food vendor whom they knew was HIV positive (i) thinks a teacher who is HIV infected but not sick should be allowed to continue teaching in school (j) would not want to keep the HIV positive status of a family member a secret. The composite indicator for accepting attitudes towards people with HIV infection showed low acceptance of HIV infected people. These low scores were heavily influenced by the low willingness to buy food from an HIV infected shopkeeper or food vendor, which may actually be less a matter of stigma than a reflection that people have fears that HIV can be spread through contact with contaminated food. 133 CAREC 2007 134 Measure Evaluation 2006 Table 3.3.3c 135 UNGASS 2008 232 HIV in the Caribbean: A Systematic Data Review 2003-2008 The results of this indicator showed that most people interviewed Males 4%, Females 5% would have discomfort having close contact/associations with people living with HIV infection or AIDS Human Rights 136 Law, Ethics and Human Rights. A Law Ethics and Human Rights Assessment was conducted in Dominica in 2006, by a local Magistrate. The consultations on the Law, Ethics and Human Rights assessment aimed at focusing on key areas of law and policy which impact on HIV/AIDS related issues. It sought to inform on best practices and situations in other countries, and made recommendations for a programme of legislative and policy reform to address the issues of stigma, discrimination and human rights in an effort to bolster treatment and care and to reduce the spread of HIV/AIDS. One-on-one sessions for lawyers were conducted for all legal professionals. In this forum the findings of the Law Ethics and human rights assessment was disseminated and other HIV/AIDS related information as it related to the law. Although the Laws of Dominica do not specifically cater for PLWH, PLWH can access legal redress and advice through some members of the legal system, especially those who have been trained in HIV/AIDS. PLWH are provided with information on registration at the Infectious Disease clinic. Provider Stigma • 137 Fifty-four percent health workers surveyed had a positive attitude towards PLHIV In Dominica, of 56 public facilities sampled, 54 percent of providers of HIV and AIDS related services responded with accepting attitudes toward. Since this is only a sample of providers in the country, one cannot make assumptions about attitudes of all providers, but there appears to be a need to sensitize health providers and better inform them. It has been reported elsewhere that health care providers without an in-depth knowledge of HIV 138 transmission hold more stigmatizing attitudes. Human Resource Shortages According to a 2002 PAHO report, the skill mix of medical personnel currently practicing in Dominica does not reflect the government’s stated desire to increase individual health skills and empower communities, but rather supports the provision of curative services. PAHO considers the medical personnel coverage rates to be satisfactory, but distribution is skewed to the capital city and secondary care facility. Twenty percent of doctors practice in the rural communities and 70 percent are located at the secondary care facility. The trend has been to fill physician vacancies by recruiting doctors from 139 overseas under the aegis of French, Cuban and Nigerian Technical Cooperation. 136 UNGASS 2008 137 Measure Evaluation 2006 138 Measure Evaluation 2006 139 PAHO 2002 233 HIV in the Caribbean: A Systematic Data Review 2003-2008 References Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. MEASURE Evaluation 2006. Dominica Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. Pan American Health Organization. 2007 Health in the Americas, 2007, Volume II – Countries found at www.paho.org/HIA/vol2paisesing.htm Pan American Health Organization. 2005. Access to care for people living with th HIV/AIDS. Provisional Agenda Item 4.15 CD46/20 (Eng.): 46th Directing Council, 57 Session of the Regional Committee, 26-30 September. Washington, DC: World Health Organization. Pan American Health Organization. 2003. Scaling up Health Systems to Respond to the Challenges of HIV/AIDS—Latin America and the Caribbean. Washington, DC: World Health Organization. PAHO. October 2002. Health Systems and Services Profile: Dominica. 1st edition. Washington, DC: Organization and Management of Health Systems and Services, Division of Health Systems and Services Development, Pan American Health Organization. Pan American Health Organization. Basic Country Health Profile for the Americas: Dominica at http://www.paho.org United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—Dominica 234 HIV in the Caribbean: A Systematic Data Review 2003-2008 GRENADA HIV Overview Complied by Dr Marcus Day 10 June 2008 235 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Table of Contents....................................................................................................................... 236 Grenada Review ......................................................................................................................... 238 STRATEGIC PLAN ..................................................................................................................... 238 Mission Statement.............................................................................................................. 238 Goal.................................................................................................................................... 238 Objectives .......................................................................................................................... 238 Strategic Priorities .............................................................................................................. 238 Revision of National Strategic Plan.................................................................................... 239 HIV Overview .............................................................................................................................. 239 CARE AND TREATMENT........................................................................................................... 240 Treatment, care and support.............................................................................................. 240 Provision of ARV ................................................................................................................ 240 Data Collection and Country Surveillance System ................................................................ 240 Testing and Diagnosis sites ............................................................................................... 241 Routine data collection for HIV and AIDS .......................................................................... 241 Prevention................................................................................................................................... 241 Condom access and use ................................................................................................... 241 Condom access ................................................................................................................. 241 Condom use at first sexual encounter ............................................................................... 241 Condom use with non-commercial sex partner ................................................................. 242 Condom use with commercial sex partners ....................................................................... 242 Rejection of myths about HIV ............................................................................................ 242 Knowledge of HIV prevention strategies............................................................................ 242 PMTCT............................................................................................................................... 242 VCT .................................................................................................................................... 243 PEP .................................................................................................................................... 243 HIV and OI ................................................................................................................................... 243 Care and Treatment .................................................................................................................. 244 Impact of Caribbean migration on local epidemic ................................................................. 244 Specific transmission groups: ................................................................................................. 244 Female / Heterosexual ....................................................................................................... 244 Discordant couples............................................................................................................. 244 Sex Workers....................................................................................................................... 244 Prisoners ........................................................................................................................... 245 Male-to-male sex................................................................................................................ 245 236 HIV in the Caribbean: A Systematic Data Review 2003-2008 General risk behaviour .............................................................................................................. 245 Alcohol consumption .......................................................................................................... 245 Drug Use and Needle Sharing ........................................................................................... 246 Use of illegal drugs............................................................................................................. 246 Sexual activity .................................................................................................................... 247 Sexual initiation .................................................................................................................. 247 Sex before 15..................................................................................................................... 247 Age-mixing at first sexual encounter.................................................................................. 247 Forced sex at first sexual encounter .................................................................................. 247 Youths sexually active in the last 12 months ..................................................................... 247 Youth with multiple sex partners ........................................................................................ 248 Commercial and transactional sex for those who have had sex in the past 12 months.... 248 Non-regular non-commercial sex partners among adults.................................................. 249 Prevalence of HIV co-infection with STIs, TB and hepatitis .................................................. 249 Self-reported Sexually Transmitted Infections (STIs) ........................................................ 249 Impact of stigma and discrimination ....................................................................................... 250 Stigma and discrimination .................................................................................................. 250 Human Rights .................................................................................................................... 251 Provider Stigma.................................................................................................................. 251 Human Resource Shortages..................................................................................................... 252 References.................................................................................................................................. 253 237 HIV in the Caribbean: A Systematic Data Review 2003-2008 Grenada Review STRATEGIC PLAN In 2001, Grenada began the process of Developing a National Strategic Plan and a plan was created and revised in 2003. During this period the National AIDS Council was created as well as most of the program and health management components of the program. The National AIDS Council (NAC) of Grenada, a multi-sectoral body, is responsible for ensuring the success of the National HIV/ AIDS Programme. It is the coordinating body responsible for the oversight, 140 advisory, policy-making, guidance and accountability for the National HIV/ AIDS Programme. 141 Mission Statement The Mission of the National Strategic Plan is "To reduce the incidence of STI / HIV AIDS in the state of Grenada and provide care, treatment and support for people living with and affected by HIV/AJDS, through the mainstreaming of education, information and other relevant medical, legal, social and economic support’. 142 Goal The primary goal of the Strategic Plan is "To reduce the risk of H1V/AiDS to the general public, while nurturing and developing a caring society where people living with and affected by HIV/AIDS will have adequate and appropriate care to facilitate economically and productive lives consistent with national developmental priorities". 143 Objectives The main objectives to be pursued in the implementation of the Strategic Plan are: • To sensitise the general public on issues related to the spread of HIV/AIDS; • To implement programs and policies to reduce the risk of HIV/AIDS transmission and reduce the impact to the general population; • To promote and provide care, treatment and support to people living with and affected by HIV and AIDS. • To discourage and prevent discriminatory practices against people living with and affected by HIV /AIDS; • To facilitate a multi-sectoral approach to management of HIV/AIDS; • To advocate for the provision of resources to implement HIV / AIDS programs; • And to sustain national development aspirations. 144 Strategic Priorities 140 UNGASS 2008 141 Charles, 2003 142 Charles, 2003 143 Charles, 2003 144 Charles, 2003 238 HIV in the Caribbean: A Systematic Data Review 2003-2008 The Strategic Plan addresses seven (7) Strategic Priorities that need to be addressed in the context of HIV /AIDS in Grenada. These are: (a) Epidemiology, Surveillance and Research (b) Stigma, Discrimination and Human Rights (c) Information, Education and Behavior Change targeted at prevention (d) Treatment, Counselling, Care and Support for people livingwith and affected by HIV/AIDS; (e) Advocacy and Policy Development (f) Resource Mobilization and Program Management (g) Monitoring and Evaluation 145 Revision of National Strategic Plan In 2007, Grenada commenced activities towards the revision of its National Strategic Plan for HIV/AIDS. Towards this end a situational analysis was conducted which included interviews with key stakeholders, a desk-top review and a national house-hold survey. The results of these analyses are currently being used to continue work towards developing a finalized Strategic Plan document in 2008. The strategic plan this is currently being developed includes the following sectors: Health, Education, Armed Forces, Women, Youth, Finance, Planning and Tourism. Health, Education, and Finance have earmarked budgets however other sectors can access financial resources from a general HIV/AIDS pool through the National AIDS Directorate and the Ministry of Finance. The strategy addresses the following risk groups: women and girls, youths (persons less than 24 years old), orphans and vulnerable children, men who have sex with men (MSM), sex workers, prisoners, uniformed personnel (police officers, prison officers), the poor, and persons living with 146 HIV/AIDS (PLWHA). Consultants note: Noticeably absent from this list are Crack Cocaine Drug users HIV Overview Since the first case of HIV in Grenada in 1984, a cumulative total of 348 HIV/AIDS cases had been reported to the surveillance system up to the end of December 2007. More males have been affected with a cumulative male-to-female ratio of 1.8 to 1. Approximately 70% of reported 147 AIDS cases and AIDS-related deaths were among persons aged 15 to 44 years. It is worthy of note that, in the age-group 15 to 24 years, there are more females than males indicating a feminization of the epidemic. The predominant recorded mode of transmission is via sexual intercourse, with heterosexual transmission being the most predominant. Transmission through intravenous drug use is low. Transmission through blood transfusion is 0% because of the systematic screening of blood for transfusion in Grenada. It must be noted, however, that risk history is not documented for many 148 cases. 145 UNGASS 2008 146 UNGASS 2008 147 UNGASS 2008 148 UNGASS 2008 239 HIV in the Caribbean: A Systematic Data Review 2003-2008 CARE AND TREATMENT 149 Treatment, care and support Provision of ARV The national HIV/AIDS care and treatment programme, managed by the National Infectious Diseases Control Unit (NIDCU) of the Ministry of Health, reported a total of 47 persons with advanced HIV disease on antiretroviral therapy at the end of 2007. If a further assumption is made that 20% to 40% of persons with HIV have advanced disease, then there were an estimated 63 to 125 persons in need of treatment. As such, the 2007 treatment coverage in the public sector likely ranged from 38% to 75%. It must be emphasized as this is very approximate as it does not take into account the potential effects of treatment availability, the PMTCT programme, etc on HIV spread in the population. The important point to note here is that there 150 were still unmet needs for antiretroviral therapy in 2007. Data Collection and Country Surveillance System The data collected is limited in scope, recording only age and sex of infected persons. This data is collected at the time of diagnosis with HIV and/or AIDS. Some of this diagnosis is done by private medical personnel, who either do not report their cases to the NAP, or do not complete the prescribed forms completely. The result is that important information for the management of the disease does not always reach the NAP. Sentinel surveys of vulnerable populations have only been initiated during 2002. At present, a survey is being conducted among pregnant mothers 151 to determine the incidence of the disease among sexually active persons. Number of blood units collected and screened – 2006 and 2007* 152 Data on testing of donated blood by the national blood bank, Grenada, Variable 2003 2004 2005 2006 # of blood units donated 808 N/A 835 1100 % of blood units screened for HIV 100% N/A 100% 91.3% % of blood units positive for HIV 0.1% N/A 0.1% 0 % of blood units positive for Hepatitis B surface antigen 2.1% N/A 1.8% 0.5% % of blood units positive for Hepatitis C virus 0.5% N/A 0.2% 0.1% % of blood units positive for syphilis 0.4% N/A 1.1% 0.3% % of blood units positive for HTLV 1 1.6% N/A 1.0% 0.5% 153 Overview of the current monitoring and evaluation (M&E) system There is currently no written monitoring and evaluation plan. The main challenge has been the development of national M&E indicators that can both effectively track progress towards programme goals and objectives while satisfying reporting requirements of donor agencies. A 149 UNGASS 2008 150 UNGASS 2008 151 Charles 2003 152 UNGASS 2008 153 UNGASS 2008 240 HIV in the Caribbean: A Systematic Data Review 2003-2008 major task of the recently hired M&E officer was to compile a list of all indicators required for these purposes and ratify them against the data currently collected by different implementing agencies/departments. With assistance from the Caribbean Health Research Council, a process of indicator harmonization was completed in 2007. Testing and Diagnosis sites, 154 Of the 20 public facilities surveyed in Grenada , 17 had an HIV testing system. An HIV testing system is defined in the HSPA as a facility offering counseling and testing, where clients are offered the HIV test, and then either the facility conducts the test or there is a system for the facility to receive results back and to follow-up clients post-testing. This is an important distinction to make since in some countries it has been shown that HIV testing happens without a full system being in place or without pre- and post-test counseling. 155 Routine data collection for HIV and AIDS There are 9 service sites across the 2 facilities offering care and support services (CSS) for HIV and AIDS clients in Grenada. Of the public facilities surveyed, 67 percent of the facilities were observed to have registers to track HIV- and AIDS-related client diagnoses in any eligible outpatient and/or inpatient clinic or unit. However, no individual client records/charts were observed across all eligible units. No confidentiality guideline was found in any of the surveyed facilities. This could be problematic, as care for people living with HIV (PLHIV) can be complicated and difficult to follow appropriately if clear and consistent records are not kept on patients, and the quality of patient care can be affected. Additionally, the government and programs may not be documenting the “full pictureâ€? of the epidemic and the number of clients being seen in their facilities Prevention Condom access and use Condom access More than 9 out of 10 interviewees could identify a place where condoms can be obtained. 156 Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. 157 Condom use at first sexual encounter Among youth in Grenada 40% of the young males and 645 of young females reported using a 158 condom during their first sexual encounter 154 Measure Evaluation 2007 155 Measure Evaluation 2007 156 CAREC BSS 2007 157 CAREC BSS 2007 158 CAREC BSS 2007 241 HIV in the Caribbean: A Systematic Data Review 2003-2008 159 Condom use with non-commercial sex partner In Grenada respondents were ask about use of a condom the last time they had sex with a non commercial partner. 69% of young males’ vs 52% of young females reported using a condom 160 with their last non-commercial partner Adults males in Grenada 69%,of males vs 42% reported condom use with last non-regular, non- commercial partner. 161 Condom use with commercial sex partners Using only those respondents who reported sex with a commercial partner in the past 12 months 97% of the young males reported using a condom at their last encounter. Only one young female 162 reported a commercial sex partner and further reported no using condom. There was no data available for adults in Grenada and their condom use with commercial partners 163 Rejection of myths about HIV Respondents were asked (a) If HIV can be transmitted through mosquito bites (b) If a person can be infected by sharing a meal with an HIV infected person (c) If a person can be infected by sitting on a toilet seat previously used by an HIV infected person, and (d) If a healthy-looking person can be infected with HIV/AIDS Almost all adults interviewed, regardless of gender, knew that a healthy-looking person can be infected with HIV. Looking at the rates of myth rejection, it can be said that as many as one-third of respondents in Grenada believed that HIV can be spread by mosquitoes. 164 Knowledge of HIV prevention strategies PMTCT In terms of the PMTCT programme, the available data for 2005 indicate that approximately 50% of HIV infected pregnant women received ARV for the prevention of mother-to-child HIV 165 transmission. In 2007, the estimated figure was higher at 70%. 159 CAREC BSS 2007 160 CAREC BSS 2007 161 CAREC BSS 2007 162 CAREC BSS 2007 163 CAREC BSS 2007 164 CAREC BSS 2007 165 UNGASS 2008 242 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV positive women receiving ARV drugs in the PMTCT programme In 2006, a total of 1,825 women received ante-natal clinic services. HIV testing uptake amongst women attending public antenatal clinics was less than optimal resulting in a total of 906 pregnant women (50%) being tested for HIV. The resulting HIV seroprevalence among these women was 0.55%. Using this seroprevalence and the data on live births, it was estimated that there were approximately ten (10) HIV infected pregnant women in Grenada in 2006. As such, the five (5) HIV-infected pregnant women who were provided with ARV in order to prevent mother-to-child transmission of HIV represent a 50% PMTCT coverage. Using similar methods (see Table 5), the seven (7) pregnant women provided with ARVs brought the 2007 PMTCT coverage to 70%, reflecting an increase. It must be noted that women who agree to be tested in ANC clinics may differ from those that refuse testing and as such the seroprevalence data may not be representative of pregnant women. Validation studies are needed in order to obtain more accurate estimates. It is also important to note that most of the HIV positive ANC clients for the period 2005 to 2007 were previously diagnosed women in repeat pregnancies – 4, 2 and 4 women in 2005, 2006 and 2007 respectively. A success of the programme is the fact that all babies provided with anti-HIV prophylaxis have thus far tested HIV negative at 18 months of age VCT Grenada requires additional scale-up to have systems and qualified staff in place for pre- and post-test counseling. Forty-seven percent of the facilities have at least one counselor trained in pre- and post-test counseling assigned to any counseling and testing site within the facility. However, only 17 percent of the facilities had an observed written policy for routine provision of pre- and post-test counseling for HIV testing, which is important for consistency and quality of information given to clients. Among the systems in place in service sites within facilities, there were only 7 percent of these facilities with observed guidelines for content of pre- and post-test counseling in all eligible service sites. Similarly, there were only 7 percent of facilities with a policy 166 on confidentiality for HIV test results in all eligible service sites. PEP The availability of PEP medicines is very limited in Grenada. PEP medicines were observed at only 5 percent of the facilities (1 out of 10 unweighted facilities that report PEP available to staff), even though 10 facilities reported that staff has access to PEP (apparently staff are being referred to another facility for PEP services). Records of staff receiving PEP was observed in only 11 percent of the facilities. Unfortunately, PEP guidelines are only available in all sites that prescribe PEP in 5 percent of the facilities where staff have access to PEP (1 out of 10 unweighted facilities), and records for monitoring full compliance for PEP are lacking in Grenada It is not expected that PEP medicines will be available at smaller facilities due to the centralized treatment 167 system in Grenada HIV and OI 17 facilities that have an HIV testing system, 67 percent offer STI services, 16 percent offer TB diagnostic or treatment services, 10 percent offer treatment for opportunistic infections for HIV and AIDS clients, and 10 percent provide palliative care for HIV and AIDS clients. Since malaria is not a widespread problem, it is not surprising that only 7 percent of the facilities with an HIV 168 testing system in place offer malaria treatment services. 166 Measure Evaluation 2007 167 Measure Evaluation 2007 168 Measure 2007 243 HIV in the Caribbean: A Systematic Data Review 2003-2008 169 Care and Treatment The national strategy includes a policy for comprehensive HIV treatment, care and support. The majority of public health care facilities offer pre- and post- test counselling and HIV blood collection services, however HIV/AIDS care, treatment and support are centralized and operate from one public facility in the country’s capital, St. Georges. This programme provides all services, including triple ARV therapy to patients with advanced HIV disease, at no cost. HIV positive pregnant women are provided with ARV to prevent transmission to their infants, according to the national PMTCT protocol. Infants receive ART/prophylaxis within 72 hours of birth and are tested for anti-HIV antibodies at the age of 18 months. Mothers cared for in by the PMTCT programme are provided with replacement infant feeding for 6 months to reduce the risk of HIV transmission via breast-milk. . ARVs, condoms, medicines for opportunistic infections and sexually transmitted infections are accessed under the Global Funds project and under the OECS governments’ regional system for procurement of medical supplies. In terms of programme implementation, the NIDCU had recorded a total of 47 persons with advanced HIV disease who were receiving antiretroviral therapy (ART) by the end 2007. This figure represents over 90% of persons with advanced HIV disease who were under care with the programme. Despite the fairly high 12-month survival rates, there are challenges with longer-term adherence that need to be addressed. Impact of Caribbean migration on local epidemic There was no data available on this topic. Given the mobile population associated with St Georges University, the proximity to Trinidad where Grenadian MSM and others go to party, and the movement of people as a result of CSME this is an under studied area. Specific transmission groups: Female / Heterosexual Much of the official documents talk about HIV in Grenada being primarily transmitted via heterosexual contact. What is interesting is the comment from the 2003 Strategic Plan that attributes transmission to MSM contact. The paucity of data on this important mode of transmission. Discordant couples No Data Sex Workers A survey commercial of sex workers was conducted in 2006 by Population Services International (PSI) 10. Results of this “TRaC-Mâ€? survey indicated a need to (1) focus on personal risk perception, (2) condom use by CSW with their paying and non-paying partners, and (3) to increase having SW practice putting a condom on a dildo. Although this survey was focused on PSI-related activities, it gives some insight on HIV-prevention education work that is needed for this high-risk group, for example, none of the interviewed SWs had ever participated in an 170 educational activity to practice proper condom application on a dildo. 169 UNGASS 2008 170 TRaC-M: 2006 244 HIV in the Caribbean: A Systematic Data Review 2003-2008 171 Prisoners In August 2005, 137 male inmates (59% of inmates on the survey days) of Her Majesty’s Prison in Grenada were surveyed11 for their HIV serological status. Eight-three percent (83%) of the survey participants were between the ages of 15 to 49 years. The sero prevalence rate for all inmates tested 2.2% - all HIV positive inmates were between the ages of 15 to 49 years. In terms of their HIV testing history, thirty-two inmates (23%), including the three HIV positive inmates, had previously been tested for HIV; seventy-two percent (72%) of the inmates who had never been tested before gave no particular reason for not doing so. It was notable that more than half of the participants (53%) had a sentence of less than 12 months or had been incarcerated for less than 12 months (remanded prisoners). The survey findings of 2.2% HIV sero prevalence was notably higher that the estimated national population prevalence of 0.42% in 2003, but similar to 172 the 2.3% prevalence in a survey of 260 STI patients conducted in 1996. Male-to-male sex Comprehensive information on MSM is also unavailable. There are a number of factors however that indicate that significant incidences of MSM may exist in Grenada: It is clinically easier for men to transfer my to women than for a woman to infect a man. It therefore follows that, as the disease progresses through heterosexual transmission, that increasing numbers of women would be infected. This has been the pattern in most countries throughout the world. The fact that the ratio of infected men to women is Grenada has been consistent at 1.7:1 could be an indication that a significant part of the transmission is from men-to men. In the survey on HIV and Sexual practices in Grenada (as reported in the 2003 Strategic Plan) 21% of the respondents to the sample survey were homosexual men and bisexual. The practitioners indicated that some of the bisexuality may be due to the negative attitudes of the Grenadian population to homosexuality; including the fact that homosexuality is illegal. .As a result, some homosexuals establish relationships with women in order to gain social respectability 173 and practice homosexuality in private. The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. The percentage of men who reported sex with men, ever or in the last 12 months was less than 174 1%. For both youth and adults General risk behaviour Alcohol consumption Alcohol is not perceived as an unhealthy or dangerous substance due to the fact that it is generally accepted and consumed within the society. Alcohol is also viewed as a beverage for 175 every social activity and is generally the beverage of choice for enjoyment and festivities. 171 UNGASS 2008 172 CAREC/PAHO/WHO. 2004. 173 Charles 2003 174 CAREC BSS 2007 175 Charles, 2003 245 HIV in the Caribbean: A Systematic Data Review 2003-2008 For adults in Grenada, 20% of the males vs 2% of the females M 20%, there was a notable gender difference for every-day consumption of alcohol, with more males than females reporting alcohol consumption everyday. For youth – daily drinking was not as common with only 3% of the males and 1% of the females aged 15 – 24 reporting daily drinking. For youth 15 – 24 30% Males vs 15% Females reported drinking alcohol at least once a week; again there was a gender difference with more males than females reporting this frequency of alcohol consumption The 176 majority of people interviewed reported drinking alcohol less than once a week or never. 177 Drug Use and Needle Sharing The Drug Control Secretariat indicated that intravenous drug use in not common in Grenada. This is because this method is used for the injection of heroin - a drug that is not widely used in Grenada. It noted however that there was a strong linkage between drug use and risky sexual behaviour as the use of drugs usually resulted in the user "dropping their guard" and becoming involved in various types of risky behavior. It was also noted that there is a growing trend of needle use among youth and students for tattooing purposes - with one person using the same needle on a number of subjects (clients). This is a process through which it is possible for infected blood to be transferred from one person to another. Use of illegal drugs Young males were more likely to report using marijuana than female youths Among males, marijuana use in the 30 days preceding the interview was 24%. By comparison, marijuana use among females was 4%. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders Compared to females, a higher proportion of adult males reported ever trying marijuana and marijuana-use in the last month. The data indicate that approximately one-third of male interviewees had ever tried marijuana, with a slightly smaller proportion 27% having used this 178 drug in the month preceding the interview. Quite a large percentage of participants in a UNODC sponsored study of drug use and HIV risk among young people show that the participants had consumed drugs in their lifetime and at least 35% had consumed an illegal drug in their lifetime. Approximately 75% of respondents have consumed alcohol in their lifetime, and almost 50% have consumed alcohol in the last 12-month period. An astounding 26.8% of respondents have consumed alcohol and engaged in unprotected sex, with 11.5% smoking marijuana and engaging in unprotected sexual activity. No participant of all focus group discussions reported personal usage of cocaine and/or crack 179 cocaine. 176 CAREC BSS 2007 177 Charles, 2003 178 CAREC BSS 2007 179 UNODC (undated0 246 HIV in the Caribbean: A Systematic Data Review 2003-2008 180 Sexual activity These indicators measure sexual activity among young people. Typically, young people have partnerships that are more often of short duration and perhaps less formal than those of older people. Moreover, they are less likely to live with their sexual partners, and this can often result in one of the partners having additional concurrent partners, thus increasing the risk of infection. Data are presented for indicators around sexual debut (age, age mixing and forced sex) and indicators of recent sexual activity (sexual intercourse, number of partners, commercial sex and sex between men, in the last 12 months). For young males, the percent of sexually active respondents was 73% in Grenada and 62% for females 181 Sexual initiation 182 Sex before 15 In Grenada, 32%,of the males and 20% of the females reported having sex before the age of 15, 183 Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. In Grenada, the proportion whose first sexual partner was between 5 and 10 years older 7% for males vs 33% for females 184 Forced sex at first sexual encounter By gender, female Grenadian youths are more likely than young males to have been forced to have sex during their first sexual intercourse. 11%, vs 2% for males 185 Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 57% of the males and 57% females were sexually active in the last 12 months. 180 CAREC BSS 2007 181 CAREC BSS 2007 182 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 183 CAREC BSS 2007 184 CAREC BSS 2007 185 CAREC BSS 2007 247 HIV in the Caribbean: A Systematic Data Review 2003-2008 This indirect measure of secondary abstinence can inform on the impact of education and prevention programmes, which encourage young people to abstain from sex after engaging in early sexual activity. 186 Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 57% of males in Antigua and Barbuda, St Kitts and Nevis and St Vincent and the Grenadines reported having more than one partner. Among females, Grenada (30%) reported having more than one partner The range of non-commercial partners in the last 12 months in Grenada Males 1 – 11 Females 1 - 6 Females 1 - 10 187 Commercial and transactional sex for those who have had sex in the past 12 months Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. Among young Grenadians, Males 6%, Females 6%, The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?". 5%,of the young males and 5%,of the young females reported this type of sexual transaction vs adults males who reported 1%, vs 2% for females In Grenada no one reported having gave drugs for sex And a similar question was also asked who received drugs for sex. It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr Day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. In Grenada 34% of the young males reported receiving drugs for sex vs 8% of the females This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. 186 CAREC BSS 2007 187 CAREC BSS 2007 248 HIV in the Caribbean: A Systematic Data Review 2003-2008 188 Non-regular non-commercial sex partners among adults Noticeably more men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than one non-regular partner in the last 12 months was 16% while among females, 7% The number of non-regular, non-commercial partners reported by at least half of surveyed men and women was one, Prevalence of HIV co-infection with STIs, TB and hepatitis The Epidemiology Unit of the Ministry of Health has not observed notable increases in tuberculosis cases over the past ten years (see Table 6). Based on reported cases, the annual incidence of tuberculosis between 1997 and 2007 ranged from 1 per 100,000 population to 5 per 100,000 population (2005). The trend has been generally stable of this ten year period indicating 189 that the low-level HIV epidemic has not caused an increase in Tb incidence. Self-reported Sexually Transmitted Infections (STIs) Sexually Transmitted Diseases (STD’s) - Trend data on the incidence of STD’s among the population was not available. However, the 2001 Community Health Services report from the Ministry of Health reported the following: • Sixty-seven (67) cases of gonorrhoea were reported in 2001 compared with forty-seven (47) cases in 2000 and sixteen (16) cases in 1999. • Thirteen (13) cases of Chlamydia infection were reported in 2001 compared with seven (7) cases in 2000 and five(5) cases in 1999. • Ninety-seven (97) cases of genital discharge were reported in 2001, compared with one hundred and nine (109) in 2000. • Six (6) cases of genital herpes were reported in 2001, compared with thirteen (13) cases 190 in 2000, and five (5) cases in 1999. Sexually Transmitted Infections (STIs) are transmitted in the same ways as HIV, and can be prevented by the same safe behaviours being promoted by HIV prevention programmes. Therefore, measures of STI prevalence are a relatively good guide to recent trends in sexual risk behaviour. The OECS BSS assessed self-reported prevalence of genital discharges and ulcers among adults and youths in the 12 months preceding the interview. Among male youths, the reported prevalence rates of 1% for genital discharge while females 191 reported 4% Among adults male the reported prevalence rates of 2% for genital discharge while females 192 reported 9% 188 CAREC BSS 2007 189 UNGASS 2008 190 Charles, 2003 191 CAREC BSS 2007 192 CAREC BSS 2007 249 HIV in the Caribbean: A Systematic Data Review 2003-2008 Among male youths, the reported prevalence rates of <1%for genital ulcers/sores while females reported 3% while male adults were similar with <1 % and females were lower the young females 193 at 2% 194 Impact of stigma and discrimination Grenada has laws that protect PLWHA from discrimination however these are general nondiscrimination provision that do not specifically mention HIV. In 2007, the National AIDS Council, with support from the Pan Caribbean Partnership against HIV/AIDS (PANCAP), sought to undertake a review of the Legal and Ethical environment surrounding the issue of HIV/ AIDS in Grenada. A national assessment was conducted and a report completed. This report cited relevant legislation and legislative gaps that existed. In 2008, consultations with stakeholders will continue in order to develop recommendations for legislative reform. This project seeks to create a legal framework that protects the rights of PLWHA and other groups at risk for or affected by HIV. In this context, it is worth mentioning that there are in existence some laws and policies that present barriers in the provision of services to certain vulnerable subpopulations. For example, it is difficult for youths under the age of 16 years to access condoms, materials, VCT and ART without first obtaining parental consent. In prisons, distribution of condoms is problematic even though there is no written law or policy to this effect. Additionally, there is no provision in the prison act for protection of medical records for HIV positive prisoners. The national strategic plan explicitly mentions the promotion and protection of human rights. The National AIDS Council established a human rights desk which received, records, documents and seeks to address human rights violations through such mechanisms as referrals, partnering and sensitization. This desk is specific to HIV and is funded and operated by the Caribbean Regional Network of People Living with HIV/AIDS through the Global Funds project. One noted area for action is the issue for new legislation to deal with the rights of PLWHA, especially with regard to stigma and discrimination in the work place. With the exception of one private sector organisation which has articulated a policy on HIV, no other organisation has a written policy that guides the management of HIV in the workplace. Currently, the Senior Management Board of the public service is working with the NAD on the articulation of such a policy. 195 Stigma and discrimination Respondents with accepting attitudes towards persons with HIV/AIDS based on a composite of 5 questions a-e (k) willingness to care for a close male relative who became sick with the AIDS virus (l) willingness to care for a close female relative who became sick with the AIDS virus (m) willingness to buy food from a shopkeeper or food vendor whom they knew was HIV positive (n) thinks a teacher who is HIV infected but not sick should be allowed to continue teaching in school (o) would not want to keep the HIV positive status of a family member a secret. The composite indicator for accepting attitudes towards people with HIV infection showed low acceptance of HIV infected people. These low scores were heavily influenced by the low willingness to buy food from an HIV infected shopkeeper or food vendor, which may actually be less a matter of stigma than a reflection that people have fears that HIV can be spread through contact with contaminated food. 193 CAREC BSS 2007 194 UNGASS 2008 195 Measure Evaluation 2007 250 HIV in the Caribbean: A Systematic Data Review 2003-2008 The results of this indicator showed that most people interviewed (M 7%, F2% 4%) would have discomfort having close contact/associations with people living with HIV infection or AIDS 196 Human Rights Confidentiality There have been reports that information on infected-persons HIV status has not been kept confidential by the authorities. In discussions with the Laboratory, it has confirmed that such breaches are possible because some samples requiring HIV testing are not coded and their results can be seen by any person having access to the laboratory records. This reality provides opportunities for non-laboratory personnel to view patients’ records without permission. It must be noted however, that most HIV samples are submitted to the laboratory without patients’ names and are identified by a code known only by the doctor who submitted the sample. Access to the laboratory’s records therefore does not automatically mean that all results are identifiable. Legislation The incidence of HIV / AIDS has raised a number of legal issues that are not explicitly covered by current legislation. These include: • Deliberate Infection By An HIV-Positive Person - there have been cases of HIV positive persons deliberately engaging in unprotected sex. The question of the Penalties to which such persons should be subjected will require new legislation. • The Right Of HIV-Positive Persons To Confidentiality - The existing laws on confidentiality does not extend to public health problems. However, given the deeply personal nature of HIV/AIDS, some advocates cite the need for legislation to protect the confidentiality of HIV-positive persons. • The Responsibility to Inform - This covers the need for information on mv positive persons to be shared with persons and institutions on a "need to know" basis. This includes: o The responsibility of HIV positive persons to inform prospective sex partners; o The responsibility of doctors to inform the Ministry of Health; and The responsibility of doctors to encourage and assist infected persons to inform their spouses, or partners. Provider Stigma To provide an estimate of the proportion of providers of HIV- and AIDS-related services reporting accepting attitudes toward PLHIV, a composite indicator was constructed to measure provider stigma. The indicator is derived from providers’ responses (recorded on a 4-point Likert scale) of agreement or disagreement with the following series of statements. Respondents with a positive score of 6 out of 6 questions are considered to have accepting attitudes toward PLHIV. 1. People who are infected with HIV should not be treated in the same place as other patients in order to protect other patients from infection. 2. People with HIV are generally to blame for getting infected. 3. Providing health services to people infected with HIV is a waste of resources since they will die soon anyway. 4. Clients who have sexual relations with people of the same sex deserve to receive the same level and quality of health care as other clients. 196 Charles 2003 251 HIV in the Caribbean: A Systematic Data Review 2003-2008 5. Health providers have to be careful not to get a reputation for treating HIV-positive clients, since this might affect who might go to them for other health services. 6. You avoid touching clients’ clothing and belongings who you know or suspect have HIV for fear of becoming HIV infected. Four of the 6 items are related to internationally recognized measures of health worker attitudes toward PLHIV (1–4), and one is related to health worker comfort working around PLHIV (6).37 Item 5 was adapted locally to further explore health worker stigma. In Grenada, of the 52 public providers of HIV- and AIDS-related services who were surveyed, 58 percent responded with accepting attitudes toward PLHIV. Since this is only a sample of providers in the country, one can not make assumptions about attitudes of all providers, but there appears to be a need to sensitize health providers and better inform them. It has been reported elsewhere that health care 197 providers without an in-depth knowledge of HIV transmission hold more stigmatizing attitudes. Human Resource Shortages During the period from 1997 to 2002, Grenada had 8.1 physicians per 10,000 people. The ratio per 10,000 people for nurses and dentists were 19.5 and 1.1 respectively. In 1998, there were 6.9 pharmacists and 0.75 nutritionists per 10,000 people. According to the MOH, the human resource capacity in the health sector is constrained by a number of factors: • The ability to retain sufficient medical practitioners, nursing staff, and medical administrators, including a Chief Medical Officer • A lack of succession planning for staff, especially specialist medical professionals and administrative personnel • Government’s “zero growthâ€? policy for new personnel • Granting of private practice privileges to consultants, specialists, district medical officers, and dental surgeons • Incentives provided to nursing staff by developed countries.30 197 Measure Evaluation 2007 252 HIV in the Caribbean: A Systematic Data Review 2003-2008 References Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS) in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. CAREC/PAHO/WHO. Status and Trends – Analysis of the Caribbean HIV/AIDS epidemic 1982- 2002. 2004. CAREC Report on an HIV seroprevalence survey among male inmates in Her Majesty’s Prison inSt. Vincent and the Grenadines conducted on April 12-13, 2005. CAREC, July 2005. Charles, L., STRATEGIC PLAN FOR HW/AIDS IN GRENADA (revised 2003) MEASURE Evaluation 2007. Grenada Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. Pan American Health Organization. 2007 Health in the Americas, 2007, Volume II – Countries found at www.paho.org/HIA/vol2paisesing.htm Pan American Health Organization. 2005. Access to care for people living with th HIV/AIDS. Provisional Agenda Item 4.15 CD46/20 (Eng.): 46th Directing Council, 57 Session of the Regional Committee, 26-30 September. Washington, DC: World Health Organization. Pan American Health Organization. 2003. Scaling up Health Systems to Respond to the Challenges of HIV/AIDS—Latin America and the Caribbean. Washington, DC: World Health Organization. TRaC-M: Sex Workers in Dominica and Grenada & Men Who Have Sex With Men in St Lucia, St Vincent & The Grenadines and Trinidad & Tobago,â€? PSI Social Marketing Research Series, 2006 United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—Grenada UNODC, The link between drug use and HIV/AIDS among young people in Grenada - A semi-qualitative research study supported by the United Nations Office on Drugs and Crime, Regional Office, Barbados, undated 253 HIV in the Caribbean: A Systematic Data Review 2003-2008 ST KITTS / NEVIS HIV Overview Complied by Dr Marcus Day 1 June 2008 254 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents St Kitts/Nevis HIV/AIDS strategic plan, including priorities and gaps ................................. 257 NATIONAL RESPONSE TO AIDS EPIDEMIC .................................................................. 257 Priorities of the 2002 – 2007 NSP for Saint Kitts and Nevis .............................................. 257 Goals and Strategies for National Strategic Plan 2008-2012 ............................................ 257 MAJOR CHALLENGES FACED................................................................................................. 258 Social and Cultural Norms ................................................................................................. 258 Institutional Capacity .......................................................................................................... 259 Overview of routine data collection ......................................................................................... 259 ROUTINE DATA COLLECTION FOR HIV AND AIDS ............................................................... 260 St Kitts ................................................................................................................................ 260 Nevis .................................................................................................................................. 260 RECORDS FOR CARE AND SUPPORT SERVICES (CSS)...................................................... 260 St Kitts ................................................................................................................................ 260 Nevis .................................................................................................................................. 260 RECORDS OF PMTCT OF HIV................................................................................................... 260 St Kitts ................................................................................................................................ 260 Nevis .................................................................................................................................. 260 PMTCT+............................................................................................................................. 261 Behavioural, biomedical and epidemiological studies .......................................................... 261 St Kitts / Nevis Secondary Data on Substances Drugs ..................................................... 261 Regulations for and completeness of HIV reporting from private sector ............................ 262 Country specific prevention activities..................................................................................... 262 Condom access and use........................................................................................................... 263 Condom access ......................................................................................................................... 263 Condom use at first sexual encounter .................................................................................... 263 Condom use with non-commercial sex partner ................................................................. 264 Condom use with commercial sex partners ....................................................................... 264 Access and availability of HIV and OI treatment ................................................................... 264 Impact of Caribbean migration on local epidemic ................................................................. 265 Data on specific transmission groups..................................................................................... 265 Men who have sex with men, including bisexual ............................................................... 265 Prevention of Mother to Child Transmission of HIV (PMTCT)........................................... 266 255 HIV in the Caribbean: A Systematic Data Review 2003-2008 At-risk Women / Heterosexual transmission .......................................................................... 266 Heterosexual transmission ....................................................................................................... 267 Sexual activity 25 – 49 years old ....................................................................................... 267 Sexual activity in the last 12 months.................................................................................. 267 Non-regular non-commercial sex partners ........................................................................ 267 Commercial sex ................................................................................................................. 267 Sexual activity for youth age 15 – 24 years old ................................................................. 268 Sexual initiation .................................................................................................................. 268 Sex before 15..................................................................................................................... 268 Age-mixing at first sexual encounter.................................................................................. 268 Forced sex at first sexual encounter .................................................................................. 268 Youths sexually active in the last 12 months ..................................................................... 269 Youth with multiple sex partners ........................................................................................ 269 Commercial and transactional sex..................................................................................... 269 Male-to-male sex................................................................................................................ 270 Discordant couples,................................................................................................................... 270 Sex Workers both Commercial, and Transactional Sex Workers...................................... 270 Drug use, injection and non-injection................................................................................. 271 Prison Study....................................................................................................................... 273 Youth .................................................................................................................................. 274 Rastafarians ....................................................................................................................... 274 Prevalence of HIV co-infection with STIs, TB and hepatitis .................................................. 275 Self report of Sexually Transmitted Infections in Youth 15 – 24 yrs old ............................ 275 Adult Self-reported Sexually Transmitted Infections (STIs) ............................................... 275 Human resources....................................................................................................................... 276 Clinical Service Providers .................................................................................................. 276 Governmental and Non-governmental Organisations ....................................................... 277 Members of Faith-Based Communities.............................................................................. 277 Stigma and Discrimination........................................................................................................ 277 People Living with HIV and AIDS (PLWHA) ...................................................................... 277 Stigma and discrimination of the general population towards PLWHA ............................. 278 MSM Stigma....................................................................................................................... 278 Human Rights Desk ........................................................................................................... 278 Cultural Taboos.................................................................................................................. 279 References (highlighted entries refer to documents not yet obtained) ............................... 280 256 HIV in the Caribbean: A Systematic Data Review 2003-2008 ST KITTS / NEVIS St Kitts/Nevis HIV/AIDS strategic plan, including priorities and gaps The five year strategic plan for HIV/AIDS for St. Kitts and Nevis, which covered the period 2002- 2007, is presently under revision in order to develop and implement programmes and activities in response to the epidemic for the period 2008-2012. NATIONAL RESPONSE TO AIDS EPIDEMIC The goals of the National Strategic Plan (NSP): 1. To reduce the spread of HIV infection 2. To reduce the impact of HIV/AIDS on individuals, family and the community. 198 Priorities of the 2002 – 2007 NSP for Saint Kitts and Nevis 1. Prevention, 2. Care, treatment and support, 3. Advocacy, 4. Research, surveillance and epidemiology, and 5. Program coordination and management. 199 Goals and Strategies for National Strategic Plan 2008-2012 Two goals remain the same: 1. To reduce the spread of HIV infection 2. To reduce the impact of HIV/AIDS on individuals, family and the community. The 5 strategic areas also remain largely relevant 1. Prevention 2. Care, treatment and support 3. Advocacy, policy development and legislation 4. Generating and using strategic information 5. National program coordination and management. National Advisory Council on HIV and AIDS heads the project and has multi-sectoral representation. Other areas being addressed are support and legislation for civil rights of PLWHA, policy recommendations and local prevention and control of the HIV and AIDS epidemic. Currently a monitoring and evaluation framework has been adopted and implemented with 200 national level indicators harmonized to donor-required indicators. Areas for focus in 2008-2011: The national structure for an expanded response has been built, but capacities still need to be strengthened. The Federal government established the organisational structure for the response, including a National Advisory Committee on HIV and AIDS (NACHA). Two secretariats exist for coordination, technical direction and information provision, the National AIDS Secretariat (NAS) and the Nevis AIDS Coordination Unit (NACU). NAS and NACU are 198 Saint Kitts and Nevis Strategic Plan 2002-2007 199 UNGASS Report 2008 200 UNGASS Report 2006 257 HIV in the Caribbean: A Systematic Data Review 2003-2008 severely stretched, in terms of staff numbers and expertise mix. Public sector and civil society are more involved, but more partners and broader involvement is needed. The ministries of health and education effectively address HIV, as do the departments of gender, labour & youth. Yet, HIV/AIDS activities have not been mainstreamed into their own workplans and budgets, and thus remain dependent on external HIV funding. Other ministries, such as tourism and defence can also mainstream HIV prevention. Civil society organisations, including PLWA and MSM organisations, churches and companies are involved in HIV prevention and care services. Yet, here are gaps: NGOs are few and of limited organisational and technical capacity; faith based organisations (FBOs) do not yet address community care needs of PLWA Prevention education takes place, but needs to become evidence based and better targeted. Now that awareness and knowledge levels are high, general population information campaigns need to be more evidence based and focus on remaining myths and misconceptions. Besides, prevention interventions need to target the most-at-risk populations better, moving towards research driven behaviour change interventions, probably relying more on interpersonal and peer communication than mass media. Life skills-based HIV and sexual health education in the school system is necessary and promising, but has never been evaluated for effectiveness. VCT service coverage is broad, but demand remains low. The MoH set up VCT services in 17 sites (11 St Kitts, 6 Nevis), including all health centres. There are national VCT days, and a cadre of trained counsellors. Yet, VCT protocols are slow and involve many health professionals, resulting in delayed results, and perceptions of low confidentiality. In addition, the requirement to notify all past sexual partners in case of positive result, may explain the low uptake. 201 MAJOR CHALLENGES FACED Despite the progress that has been made, many challenges remain. The number of new HIV infections continues to increase in spite of current efforts. Social and Cultural Norms Strong stigma against PLWHAs serves to drive the epidemic underground making it difficult to conduct effective prevention, care and treatment. The OECS BSS reported that only 1% (15-24 yr olds) to 5% (25 – 29 yr olds) percent of population in Saint Kitts and Nevis expressed accepting attitudes towards people living with HIV and AIDS. While there appeared to be a compassionate response by individuals to hypothetical questions on willingness to care for HIV-positive family members and willingness to allow an HIV-positive student, teacher or co-worker to conduct their 202 normal school/work activities, there was a low willingness for food-related contact. This may reflect persistent fear of HIV transmission through food and suggests that stigma on the islands might be susceptible to change with proper education and sensitization. According to the Saint Kitts and Nevis UNGASS 2006 report: …stigma and discrimination associated with HIV and AIDS continues to exist. This affects the willingness of PLWHA to be more visible champions for change and advocates for human rights. It may also act as a deterrent to persons who want to get tested for HIV. While there has been some increase in the awareness of the general public, technical support is needed to develop and implement a comprehensive strategy to address stigma and discrimination. While there has been a thrust towards greater involvement of PLWHA in programme planning and implementation, they 201 MEASURE Evaluation. 2007 202 CAREC. 2007 258 HIV in the Caribbean: A Systematic Data Review 2003-2008 remain invisible on the front line in the fight against HIV and AIDS. Further the ability of PLWHA to provide peer support to each other has been limited because of fear and reluctance to disclose serostatus even among PLWHA. Several strides have been made to address discrimination against PLWHA, such as the establishment of a human rights desk located in the National AIDS Secretariat, as well a formal complaint procedure. Institutional Capacity Another challenge facing Saint Kitts and Nevis is the lack of knowledge about the dynamics and behavioural factors driving the HIV and AIDS epidemic. According to the Saint Kitts and Nevis 2006 UNGASS report and further supported by the 2008 UNGASS report: “HIV surveillance is weak compounded by the limited capacity to conduct behavioural research. This has contributed to a poor understanding of the scope and magnitude of the local epidemic as well as the underlying factors that contribute to its continued escalation. Without this information, it is very difficult to determine which interventions are more likely to mitigate the impact of HIV and AIDS. While tremendous progress has been made in the scale up of comprehensive care and treatment, an array of essential support services remain largely inadequate. This includes provisions for psychosocial support, home based care and laboratory capacity for monitoring CD4 counts and viral load.â€? Management of the national programme has improved, thanks to international funding and technical assistance, but needs to sustain and expand. The GoSKN secured external funding for the national response has been obtained through regional initiatives from the World Bank (a loan through OECS) and Global Fund (a grant, through PANCAP). Funding from both sources will terminate during the NSP period, so NAS needs to ensure sustainability of the national 203 programme, trough resource gap analysis and a resource mobilisation strategy and plan. Overview of routine data collection Overview of routine data collection, including description of country surveillance system, all aspects of HIV and STI surveillance and reporting. “In 2005, the Ministry of Health (Saint Kitts and Nevis) established a monitoring and evaluation team headed by the National Epidemiologist. With the assistance of a consultant, the team was charged with the responsibility of harmonizing the various programme indicators and development of a monitoring and evaluation plan. When completed the plan will define the program’s indicators, tools for data collection and analysis as well as a strategy for dissemination of the information. The National Epidemiologist is based in the Health Information Unit of the Ministry of Health and is the focal point for the collection of all HIV and AIDS-related information. Data from health facilities (including laboratories) is collated and disseminated for use at all levels. HIV surveillance reports are available quarterly and annually however a comprehensive programme report has not 204 been written since 2003.â€? 203 UNGASS 2008 204 UNGASS 2006 259 HIV in the Caribbean: A Systematic Data Review 2003-2008 ROUTINE DATA COLLECTION FOR HIV AND AIDS St Kitts The results show that there are four service sites across the three facilities offering care and support services (CSS) for HIV and AIDS clients. Of the public facilities surveyed that offer CSS, 67 percent were observed to have registers to track HIV- and AIDS- related client diagnoses in any eligible outpatient and/or inpatient clinic or unit. Nevis The results show that there are four service sites across the one facility offering care and support services (CSS) for people living with HIV (PLHIV). The facility hadregisters to track HIV- and AIDS-related client diagnoses in an eligible outpatient and/or inpatient clinic or unit. However, no individual client records/charts or confidentiality guidelines were observed across all eligible client clinics/units. RECORDS FOR CARE AND SUPPORT SERVICES (CSS) St Kitts Among the 11 public facilities offering VCT services, 55 percent had observed records for service with 64 percent routinely submitting reports on service. In the case of the 3 facilities offering CSS, 67 percent had observed records of service with 33 percent routine record submission. Nevis Among the seven public facilities offering voluntary counseling and testing (VCT) services, 100 percent had observed records of service with only 43 percent routinely submitting reports on service. In the case of CSS and ART, there were no observed records for service and hence no routine record submission. RECORDS OF PMTCT OF HIV Tracking prevention of mother to child transmission (PMTCT) service delivery / tracking antiretroviral medicine (ARV) treatment among pregnant women St Kitts PMTCT is offered in 11 facilities (12 sites), only 9 percent could provide records of all items for routine recordkeeping for PMTCT services. 27 percent of the facilities offering PMTCT services had observable records of women attending ANC and who accepted HIV testing. Likewise, 27 percent had records of women who received their HIV test results and records of women who received post-test counseling for HIV (by serostatus). Nine percent had a record of HIV-positive pregnant women who were provided a complete ARV course for PMTCT. Nevis 260 HIV in the Caribbean: A Systematic Data Review 2003-2008 In Nevis, PMTCT is offered in seven facilities (nine sites). However, only 43 percent of the facilities offering PMTCT services had observable records of women attending antenatal clinics (ANCs) and who accepted HIV testing; 29 percent had records of women who received their HIV test results and 14 percent had records of women who received post-test counseling for HIV (by serostatus). There were no facilities that had a record of HIV-positive women who were provided a complete ARV course for PMTCT. This illustrates the need to strengthen record-keeping capacity among facilities offering PMTCT, not only for reporting but for planning, programming, and advocacy needs. 205 PMTCT+ There were no facilities offering PMTCT+ services in either St Kitts or Nevis. Behavioural, biomedical and epidemiological studies Caribbean Epidemiology Center (CAREC) survey report, 2004 Seroprevalence Survey of 169 Prisoners (Saliva – antibodies) Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. St Kitts / Nevis Secondary Data on Substances Drugs National Poverty Assessment Survey (2000) – revealed that almost 30.5% of the poor lived in St. Kitts and 32% in Nevis. The monthly poverty lines were EC$280.05 (St. Kitts) and EC$328.40 (Nevis). The monthly indigence lines were EC$177.94 (St. Kitts – 11%) and EC$204.40 (Nevis -17%). For St. Kitts, more than 67.8% were under 25 years (males = 29%; female = 32%), while for Nevis, 58% were under the age of 25 (males = 26% and females = 36%). The poor were largely unskilled / lacked educational qualifications. Furthermore, it was revealed that drug trafficking (and alcoholism) was a major problem in a number of poverty-stricken / high-risk communities. National Drug Prevalence Survey of Secondary Schools Students (2002) – 1,927 students were surveyed (St. Kitts = 79%; Nevis = 21% / males = 51% / females = 49%). The age ranged 14 to 19 years. The lifetime use prevalence rates for drugs were as follows: Alcohol (62.6%), Cigarettes (16.6%), Marijuana (17%), Stimulants (2%), Solvents/Inhalants (2.5%), Heroin (1%), Ecstasy (1%), Methamphetamine (0.9%), Morphine (1%), Cocaine HCL (1.1%), Crack (1.6%), Opium (0.8%), and Tranquilizers (1%), Hallucinogens (1.3%), Other drugs (3.1%), and Any Illicit drugs (3.1). Alcohol /marijuana were the legal / illegal drugs of choice for lifetime use respectively. Focus Assessment Study on Drugs Selected High-risk Communities (2003) – 41 young people participated (males = 25; females = 16). Ages ranged 12 to 33 years. Approximately, 29% had close friends that used drugs; and 21.2% reported living with a heavy drinker. Lifetime use prevalence rates for drugs were as follows: alcohol (75.8%), Marijuana (39.4%), and Cigarettes (33%) respectively were the most frequently used substances. Overall, the lifetime prevalence of the other drugs was insignificant. Age of first use varied from 5 to 15 years. Drugs mainly 205 PMTCT+ services have been defined to include counseling and testing (CT) services, ARV prophylaxis for mother and newborn, counseling on infant feeding and family planning, ARV treatment for HIV- positive women and family members, counseling and testing records for ANC clients, records on ARV prophylaxis provided, and records on therapeutic ARV for women receiving PMTCT services 261 HIV in the Caribbean: A Systematic Data Review 2003-2008 consumed were marijuana, alcohol, and cigarettes; and to a lesser extent angel dust and cocaine/crack. Marijuana / alcohol were the favorite illicit / licit drugs respectively. The bathrooms at schools, social gatherings, abandon houses, homes, and streets were the favorite places for drug use. Participants believed drug use increase the propensity to engage in unprotected sexual activities. Spranger cocaine/crack and marijuana mixed) and Fonto (marijuana and tobacco mixed) were the two main new drug trends. National Drug Prevalence Survey of Civil Service Employees (2003) – 2,106 employees participated (St. Kitts = 81.4%; Nevis = 18.6% / 40% males 60% females). The age ranged between 17 to 66 years. Lifetime use of drugs was more prevalent among males than females for alcohol (males = 86.6 % vs. females = 66.8%), cigarettes (37.1% vs. 12.3%), marijuana (22.6% vs. 6.9%), and any illicit drug (20.6% vs. 7.2%). However, overall the lifetime prevalence of the other drugs was insignificant. Approximately 12.8% of the employees were curious about trying an illicit drug, while 6.7% said that maybe they would try if they had a chance, and another 2% would definitely try an illicit drug. FOCUS ASSESSMENT STUDY ON DRUG USE: IDENTIFYING PATTERNS Illicit Drug Trafficking (2002 – 2004) – revealed that cocaine/crack and cannabis were the major drugs seized. In 2002, cocaine HCL/crack (0.1g) was seized. In 2003, cocaine HCL/crack (36g); cannabis plants (33,367), cannabis leaves (9,604g) and seeds (20,555g) were seized. For this current year (2004), there were seizures of cannabis seeds (443g) and leaves (1,599g). The number of persons charged for illicit drug trafficking were 12 (2002); 7 (2003); and 4 (2004). For those convicted for illicit drug trafficking were 6 (2002); 8 (2003); and 0 (2004). The number of persons charged for illicit drug possession for personal use was 48 (2003); data for 2002 and 2004 were unavailable. Also, the number of persons convicted for illicit drug possession for personal use was 19 (2003); data for 2002 and 2004 were unavailable. Regulations for and completeness of HIV reporting from private sector There is a large gap in HIV and AIDS information, as the private health sector is not very well integrated into the overall health system. In the vulnerable population assessment most respondents preferred the private health sector and many health professionals work in both the private and public sectors, reporting is focused on the public sector. Mandatory HIV reporting is not enforced within the private sector, thus resulting in not-as-accurate a picture of the epidemic. Policies to integrate private health care fully into participating with communicable disease 206 reporting should be encouraged. Country specific prevention activities Prevention of HIV infection is listed as Saint Kitts #1 priority in its national strategic plan and yet a search of the reference documents on Saint Kitts/Nevis for prevention activities turned up little. There was mention of PMTCT, prevention using PEP and a reference to prevention in terms of providing individuals in trained in youth friendly services. Many of the references in the document to prevention are followed by “and careâ€? as if “prevention and careâ€? is a mantra that if repeated enough would solve the problem. Saint Kitts was unable to report on indicator 9 percentage of most-at-risk populations reached with HIV prevention programmes: The response was data not available that there was no major population study and there was a comment that they “need to conduct studies in 2008-9â€? Much of the prevention work done with vulnerable populations is funded through a project by the 207 Caribbean HIV/AIDS Alliance which was able to reach “hiddenâ€? populations by carrying out 206 Measure Evaluation 2007 207 UNGASS 2008 262 HIV in the Caribbean: A Systematic Data Review 2003-2008 prevention interventions through outreach workers called ‘community animators’ drawn from the community and supervised by a Programme Officer. These Community Animators engage at risk populations at ‘hot-spots’- bars, beach and Spanish bars, on the streets, private homes and private parties. Interventions are primarily one-to one, and a single intervention is considered to include a risk assessment with the client, risk reduction practices and condom demonstration. Animators also provide information about HIV and other sexual health services, and will accompany persons for services if requested. The Programme Officer provides support, mentoring and guidance to the Animators as well as engages with the National Authorities and other key stakeholders to build partnerships to facilitate greater involvement of civil society in the national response. In addition, the Alliance provided 60,189 condoms to Most at Risk Populations as well as people gathering at public events. 208 Knowledge of HIV prevention strategies The OECS BSS questionnaire had three questions to assess knowledge of HIV prevention methods – abstinence from sex, having one faithful uninfected partner, and consistent condom use. A composite of the three questions was calculated for an indicator on overall knowledge of the “ABCâ€? of HIV prevention methods. Generally, all three prevention methods were identified by many respondents In St. Kitts and Nevis the proportion of young males with overall correct knowledge was higher than females. (M 80%, F 61 All 70%) Among respondents 25 – 49 the results were similar, (M 70%, F 64%, All 67%), This begs the question of prevention work among females. If females as the receptive partner are more vulnerable to HIV infection why is not more being done to reach females with prevention education. These findings also highlight the fact that 3 in 10 survey participants did not have comprehensive knowledge of the ABCs of HIV prevention. 209 Condom access and use Condom access More than 9 out of 10 interviewees could identify a place where condoms can be obtained. Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. Though only 39% of respondents age 25 – 49 reported being able to obtain condoms within one hour of their home or workplace, Generally, respondents preferred to obtain condoms at shops or pharmacies. There were some gender differences with more males than females cited ‘shop’ as a preferred place to obtain condoms. Condom use at first sexual encounter 208 CAREC 2007 209 CAREC 2007 263 HIV in the Caribbean: A Systematic Data Review 2003-2008 About 1/3 of young males surveyed in St Kitts reported using a condom during the ir first sexual encounter as compared to 64% of young females Condom use with non-commercial sex partner Respondents were asked about sex with different partner types and about the frequency of their condom use with each partner type. Consistent condom use is defined here as using a condom “every timeâ€? with the specified partner type. In St Kitts more than half of the young respondents (56%) reported using a condom the last time they had sex with a non-commercial partner with males leading females 64% - 48%. However this still shows that there are still significant numbers of young people not using condoms in these potentially high-risk partnerships. Among the 25 – 49 age group male condom use was more then twice as high then female (M 71%, F 31%) Overall condom use at last sex was consistently higher amongst males compared to females. Condom use with commercial sex partners The findings in show that both young males and females in St Kitts/ Nevis, n= 33 M 88%, n= 11 F 82% had high levels of reported condom use rates at last sex with a commercial partner. These results should be interpreted with caution as the denominators are quite small. It is expected that there was strong potential for response bias to questions on illegal activities, such as engagement in commercial sex. For the age group 25 – 49 only males were asked this question n= 53, 85% reported condom with last commercial partner while 57% reported consistent condom use with the same. Internationally, this indicator is usually calculated for males only, but in this BSS, the question was also posed to female respondents. The results are surprising and interesting, with much lower condom use rates reported by females compared to males. Although the question did not specify if the respondent was the client or the commercial sex worker, the assumption can be made that these young women were more likely the recipients of the money and therefore not in a strong position to negotiate condom use. 210 Access and availability of HIV and OI treatment Summary of country-specific treatment issues such as access and availability of HIV and OI meds, sources, regimens, uptake, any efforts or successes in tracking adherence and patient follow-up Medical management of people with HIV and AIDS is of high quality, but broader needs of PLWA remain under-addressed. Antiretroviral treatment (ART) is available free of charge, thanks to external (World Bank) funding, and coverage for people with advanced HIV disease is high. The Clinical Care Team (CCT) developed protocols for management of HIV and opportunistic infections exist, and provide assistance and supervision to clinical care providers. St. Kitts and Nevis has made significant progress in ensuring that persons living with HIV/AIDS are able to receive the free anti-retrovirals and supplements to ensure that they are able to lead, 210 UNGASS 2008 264 HIV in the Caribbean: A Systematic Data Review 2003-2008 a healthy life. Food vouchers and living allowances are not yet a reality for all those who are in need Services in the area of HIV/AIDS need to move outside of the traditional mode, in order to provide the level of confidentiality necessary for the comfort of users, in a very small community. Impact of Caribbean migration on local epidemic Much mention is made of “Spanishâ€? sex workers in many of the reports reviewed including the country UNGASS report and the Measure Evaluation Vulnerable Population study (2007). Tourism, while not thought of exclusively as a “Caribbean migrationâ€? phenomenon has been 211 referred to as a contributor to the sex work industry . Saint Kitts is the seat of the Eastern Caribbean Central Bank which draws its staff from the OECS member states and experiences a regular turnover of mostly staff, many young and unattached starting their careers. There are 2 offshore medical schools located in Saint Kitts and one in Nevis that attract a large mobile, affluent by local standards, population of mostly young adults. There is also one offshore nursing school. No research has been carried out with regard to the sexual mixing of the offshore school population and the local population. 212 The St Kitts / Nevis Defence Force (SKNDF) - No research is available looking at the SKNDF and its role if any in the migration of HIV. There are references to training on other islands of the Caribbean, participation in the Regional Security System, training of uniform services from other CARICOM countries at Camp Springfield all of which could play a role in the movement of the epidemic in the region. Data on specific transmission groups The Caribbean HIV/AIDS Alliance has been working in the federation of St. Kitts & Nevis for almost 3 years. During the period January 2006 – December 2007, the Alliance was able to reach approximately 2,195 people through Individual health promotion. These include some 1,082 Men who have sex with men, 470 sex workers and 165 people living with HIV/AIDS. Men who have sex with men, including bisexual The general cultural of the Federation is homophobic. Thus, while the number of men reporting anal intercourse with men is around 10%, a vast majority are also engaged in sex with female partners. This makes it truly difficult to distinguish a separate population of men having sex with 213 men . Interviews were conducted with 23 MSM. Twenty-one interviews were conducted in Saint Kitts 214 and two in Nevis . • Multiple partnerships exist both among MSM and men having sex with both men and women. • There is engagement in some form of transactional sex among MSM, that is exchanges of sex for gifts or favours • There is a good awareness of factors that influence risk of HIV infection in the MSM community and familiarity with the risks of being sexual active, having more 211 NCDAP/FAS/Prisoners 2004 212 http://www.cavehill.uwi.edu/bnccde/sk&n/conference/papers/DEPhillips.html 213 UNGASS 2008 214 MEASURE Evaluation. 2007 265 HIV in the Caribbean: A Systematic Data Review 2003-2008 than one partner, and not always using protection; but this knowledge is not often reflected in behaviours • Most of the men also admitted that they had not disclosed their sexuality to their families or health care professionals for fear of stigma and discrimination. • Only 1/3 of respondents had ever been tested for HIV. 215 Male-to-male sex as reported in the OECS BSS The OECS BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. The percentage of men who reported sex with men, ever or in the last 12 months in St. Kitts and Nevis were 10%. The highest in all the OECS but the report points out that this may have been so due to a deeper sensitisation among interviewers seems to have played a role in the findings from St Kitts and Nevis These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report 216 Prevention of Mother to Child Transmission of HIV (PMTCT) In 2005 the Ministry of Health and Environment, in collaboration with CAREC, conducted a sero- prevalence survey in the ante-natal population. However, several drawbacks were met in the collection of the samples and the study had to be abandoned. It was reported in their UNGASS report that they planned a new study in 2008. PMTCT is an integral component of the national strategy for the prevention and control of HIV/AIDS. However, in the past and at present, HIV testing of pregnant mothers is not done systematically but instead dependent upon the individual physician. From March 2005 to December 2006, 324 pregnant women seen in the public sector in St. Kitts volunteered to be tested for HIV antibodies through the national programme aimed at reducing mother-to-child transmission of HIV. Of the 324 women tested, 2 were found to be positive yielding an average sera-prevalence rate of 0.62 %. It should be recognized that this rate represent only the status of HIV infection among pregnant women who have agreed to be tested for HIV antibodies. These cases were in the 15- 19 and 25-29 age groups and anti-retroviral treatment was provided through the PMTCT programme. 217 At-risk Women / Heterosexual transmission • Despite the fact that many women in long-term relationships indicate that they feel vulnerable to HIV because of men not being faithful to them; they do not use condoms based on the longevity of the relationship. 215 CAREC 2007 216 UNGASS 2008 217 Measure Evaluation 2007 266 HIV in the Caribbean: A Systematic Data Review 2003-2008 • Women who often have unfaithful partners do nothing about it, because of the economic support and security that comes from their partners. • There in an element of intergenerational sex—the women interviewed were aware of young women who have sex with older men, often with married men. • Low self-esteem among women makes them vulnerable to staying in bad relationships with men. Heterosexual transmission 218 Sexual activity 25 – 49 years old Respondents who reported ever having had sex were asked about their sexual activities in the 12 months preceding the interview. The survey sought information on: (1) sexual activity in the last 12 months (2) number and type of sexual partners (3) commercial sex (4) male-to-male sex (5) transactional sex and (6) forced sex in the last 12 months. Sexual activity in the last 12 months This indicator was calculated using all survey participants as the denominator. The findings showed that approximately eight out of ten males and females were sexually active in the last 12 months. Non-regular non-commercial sex partners Noticeably more men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than one non-regular partner in the last 12 months was 36%, while among females, 10%. The number of non-regular, non-commercial partners reported by at least half of surveyed men and women was one. In St Kitts the number of non-regular, non-commercial partners reported by at least half of surveyed men was two and women was one Commercial sex The proportion of men who reported engaging in commercial sex was 18% vs 1% for females. Men who declared having commercial partners were asked if they had received money or gifts in exchange for sex in the 12 months preceding the interview. The data show that few of these men received payment, except in St. Kitts where 9% of men reported this. There were negligible reports (high of 2% in St. Kitts and Nevis, less than 1% in all other countries) of giving or receiving drugs in exchange for sex. Male-to-male sex In all countries except for St. Kitts and Nevis, the proportion of men reporting ever engaging in male-to- male sex was one percent (1%) or less. However, one in ten Kittitian male respondents (10%) stated that they had ever had sexual relations with another male. Under-reporting is highly likely to have occurred in all the countries, due to the illegal aspect of homosexuality and the high level of stigma and discrimination in the society toward Men who have Sex with Men (MSM); a deeper sensitisation among interviewers seems to have played a role in the findings from St Kitts and Nevis. 218 CAREC 2007 267 HIV in the Caribbean: A Systematic Data Review 2003-2008 Sexual activity for youth age 15 – 24 years old These indicators measure sexual activity among young people. Typically, young people have partnerships that are more often of short duration and perhaps less formal than those of older people. Moreover, they are less likely to live with their sexual partners, and this can often result in one of the partners having additional concurrent partners, thus increasing the risk of infection. Data are presented for indicators around sexual debut (age, age mixing and forced sex) and indicators of recent sexual activity (sexual intercourse, number of partners, commercial sex and sex between men, in the last 12 months). Sexual initiation More than 60%f of the youth surveyed reported having ever had sex. More male youths were sexually experienced compared to their female counterparts, For young males, the percent of sexually active respondents was 71% in St. Kitts and 49% for females 219 Sex before 15 St Kitts/ Nevis, M 36%, F 10%, All 22%, Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. For young women in particular, sex with older men is often risky because young women lack the power in the relationship to negotiate safe sex. It is also an efficient means of spreading HIV infection, since, for physiological reasons younger women are more likely to become infected. Each sexual act with an infected man carries a higher risk of infection for a young girl, and older men are more likely than younger men to be infected. Age mixing is a term that refers to sexual activity between two partners that are separated by ten or more years in age. For first partner older by 10 years the percentage for all was less then 5% The proportion whose first sexual partner was between 5 and 10 years older was M 7%, F 21%, All 13%, as this scenario appeared to be more frequent amongst those surveyed. Forced sex at first sexual encounter By gender, female youths are more likely than young males (M 5% vs F 10%), to have been forced to have sex during their first sexual intercourse. Even if females are more likely to have reported forced sex, findings show that both genders experienced this form of violence. In addition, with such a sensitive question, respondents may have been unwilling to report being raped due to feelings of fear and/or shame and so these statistics are likely to be under-reported 219 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 268 HIV in the Caribbean: A Systematic Data Review 2003-2008 and may represent just the tip of the iceberg. Additionally, the interpretation of this question was physical force, and so does not represent psychological force (i.e. coercion). Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 57% of the males and 41% females were sexually active in the last 12 months. This indirect measure of secondary abstinence can inform on the impact of education and prevention programmes, which encourage young people to abstain from sex after engaging in early sexual activity. Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 64% of males in St Kitts and Nevis reported having more than one partner Among females, St Kitts/ Nevis, F 24% reported having more than one partner The range of non-commercial partners in the last 12 months in St Kitts/Nevis Males 1 – 20, Females 1 - 10 Commercial and transactional sex Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. I St Kitts/ Nevis, M 13%, F 5%, All 9%, The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?" M 11%, F 4%, All 8%, Gave drugs for sex was very low St Kitts/ Nevis, M 2%, F 0%, All 1%, And a similar question was also asked who received drugs for sex. It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr Day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. M 6%, F 5%, This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. 269 HIV in the Caribbean: A Systematic Data Review 2003-2008 Male-to-male sex The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. The percentage of men who reported sex with men, ever or in the last 12 months, varied according to country. In St. Kitts and Nevis the proportions of men who reported having had male partner(s) in the last 12 months were 10%. These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report. Discordant couples, No mention was made of any special work with discordant couples Sex Workers both Commercial, and Transactional Sex Workers 220 Commercial and Transactional Female Sex Workers There are two types of engagement in sexual negotiations in Saint Kitts and Nevis—commercial sex work and transactional sex. • Those involved in commercial sex work include both foreign Spanish-speaking girls and women and local English-speaking girls and women. • Those involved in transactional sex most often include local girls and women. • Spanish-speaking women and local women involved in sex work are moving between Saint Kitts and Nevis. • Spanish-speaking women we interviewed did not identify themselves as sex workers, — which is similar to the issue of local women not distinguishing themselves as CSWs— because they are not “visiblyâ€? practicing sex work, they are not street based nor do they necessarily operate out of bars or brothels or work with a pimp; they are not even engaged in the CSW activity full time. Spanish bars may be a venue for sex work, but they are also seen as community centres for the women to socialise. • Tourists will work with taxi drivers and hotel staff to set up dates with local sex workers. • Local women involved in transactional sex will often exchange sex for favours—including paying bills, buying groceries, buying clothing and electronics, or in many cases, receiving a cell phone top-up (extra money added to post-paid phones). Exchanges will also involve money. Transactional Sex among Men Who Have Sex with Men 220 Measure Evaluation 2007 270 HIV in the Caribbean: A Systematic Data Review 2003-2008 While usually when we refer to sex work we are referring to female sex workers there are often MSM engaged in sew work activities also. In the HIV and AIDS Situational Assessment: Barriers to access to Services for Vulnerable Populations the interviewers documented that during the course of their discussions that seven of the men interviewed engaged in some form of transactional sex. However, when directly asked the question as a part of the demographic form, only three admitted to engaging in transactional sex. Some exchanges between men were documented as exchanges for purchases, like cell phone top ups (extra money added to pre-paid phones), which is documented several times with other groups in this assessment (for example with women). Two interviewers noted that some exchanges may not have been solely done for the money as the exchange was for relatively small amounts (XCD $5-10) following a statement/comment such as “Give meh something, nuh…â€? after the sexual interactions—as if the money exchange would “cancel outâ€? the sex and become the primary interaction. The interviewers discussed this occurrence and thought that this may be connected to wanting to deny the act of having just had sex with a man. The assessment recommended that more information is needed to understand transactional sex within the MSM community. In that same report there was mention in informal interviews that there are local male sex workers or ‘beach boys’ who ‘hook up’ with older foreign men and women, though same as MSM sex workers activities involving these groups are hardly mentioned when discussing commercial sex work or transactional sex. Drug use, injection and non-injection There is no empirical data on the overlap of HIV and drug use in Saint Kitts and Nevis. As St Kitts / Nevis is a transhipment route for cocaine, this is the major “hardâ€? drug used. In payment for helping with the transhipment of cocaine through the twin island federation, local traffickers are paid in pure cocaine which is mostly boiled up into smokable “crack cocaineâ€?. Interdiction records show no seizures of opiates through St. Kitts/Nevis, an indication that little to no opiates are found in the local market. Though one respondent in the Prison FAS reported that heroin was said to be used primarily within one specific community / culture: “mostly Spanish people ... people from Santo Domingo and Puerto Rico ... You find heroin mostly in de Spanish communityâ€? which is supported by studies of drug use in the Dominican Republic and Puerto Rico. The 2008 UNGASS even reports that “injecting drug use is very uncommonâ€? but makes no mention non-injecting crack use. 221 Sex for drug exchanges are also mentioned in the Prison FAS In order to assess their perspective on sex for drugs exchanges, the participants in the focus groups were asked to share their opinions. As with the other questions, the responses varied. In some cases, participants reported their having sex with users who can not afford to pay them with cash. This was what a group participant revealed: It happened to me many times. You see, when a female is addicted to a drug and dey want it and don’t have money, and you say, ‘I am de man in control; I got de money and got de drugs, and wha I want you do to me, you got to do to me.’ I might just say, ‘girl come suck me dick for some coke, and she will come.’ And I would say, ‘girl a gah de weed if you addicted.’ I do enjoy that; that’s a fun a mine. When you in control, you just abuse de girl dem in that manner. And others reported seeing the sexchange taking place right before their very eyes. One prisoner disclosed: 221 NCDAP/FAS/Prisoners 2004 271 HIV in the Caribbean: A Systematic Data Review 2003-2008 A time, I could remember a saw a guy and a kind a crazy lady, I can’t believe. He say “girl come here lay me gee you a water; he just hold de girl through a alley bend her over and just knock a water on her. I say, ‘boy, you going sex she without a condom.’ He said, ‘while ye warm and alive, ye good to go.’ Some people are very careless even though AIDS is around. Some people don’t matter, they just aint using dey head. Dey don’t have to be crazy; dey don’t have to be addicted; you got some men and women out dere, sometime yougoing with a woman and she wouldn’t even say, hey boy you aint going to use a condom? Some girls aint care. Dey will tell you upfront that they aint using a condom. You got some more securing ones, dey aint playing with dey lives, and I could wuk wid them dere because it aint good to play. Protection on both part. Also, sex without protection was a concern raised by many. They revealed that many people know about condoms; but many do not use them. One prisoner shared this with the group: If you gonna have sex with her, we have to use condoms because dey are more expose and more addicted [and being] with other men just to get dere fulfillment of dere addiction …You have to use condom if you see one a dem look kind a good to de eyes, and you want to have sex with dem. Whiching, I don’t really have dat appeal with them … I more ley themsuck me dick … wha’ condom? Nobody suck dick with condom … we do call it, ‘Cleaning deRiffle.’ One of the prisoner s was ambivalent about condom use while promiscuously having sex. This was how he explained: I have my girl and children. I always be careful who I deal with because ah love me girl and don’t want to hurt my girl. Wha I am saying… I use to drop girls. If a girl come around for the first time as oppose to dem [already] around … a girl could gah it [HIV/AIDS] and you don’t know, but you would still tek a chance if you aint hearing nothing bad ‘bout her. I would still tek a chance; you check it? The use of condoms is not a ‘normal’ thing in every community. Another participant expressed his views coming from such a community: That does happen to me in the exchange of weed for wife [sex] … Dat a usual thing eh! In the ghetto … But me aint use no condom and dem tings, eh … Me aint really like to use condom and dem ting differently, eh! But is so we be in de ghetto ... Exchange is no robbery... Bare back. With regard to injecting the Prison FAS mentions that most of the injecting that was observed was experienced abroad either in neighboring countries such as St. Maarten or in the U.S. It was also noted that many Kittians are afraid of injections in general. It is believed that this phobia of injections started when they had to be vaccinated as early as in primary school. Therefore, it is no surprise that the majority did not use needles to inject illicit drugs. However, the 2 comments noted in the research were that they had injected but they did not share. These were two responses from the groups: • I “injected cocaine… Everybody had their own thingsâ€?. • “I don’t deal with that (sharing injecting equipment). I am a man who uses my own apparatus, eh. I am a man who knows these things... Ye got people who don’t scrub dey mouth for weeks, and don’t bathe for weeks. In the HIV and AIDS Situational Assessment: Barriers to access to Services for Vulnerable Populations - One of the MSM that was interviewed openly admitted to using crack/cocaine. This interview also shed some light on not only the occurrence of drug/alcohol use with this particular person, but more importantly with visitors to the island and with neighbourhoods where individuals are purchasing their drugs. As an active crack user, the interviewee expressed that he felt people more associated and stigmatised him with his drug use rather than his sexuality. He 272 HIV in the Caribbean: A Systematic Data Review 2003-2008 also self-identified as bisexual, having had both male and female sex partners. He shed light on the issue of tourist engaging in buying drugs. His experiences were mostly with tourists who came for diving purposes. The researcher stated that as this is only one person’s experience, they could not generalise this information across all sectors of tourism, but it is interesting to note the various instances of tourists engaging in drug or sex trade activities. 222 Daily alcohol consumption amongst surveyed youths appeared to be low (M 3%, F <1%) compared to adults 25 – 49 (M 17%, F 2%) Overall, males were more likely to report alcohol consumption on an every-day basis than females. The majority of people interviewed reported drinking alcohol less than once a week or never. 223 Use of illegal drugs reported in the OECS BSS Young males 15 – 24 were more likely to report using marijuana than female youths Among males, marijuana use in the 30 days preceding the interview was 20% as compared to 11% for females, this also held true for males 25 – 29 who Had a a higher proportion of males reporting ever trying marijuana and marijuana-use in the last month. The data indicate that approximately one-third of male interviewees had ever tried marijuana, with a smaller proportion of females having used this drug in the month preceding the interview. Few survey participants reported using crack and cocaine, ever and in the last month though again males out used females. Also in St Kitts 5% of males (F 1%) 25 – 49 reported having tried crack in their life time which is considered high. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders These results may not be reflective of reality as it is likely to be under-reported due to the illegal nature of the activity. 224 Prison Study In 2004 the Ministry of Health and Environment of St. Kitts and Nevis in collaboration with CAREC conducted HIV Sero-prevalence survey in Her Majesty’s Prison in St. Kitts and Nevis. All male inmates who were incarcerated during the time of the survey were eligible to participate. At that time there were 212 male inmates, 177 in St. Kitts and 35 in Nevis. The study population consisted of 169 male inmates. No inmates refused to participate, however, for security reasons, those in maximum security and those who were condemned were not allowed to participate. Of the 212 male inmates, 169 were permitted to and did participate in the survey, giving a participation rate of 100 % among eligible inmates and 80 % of the whole prison population. Four inmates tested positive for HIV, giving a prevalence of 2.4 %. No HIV result was available for one of the 169 study participants, who had a sample that was insufficient for testing. To demonstrate the lack of opiate and other potential injectable substance a focus assessment conducted in the prison depicted prisoners’ lifetime substance use. Overall, marijuana (73%) was the most used substance. Following closely were alcohol (54%), cigarettes (52%), and cocaine/crack (41%). Solvents/inhalants, hallucinogens, morphine, opium, tranquilizers, and other 222 CAREC 2007 223 CAREC 2007 224 UNGASS 2008 273 HIV in the Caribbean: A Systematic Data Review 2003-2008 drugs each had a lifetime prevalence rate of 4% (n=2); while stimulants, heroin, ecstasy, and 225 methamphetamine each had a lifetime prevalence rate of 2% (n=1). In that same prison study one inmate, when asked why these substances were the most problematic he mentioned that alcohol caused him to do things that normally he would not even considered doing. Such things included hustling and stealing. He put it like this: “Say well, alcohol would gay you more drunk. You aint tinking in your senses that how alcohol do gah you; … mek you do things you aint want to do … sex with man, mash up people vehicle, and do tings out of de way and dem tings Youth Some attention is being given to youth, who are a major target group in HIV and AIDS prevention and treatment programs. Four facilities had at least one trained provider of Youth Friendly Service (YFS), but policy/guidelines for YFS need to be scaled up and conditions at facilities made more 226 amenable to youth. 227 A discussion group with young people in Saint Kitts yielded the following: • There was generally no great concern about contracting HIV within the group—many reported that they were not engaged in sexual activity. This response was more common within the 18–26 age group. • Regarding access and use of condoms to prevent transmission, the group felt that among young people there was discussion about HIV and many discussions about sex and condoms, but that discussion about sex and condoms were divorced from discussions of HIV; they were more centred on condom use as a means of contraception. • Young people felt that factors that influenced these sexual behaviours and attitudes included (a) male promiscuity and its acceptance in Kittitian society, (b) the lack of societal role models for both young males and females and (c) the influence of religion. • Respondents felt that many young people are hesitant to buy condoms, even though they are aware that they should use them. Reasons provided include shyness and religious upbringing, as it is difficult for an underage and unmarried young person to go to a pharmacy to ask for condoms, especially in a small society. • They were not aware that public clinics offered VCT services. • They highlighted that the “top-up phenomenonâ€? is a big issue among young men and women and that youth are using their text messaging on cell phones to engage in transactional sex (i.e., an “I want a top-upâ€? message means to trade sex for a top-up) 228 Rastafarians • Rastafarians mention that the preference to using herbalists as health care providers— this choice is influenced by a dissatisfaction with both the level of professional care received by medical staff as well as the medical treatment options provided by the system, and preferences for less invasive treatments that do not require drawing of blood or use of needles 225 NCDAP/FAS/Prisoners 2004 226 Measure Evaluation St Kitts 2006 227 Measure Evaluation 2007 228 Ibid 274 HIV in the Caribbean: A Systematic Data Review 2003-2008 • Rastafarians respondents stated a general preference for not using condoms, but felt they were not different from other males. Decisions to use were sometimes personal, but also based on theories about the effectiveness of condoms and the conspiracy theory behind an international drive to promote them. • Rastafarian men may engage in multiple sex partnerships, although they may or may not have a steady girlfriend. Often these partnerships might be with non-Rastafarian women, as many Rastafarian women already have a ‘king man’ or steady partner. Prevalence of HIV co-infection with STIs, TB and hepatitis The UNGASS 2008 report reported a recent rise in the incidence of sexually transmitted infections (STIs) following a decline in the 90s. STI prevalence is a proxy indicator for HIV prevalence because of the similar transmission pattern. Unfortunately, there is little STI prevalence data, as most STIs are treated outside the government health services, and most STIs are not diagnosed in the Central Laboratory, but managed symptomatically. Yet, STI prevalence seems to be relatively high compared to the OECS region: in 2006, 5% of young people (15-24) and 10% (25-49) of adults reported STD symptoms in the preceding year. Symptoms of STD are relatively high for the region for men, 8% 229 discharge, 4% sores) In St Kitts the three public facilities offering care and support services were strong in the areas of STI and TB diagnostic and treatment services. Eight of the public facilities reported following DOTS but all first-line TB medicines were not available at all facilities. The capacity at public facilities in term of elements for preventing nosocomial infections was good, and the infrastructure for laboratory testing has attained a reasonable level for most tests in those facilities that offer CSS. Sixty-seven percent of the facilities offering any CSS had at least two medicines for 230 managing many different opportunistic infections. Self report of Sexually Transmitted Infections in Youth 15 – 24 yrs old Sexually Transmitted Infections (STIs) are transmitted in the same ways as HIV, and can be prevented by the same safe behaviours being promoted by HIV prevention programmes. Therefore, measures of STI prevalence are a relatively good guide to recent trends in sexual risk behaviour. The surveys assessed self-reported prevalence of genital discharges and ulcers among youths in the 12 months preceding the interview. Among male youths, the reported prevalence rates of 4% for genital discharge while females reported 5%. Among male youths, the reported prevalence rates of 3% for genital ulcers/sores while females reported 1%. The gender difference in the range of genital discharge may have been due to females reporting normal genital discharge as an abnormal one. These low self- reported rates carry a high likelihood of bias and should not be used to represent national STI prevalence. Adult Self-reported Sexually Transmitted Infections (STIs) This survey assessed self-reported STIs among adults, with questions on the history of genital ulcer/sores and unusual genital discharge in the 12 months preceding the interview. STI prevalence based on self-reports varied by country and by gender (Table 5.15). Genital discharge 229 UNGASS 2008 230 Measure Evaluation St Kitts 2006 275 HIV in the Caribbean: A Systematic Data Review 2003-2008 rates among surveyed males ranged from less than 1% in St. Vincent and the Grenadines to 8% in St. Kitts and Nevis. Genital ulcers/sores were reported by adult males was 4% in St Kitts and Nevis. Among females, the prevalence of genital discharge was10% and 8% in Males in St. Kitts and Nevis while the prevalence of genital ulcers/sores was 1% Human resources The national AIDS programmes in both Saint Kitts and Nevis currently are limited in terms of human resources. While the programmes are both supported as functioning agencies within the Ministry of Health, the dual and sometimes triple roles that key staff plays mean that there is a strain in the management of the HIV programme. At the time of this report, Saint Kitts NAP did not have a designated finance officer, behaviour change program coordinator, or support staff. Rather, these roles are shared within the Ministry. This can make it difficult to implement, monitor and evaluate activities. The Ministry of Health is actively addressing these issues. The Nevis programme could benefit from having an M&E staff person as well. The NACHA, the National Advisory Council on HIV and AIDS Coordinating in Saint Kitts, which has the responsibility to 231 programme the World Bank funding, has a somewhat active membership. Yet, barriers to participating in this process have not been assessed. There is a need to scale up the staffing in both Saint Kitts and Nevis NAP offices. In 2003 St. Kitts and Nevis Health Minister warned that the recruitment of trained Caribbean nurses to Europe and North America is posing a real threat to the survival of adequate health care in the twin island federation and the wider Caribbean. "The recruitment is a real threat to the survival of our health care delivery system" and the region "cannot underestimate the severe consequences to our health care delivery system, should mass migration of nurses continue 232 unabated," he said . Clinical Service Providers Thirteen interviews were conducted with clinical service providers in Saint Kitts and Nevis; they yielded the following: • Most clinical service providers interviewed worked in both the public and private sectors. • A consistent message that emerged from discussions with clinical care providers, especially doctors and nurses, was their inability to provide VCT services consistently, and their need for dedicated staff to provide VCT. • Providers were aware of the public’s fear of lack of confidentiality in facilities. It was mentioned that in general, people do not want to go to the hospital to be tested for HIV because of a perceived lack of confidentiality. • Even though providers were aware of perceived lack of confidentiality, few providers could cite past breaches in confidentiality. Despite this, providers take extra precaution to protect the status of their patients. 231 Measure Evaluation 2007 232 http://www.montserratreporter.org/fra0503-3.htm 276 HIV in the Caribbean: A Systematic Data Review 2003-2008 Governmental and Non-governmental Organisations Formal interviews were conducted with both governmental and non-governmental organisations in both Saint Kitts and Nevis; they yielded the following: • Many Ministries outside of the Ministry of Health are engaged in HIV and AIDS-related work. There is a strong programmatic focus on prevention programs with youth, condom distribution and establishing policies to protect PLWHA against discrimination in the workplace and in the general community. There is room, however, for scale-up in other programmatic domains, especially in programs targeting vulnerable groups. • There is a need to integrate monitor and evaluate programs implemented by NGO’s and Ministries outside of the Ministry of Health. • Many respondents said that the biggest barrier to providing HIV and AIDS services to vulnerable groups was knowing more about them. 233 Members of Faith-Based Communities This assessment conducted informal interviews with clergy in Saint Kitts, as well as three members of the Rastafarian community in both Saint Kitts and Nevis. • There was an expressed desire by the clergy to be more involved in activities related to the care of PLWHA. • There was a feeling that the church should be a domain of reconciliation and compassion, and perhaps this is not being emphasized enough to those living with HIV. • The clergy also expressed that the church’s role was in promoting abstinence, especially among young people. Stigma and Discrimination 234 People Living with HIV and AIDS (PLWHA) FACTTS, a PLWHA group exists since 1999, but stigma prevents most PLWA to join, and impedes its effectiveness as a self-support or activist group. The broader needs of PLWHA and their carer, including home and community care, nutritional, psychosocial and pastoral needs have not been assessed and/or addressed so far. Strong stigma against PLWHAs serves to drive the epidemic underground making it difficult to conduct effective prevention, care and treatment. Several strides have been made to address discrimination against PLWHA, such as the establishment of a human rights desk located in the National AIDS Secretariat, as well a formal complaint procedure. Researchers working a report on Vulnerable Populations published in 2007 were able to speak with four people in Saint Kitts who are HIV-positive. They reported the following: • Stigma and fear of a lack of confidentiality in the public health care system associated with picking up HIV medications at the pharmacist means PLWHAs often feel more comfortable accessing medications off-island through a friend or having to travel themselves to obtain them. • Doctors often have to go and pick up medications at pharmacies themselves to protect the identity of their HIV+ patients from the public and other health care professionals. 233 Measure Evaluation 2007 234 Measure Evaluation 2007 277 HIV in the Caribbean: A Systematic Data Review 2003-2008 • There was an expressed need for professional and psychosocial support and trained counsellors in both the private and public sector. • There is a reported great satisfaction and comfort with the relationship with clinical providers among the PLWHAs interviewed. 235 Stigma and discrimination of the general population towards PLWHA This section uses proxy indicators to assess the level of stigma and discrimination among the target population. Attitudes of the respondents towards people with HIV/AIDS were assessed using a series of questions about willingness to have contact with infected people Respondents with accepting attitudes towards persons with HIV/AIDS based on a composite of 5 questions a-e (p) willingness to care for a close male relative who became sick with the AIDS virus (q) willingness to care for a close female relative who became sick with the AIDS virus (r) willingness to buy food from a shopkeeper or food vendor whom they knew was HIV positive (s) thinks a teacher who is HIV infected but not sick should be allowed to continue teaching in school (t) would not want to keep the HIV positive status of a family member a secret. The results of this indicator showed that most people interviewed would have discomfort having close contact/associations with people living with HIV infection or AIDS Youth St Kitts/ Nevis, M 1%, F 1%, All 1%, Adults St Kitts/ Nevis, M 4%, F 7%, All 5%, MSM Stigma Male to male sex appears to be much more common in Saint Kitts than acknowledged, according to the behavioural surveillance. Yet, homophobia is rampant. The stigma associated with male-to- male sex leads some homosexuals to have a female partner as an alibi, thus putting her at risk. Also, the illegal status of ‘buggery’ drives MSM underground, thus impeding access to health education and STD/HIV treatment. 236 Human Rights Desk A Human Rights Desk that will receive and respond to human rights violations against people living with HIV (PLHIV) is being established in St. Kitts. This is an initiative of the Caribbean Regional Network of People Living with HIV/AIDS (CRN+) and the Caribbean Coalition of National AIDS Programme Coordinators (CCNAPC) and will support efforts being made to reduce the high incidence of stigma and discrimination, which remains as one of the root causes for the region’s increasingly high HIV prevalence. The desks will serve as mechanisms for seeking redress for PLHIV when their human rights are violated and will provide much-needed information to PLHIV and the public about their basic human rights. It will also serve as an advocacy tool for promoting legal changes which protect the 235 CAREC 2007 236 ILO 278 HIV in the Caribbean: A Systematic Data Review 2003-2008 rights of PLHIV. It is funded by CRN+ grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Cultural Taboos Cultural taboos around HIV, sex and sexuality are barriers to access sexual health services. Saint Kitts and Nevis are relatively small and close-knit island communities, resulting in stigma and discrimination. Many people are reluctant to admit (and seek support to change) risky behaviours; young people are reluctant to buy condoms; few people access VCT or STD treatment, for fear of breach of confidentiality. Many AIDS patients don’t want to get their ARV from the pharmacy, or even seek care abroad. 279 HIV in the Caribbean: A Systematic Data Review 2003-2008 References (highlighted entries refer to documents not yet obtained) Ameen, A., Lloyd. E. 2004. Assessment of the National HIV/AIDS Programme (NAP) of the Federation of St. Kitts and Nevis. Caribbean Health Research Council: Trinidad. CAREC (Caribbean Epidemiology Center). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. ILO Subregional Office for the Caribbean. WorkPlace Response, March 2007, Port of Spain, Trinidad and Tobago. MEASURE Evaluation. 2006. Nevis Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. MEASURE Evaluation. 2006. Saint Kitts Caribbean Region HIV and AIDS Service Provision Assessement. Calverton, MD: Macro International Inc. MEASURE Evaluation. 2007, An HIV and AIDS Situational Assessment: Barriers to access to Services for Vulnerable Populations in Saint Kitts and Nevis, TR-07-61 USAID National Council on Drug Abuse Prevention, Drug Prevalence Survey of Civil Service Employees 2004, Office of the Prime Minister, Federation of St. Kitts and Nevis - West Indies National Council on Drug Abuse Prevention, Focus Assessment Study on Drug Use: Identifying Patterns among Prisoners Prior to Incarceration 2004, Office of the Prime Minister Federation of St. Kitts and Nevis - West Indies Cited as NCDAP/FAS/Prisoners 2004 Saint Kitts and Nevis Strategic Plan 2001-2005. St. Kitts/Nevis National AIDS Programme.2007. Draft St. Christopher and Nevis Strategic Plan for HIV/AIDS 2008-2012 St Kitts/Nevis National Assessment Team., Cenac, Veronica. 2007. The St. Christopher and Nevis Final Report on the Law, Ethics and Human Rights The World Bank, 2002. Project Appraisal Document on a proposed Loan in the Amount of US$ 4.045 Million to St. Kitts/Nevis for a HIV/AIDS Prevention and Control Project . Available at http://www- wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64187937&theSitePK=5236 79&menuPK=64187510&searchMenuPK=64187283&siteName=WDS&entityID=000094946_030 10904013882 United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—St. Christopher and Nevis. Available at http://data.unaids.org/pub/report/2008/saint%20kitts_and_nevis_2008_country_progress_report_ en.pdf 280 HIV in the Caribbean: A Systematic Data Review 2003-2008 SAINT LUCIA HIV Overview Complied by Dr Marcus Day 10 July 2008 281 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Table of Contents....................................................................................................................... 282 Review Strategic Plan 2005-2009 ............................................................................................. 284 Background Country Data ........................................................................................................ 284 HIV Overview .............................................................................................................................. 284 Status of the Epidemic .............................................................................................................. 285 Care and Treatment ................................................................................................................... 285 Provision of ARV ................................................................................................................ 286 Data Collection and Country Surveillance System ................................................................ 286 Research and Technological Development in Health ............................................................ 286 Monitoring and Evaluation (M&E ....................................................................................... 287 Testing and Diagnosis sites ............................................................................................... 287 Prevention................................................................................................................................... 287 Condom access ................................................................................................................. 287 Condom use at first sexual encounter ............................................................................... 287 Condom use with non-commercial sex partner ................................................................. 287 Rejection of myths about HIV ............................................................................................ 288 Knowledge of HIV prevention strategies............................................................................ 288 PMTCT............................................................................................................................... 288 HIV positive women receiving ARV drugs in the PMTCT programme ................................. 289 HIV testing and status ........................................................................................................ 289 HIV testing history .............................................................................................................. 289 Voluntary versus “requiredâ€? HIV testing ............................................................................. 289 HIV Test last 12 months .................................................................................................... 289 Current knowledge of HIV status ....................................................................................... 289 PEP Post Exposure Prophylaxis .............................................................................................. 290 HIV and OI ......................................................................................................................... 290 Impact of Caribbean migration on local epidemic ................................................................. 290 Specific transmission groups: ................................................................................................. 291 Female / Heterosexual ....................................................................................................... 291 Discordant couples............................................................................................................. 291 Sex Workers....................................................................................................................... 291 Drug Use and Prisoners..................................................................................................... 291 Male-to-male sex................................................................................................................ 291 282 HIV in the Caribbean: A Systematic Data Review 2003-2008 General risk behaviour .............................................................................................................. 292 Alcohol consumption .......................................................................................................... 292 Use of illegal drugs............................................................................................................. 292 Sexual activity .................................................................................................................... 292 Youth .................................................................................................................................. 292 Sexual initiation .................................................................................................................. 293 Sex before 15..................................................................................................................... 293 Age-mixing at first sexual encounter.................................................................................. 293 Forced sex at first sexual encounter .................................................................................. 293 Youths sexually active in the last 12 months ..................................................................... 294 Youth with multiple sex partners ........................................................................................ 294 Commercial and transactional sex for those who have had sex in the past 12 months.... 294 Non-regular non-commercial sex partners among adults.................................................. 294 Impact of stigma and discrimination ....................................................................................... 295 Stigma and discrimination .................................................................................................. 295 Human Rights .................................................................................................................... 296 Provider Stigma.................................................................................................................. 296 Criminalisation of Sexual Offenses .................................................................................... 296 Human Resource Shortages..................................................................................................... 297 References.................................................................................................................................. 299 283 HIV in the Caribbean: A Systematic Data Review 2003-2008 Review Strategic Plan 2005-2009 As part of the Saint Lucia National HIV/AIDS Strategic Plan 2005-2009 for the expanded response to HIV/AIDS in, the Government aims to: Strategic goal: To reduce HIV transmission and to mitigate the impact of HIV and AIDS on all levels of society Four broad strategies: STRATEGY 1: Advocacy, Policy Development Including advocacy, policy and legislation, poverty reduction, human rights STRATEGY 2: Comprehensive HIV/AIDS care for all PLWHA Including treatment, care and support; guidelines and protocols; psychosocial care; stigma and discrimination; workplace interventions; community and health systems interventions STRATEGY 3: Preventing further transmission of HIV Including PMTCT, VCT and STI interventions among targeted and vulnerable groups STRATEGY 4: Strengthening national capacity to deliver an effective, coordinated and multi-sectoral response to the epidemic. Including research and surveillance; monitoring and evaluation; empowering the NACC; multi- sectoral coordination and collaboration Background Country Data The small island developing state Saint Lucia, with a total land area of 616 sq km and a population of approximately 170,649, is located in the Eastern Caribbean. It is a member of the Organisation of Eastern Caribbean States (OECS), the Caribbean Community and Common Market (CARICOM), the Organisation of American States and the Commonwealth of Nations. HIV Overview HIV/AIDS in Saint Lucia falls within the category of concentrated, low prevalence epidemics. During the late 1980s and early 1990s the disease was characterized by relatively low levels of infection among STI patients and little, if any infection among pregnant women and blood donors. The AIDS Epidemic Update 2006 reported an average adult HIV seroprevalence of 1.2% (range 0.9%–1.7%) in the Caribbean region. While HIV infection continues to be characterised as being transmitted largely through heterosexual intercourse, in the Saint Lucian context this includes: • transactional sex where no cash is exchanged but gifts are given and support supplied, • sex for drugs (crack cocaine) transactions and • more traditional sex work (exchanges for cash) either by primarily foreign women working in brothels and dance halls or largely locals working the streets. In addition there is a hidden but assumed to be substantial population of men having sex with men exclusively (MSM) and bi-sexual men who have sex with both sexes. Male bisexuality has created a bridge for the virus to migrate between the sexes. As sex work, male on male sexual 237 contact and crack use are heavily stigmatised and for the most part illegal this significant but neglected aspect of the epidemic remains largely unstudied. The report states that as the epidemics in the region evolve, more women are being infected and the number of new infections among women now outstrips that among men. 237 While male on male sexual contact is not illegal, anal intercourse (buggery) continues to be listed in the Criminal Code of 2002 as an offense. 284 HIV in the Caribbean: A Systematic Data Review 2003-2008 Status of the Epidemic Studies to determine Saint Lucia’s HIV prevalence rate have not been conducted. Rates from .22% to .51% have been applied to the epidemic in with some stating figures as high as 1.8% said to represent the top end of the range. With poor surveillance of groups involved in high-risk behaviours, under-reporting due to stigma and local modelling non-existent, we are unable to determine the actual prevalence rate. The available data shows a steady increase in new cases of HIV and AIDS from 1985. There were 10 AIDS cases in the first 3 quarters of 2007 compared to 27 cases of AIDS in 2005. There is a decline in the number of cases seen in children reflecting an increasing success of the PMTCT programme. Two children under 6 were initiated on ART in 2007. Heterosexual transmission accounts for 25% of all reported cases reported. And while 55% of reported cumulative HIV cases, the mode of transmission is unknown more rigorous data collection at the time of a patient’s first visit has reduced this “unknownâ€? category substantially in recent years. 238 While males out rank females in cumulative cases of HIV 50.4% vs. 43.4%, by the end of the rd 3 quarter 2007 new cases of HIV were almost equal between males and females (51% vs. 49%) a clear trend to the feminisation of the epidemic so widely discussed. There is now an equal rate of HIV infection between the sexes, a marked difference from the first reports in 1985 when males were accounted more affected than females The most impacted group for HIV infection is the age group 25-29 females 7.73% and males 40- 44 9.57% (see table in Annex 4) In treatment females predominate in all age groups except the over 45+.. During 2006, 53 new cases of HIV infection were registered (32 male and 20 female, 1 unknown), and 47 new cases during the first 3 quarters of 2007 (24 male and 23 female, a 1.1 ratio). 19 individuals died of in 2005 with the introduction of ARV in that year 2005 the death rate has been reduced to 4 as of September 2007. As of the end of 2007 the adult HIV/AIDS – adult (20-49 y.) prevalence rate HIV prevalence was estimated to be 0.23% (2007) with the 15 – 24 year old rate set at .51% based pre-natal clinic 239 data Table 1 New HIV Cases in Grand Females Males Unknown Total 2006 20 32 1 53 1 2007 23 24 47 Total 43 56 1 100 1 January 1 – 30 September 2007 240 Care and Treatment National care and treatment protocols developed and disseminated in 2006. 238 1985 to present – Figures from MoH NAP statistics 239 National Aids Programme statistic 240 UNGASS 2008 285 HIV in the Caribbean: A Systematic Data Review 2003-2008 Treatment is centralised with the main STI and only HIV clinic based at Victoria Hospital run by a part-time Clinical Care Coordinator paid under the World Bank agreement. Antiretroviral treatment is provided free of charge to all patients at the Castries STI clinic. Individuals who select to be treated by a private physician must pay for their services but are provided free ARVs. An assessment of the health systems infrastructure was conducted as part of a WB review during 2007, including Victoria Hospital and STI clinics – The VH STI clinic was declared inadequate for major refurbishing but will receive a facelift until a new facility can be indentified. STI/HIV patients continue to receive care under poor conditions. Provision of ARV Treatment is centralised with the main STI and only HIV clinic based at Victoria Hospital run by a part-time Clinical Care Coordinator paid under the World Bank agreement. Antiretroviral treatment is provided free of charge to all patients at the Castries STI clinic. Individuals who select to be treated by a private physician must pay for their services but are provided free 241 ARVs . Data Collection and Country Surveillance System Surveillance (sentinel and population based) systems need strengthening. Public free HIV and STI testing is available in Castries at Victoria Hospital daily, and at Dennery Hospital one day every two weeks, Soufriere Hospital and Vieux Fort health centre weekly. Testing is by Elisa and results are usually available in 2 – 3 weeks which necessitates a return visit to the clinic. There is no mechanism other then checking each individual patient record to determine which clients returned for their results. 242 Research and Technological Development in Health In 2004, the Government conducted a knowledge, attitude, and practice survey (KAPS) of young persons (10–30 years of age) regarding HIV/AIDS in Gros Islet, Vieux Fort, Canaries, and Dennery, as part of a joint effort with the Organization of Petroleum Exporting Countries and UNFPA; the survey revealed the need for a deliberate strategy to arrest and control the HIV/AIDS 243 epidemic among Saint Lucian youth . In 2004, the above-mentioned core welfare indicators survey included the monitoring of poverty and household welfare, covering a sufficiently large and representative sample to provide reliable welfare indicators for planning and policy formulation. In 2005, a UNICEF-sponsored child vulnerability study provided the Government pertinent findings and recommended priorities for action. That same year, a survey conducted by the Substance Abuse Advisory Council Secretariat to determine the level of drug abuse and drug education activities among the secondary school population found that the drugs most commonly used were marijuana, crack, and cocaine. Number of blood units collected and screened – 2006 and 2007* Approximately 2500 units of blood are collected annually. 100% of blood collected is screened for 244 HIV, HTLV1, HBV, HCV, VDRL 241 UNGASS 2008 242 PAHO Health in the Americas 2007. Vol II – Countries – Saint Lucia 243 Government of Saint Lucia; United Nations Population Fund; Organization of Petroleum Exporting Countries. Knowledge, Attitude, and Practice Survey of Youth regarding HIV/AIDS, 2004. 244 Reported to author by government pathologist Dr Stephen King 286 HIV in the Caribbean: A Systematic Data Review 2003-2008 245 Monitoring and Evaluation (M&E) The following 3 areas were mentioned in the 2008 UNGASS as needing improvement • More primary research is required to get evidence related to vulnerabilities in St Lucia. • Improved M&E systems require stronger collaboration between the NAPS and the epidemiology and statistics units of key line ministries. • For some new HIV cases, the mode of transmission is still unknown, which points to gaps in the surveillance system, and a lack of trust in the system on the part of the patients and buy-in for improved understanding of the trends and drivers of the epidemic. Testing and Diagnosis sites, Counselling and Testing for HIV In the 4 STI sites noted above free ELISA HIV testing and counselling was provided during 2006- 7. Counselling is carried out by community health nurses who have been trained in national VCT protocols/guidelines. Prevention 246 Condom access More than 9 out of 10 interviewees could identify a place where condoms can be obtained. Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. 247 Condom use at first sexual encounter Saint Lucia, M 42%, F 42% All 42%, Less than half of the surveyed youths in St. Lucia reported using a condom during their first sexual encounter 248 Condom use with non-commercial sex partner Respondents were asked about sex with different partner types and about the frequency of their condom use with each partner type. Consistent condom use is defined here as using a condom “every timeâ€? with the specified partner type. Across all countries, more than half of the respondents reported using a condom the last time they had sex with a non-commercial partner. Saint Lucia, M 60%, F 49% All 55%, However this still shows that there are still significant numbers of young people not using condoms in these potentially high-risk partnerships. Condom use at last sex was consistently higher amongst males compared to females. The findings show that Saint Lucia males had the lower reported condom use rates at last sex with a commercial partner (n= 26 69%) then females (n= 54 F 83%) 245 As reported in the UNGASS 2008 246 CAREC 2007 247 CAREC 2007 248 CAREC 2007 287 HIV in the Caribbean: A Systematic Data Review 2003-2008 These results should be interpreted with caution as the denominators are quite small, with 26 males and 54 females reporting having had sex with commercial sex partners in the last 12 months. It is expected that there was strong potential for response bias to questions on illegal activities, such as engagement in commercial sex. Internationally, this indicator is usually calculated for males only, but in this BSS, the question was also posed to female respondents. Males reported much lower condom use rates when compared to females. Although the question did not specify if the respondent was the client or the commercial sex worker, the assumption can be made that these young women were more likely the recipients of the money and therefore not in a strong position to negotiate condom use. 249 Rejection of myths about HIV BSS Respondents were asked 7. if HIV could be transmitted through mosquito bites 8. if someone can be infected by sharing a meal with an HIV infected person 9. if a healthy-looking person can be infected with HIV. Most young people surveyed, regardless of their gender, knew that a healthy-looking person could have HIV. Similar proportions of respondents rejected myths about HIV transmission via mosquito bites and by sharing a meal with an HIV infected person. Likewise almost all adults interviewed, regardless of gender, knew that a healthy-looking person can be infected with HIV. 250 251 Knowledge of HIV prevention strategies The questionnaire had three questions to assess knowledge of HIV prevention methods – abstinence from sex, having one faithful uninfected partner, and consistent condom use. A composite of the three questions was calculated for an indicator on overall knowledge of the “ABCâ€? of HIV prevention methods. Generally, all three prevention methods were identified by many respondents. In Saint Lucia the proportion of females with overall correct knowledge was higher than males. These findings highlight the fact that 3 in 10 survey participants did not have comprehensive knowledge of the ABCs of HIV prevention. PMTCT 252 In 2007 99+% of pregnant women were reached with VCT services, and of these, only one opted out from having an HIV test. PMTCT has assisted in allowing us to diagnose females. They are more willing to access treatment as they care about the possibility of their unborn child contracting the disease. The three patients who are all known to have had peri-natal transmission are female. The Clinical staff is monitoring the PMTCT programme to see if there is any disproportionate tendency for transmission in one sex over the other. All relevant wards have protocols for the management of HIV positive mothers in hospital, but there was poor communication between the obstetric and paediatric departments during much of 249 CAREC 2007 250 CAREC 2007 251 CAREC 2007 252 The reason this is not registered as 100% is that a few women continue to birth at home 288 HIV in the Caribbean: A Systematic Data Review 2003-2008 2006-7. Transfer of new-borns from paediatric departments to community paediatric services, was also assessed to be in need of improvement. HIV positive women receiving ARV drugs in the PMTCT programme In 2007 11 women were receiving PMTCT services. It was unknown the proportion of cases determined at the point of delivery. It was estimated that 14 women required this treatment so it was reported that 78% of those women requiring treatment were receiving ART. In fact 100% of those women identified received treatment to prevent mother to child transmission. 253 HIV testing and status This section provides information on: 1. perceptions of confidentiality of HIV testing in the community 2. HIV testing history 3. whether HIV testing was voluntary or required and 4. current knowledge of HIV status 254 Perceptions regarding confidential HIV testing 56% of young males and 72% of female youth in all surveyed thought it was possible to get a confidential HIV test in their community 255 HIV testing history Less than 31% of 10 survey participants reported ever being tested for HIV; females (31%) are more likely than males (22%) to have ever had an HIV test. 256 Voluntary versus “requiredâ€? HIV testing There was a lower proportion of men (24%) reporting voluntary testing compared to females (38%). 257 HIV Test last 12 months Of the respondents ever tested the percentage tested in the past 12 months M 64%, F 34% 258 Current knowledge of HIV status This indicator is designed to show how many people have been tested and received their results in the last 12 months. Of the people who had ever received an HIV test, less then 1/2 of them had been tested within the 12 months preceding their interview. 253 CAREC 2007 254 CAREC 2007 255 CAREC 2007 256 CAREC 2007 257 CAREC 2007 258 CAREC 2007 289 HIV in the Caribbean: A Systematic Data Review 2003-2008 Analysis of the data for these people tested within the preceding 12 months showed that the majority (80% or greater in all countries) had received the result of the test, regardless of their gender. The indicator for the population receiving an HIV test and result in the last 12 months shows that 13% of the males and 10% of the females surveyed had current knowledge of their HIV status. 259 PEP Post Exposure Prophylaxis Post Exposure Prophylaxis (PEP) is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or through sexual intercourse. Within the health sector, PEP is provided as part of a comprehensive universal precautions package that reduces staff exposure to infectious hazards at work. There were 36 incidents potentially requiring PEP that were reported to the MoH during the first 3 quarters of 2007. 24 of those cases received PEP and 10 did not. One person started PEP and stopped due to side effects. All but two persons worked in the health sector. Of those two one was a tourist (child) who was injured with hollow bore needle on beach, the other a hotel guest services attendant who was also injured with hollow bore needle. Both of these cases are indicative of unsafe disposable of injecting equipment. While this could be a simple case of the unsafe disposal of a syringe used in the administration of insulin, one would assume diabetics would be more schooled in proper syringe disposal. No one attending the MoH review of this document was award of any protocols in place for the use of PEP in the event of rape HIV and OI 9 deaths occurred in 2007 – the cause of death was varied with multiply OIs attributed to each person 5/9 PCP Pneumocystis carinii pneumonia 3/9 Wasting Syndrome 3/9 Renal Failure / CRF chronic renal failure /9 Toxoplasmosis of the brain 2/9 Tuberculosis 2/9 Oral candidiasis Mentioned only once: PPD, Cryptosporidiasis, Wasting Syndrome, Anemia GI bleeding, Thrombocytopenia, Syphilis, HIV Encephalopathy 28 persons (this excluded the nine persons that passed away) were hospitalised and survived during 2007 10 were hospitalised for child birth / pregnancy issues while the remaining 18 presented with many with the same illnesses listed above Impact of Caribbean migration on local epidemic There is no data on migration issues as they relate to Saint Lucia. In addition to many workers who migrate for employment there are sex workers from the DR, Guyana, Jamaica, and Trinidad. 259 UNGASS 290 HIV in the Caribbean: A Systematic Data Review 2003-2008 Specific transmission groups: Female / Heterosexual Discordant couples No data on discordant couples in Saint Lucia was found Sex Workers No data on sex workers other then what is reported in the OECS BSS is available for saint Lucia No data was available for the 2008 UNGASS report Drug Use and Prisoners Although population surveillance systems are weak, data suggests much higher levels of HIV 260 infection in the prison population and among non-injecting cocaine users. A seroprevalence survey carried out by CAREC among inmates at the Bordelais Correctional Facility in St Lucia in 2004 found a 2% prevalence rate. This study involved the voluntary participation of 347 male inmates (with approximately 150 inmates opting out). A more recent study conducted in 2007 among 106 homeless and poor crack cocaine users, revealed an HIV prevalence rate of 7.5% and very high rates of other sexually transmitted infections. HIV and STI among cocaine Users HIV and STI among cocaine Users (N=106) participating in a BSS of homeless and poor crack users in Castries 2007 Positive Negative No Results HIV Status 8 (7.5%) 98 (92.5%) 0 (0%) Hepatitis B 3 (2.8%) 101 (95.3%) 2 (1.9%) HTLV1 10 (9.4%) 96 (90.6%) 0 (0%) VDRL 62 (58.5%) 43 (40.6%) 1 (0.9%) This sero-prevalence and behavioural survey was carried out by the Caribbean Drug Abuse Research Institute as part of a cooperation project of the Caribbean Harm Reduction Coalition’s (CHRC) outreach support programme for homeless addicts. Activities include facilitation of access to antiretroviral treatment for HIV positive clients and adherence counselling in addition to on-going harm reduction services. Male-to-male sex There are no data available on HIV rates among sex workers or men who have sex with men in Saint Lucia and this is seen as a serious void when developing evidenced based programming. These are groups known to be at risk in the region; significantly higher rates of HIV have been 261 found in these population and yet males present at a rate of ¼ that of females. The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. 260 There have been no reported cases of injecting drug use at the drug treatment centre, in the prison or by the police during drug raids in Saint Lucia. 261 UNGASS 2008 291 HIV in the Caribbean: A Systematic Data Review 2003-2008 The percentage of men who reported sex with men, ever or in the last 12 months, varied according to country. In St. Lucia only 1% of the males reported having had male partner(s) in the last 12 months but this contradicts the above statistic where 7% of the males received drugs for sex. These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report 262 General risk behaviour Alcohol consumption For adults in Saint Lucia there was a notable gender difference for every-day consumption of alcohol, with more males than females reporting alcohol consumption everyday, 8% of the males vs 1% of the females. For youth – daily drinking was not as common with only 3% of the males and 1% of the females aged 15 – 24 reporting daily drinking. The majority of people interviewed 263 reported drinking alcohol less than once a week or never. Use of illegal drugs Young males were more likely to report using marijuana than female youths Among males, marijuana use in the 30 days preceding the interview was 40%. By comparison, marijuana use among females was 13%. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders. Compared to females, a higher proportion of adult males reported ever trying marijuana and marijuana-use in the last month. The data indicate that 14% of adult male interviewees had ever tried marijuana, with a 6% of females. Very few survey participants reported using crack and cocaine, ever and in the last month. These results may not be reflective of reality as it is likely to 264 be under-reported due to the illegal nature of the activity. Sexual activity Respondents who reported ever having had sex were asked about their sexual activities in the 12 months preceding the interview. The survey sought information on: (1) sexual activity in the last 12 months (2) number and type of sexual partners (3) commercial sex (4) male-to-male sex (5) transactional sex and (6) forced sex in the last 12 months. Youth These indicators measure sexual activity among young people. Typically, young people have partnerships that are more often of short duration and perhaps less formal than those of older people. Moreover, they are less likely to live with their sexual partners, and this can often result in one of the partners having additional concurrent partners, thus increasing the risk of infection. 262 CAREC 2007 263 CAREC 2007 264 CAREC 2007 292 HIV in the Caribbean: A Systematic Data Review 2003-2008 Data are presented for indicators around sexual debut (age, age mixing and forced sex) and indicators of recent sexual activity (sexual intercourse, number of partners, commercial sex and 265 sex between men, in the last 12 months). Sexual initiation Across all countries, more than half of the people surveyed reported having ever had sex. More male youths were sexually experienced compared to their female counterparts, For young males, the percent of sexually active respondents was 82% in St. Lucia and 67% for females It is important to note that these differences may have been due to the difference in age profiles for 266 people surveyed in the respective countries. Sex before 15 267 In Saint Lucia, 32% of males reported sex before the age of 15 vs 20% for females Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. For young women in particular, sex with older men is often risky because young women lack the power in the relationship to negotiate safe sex. It is also an efficient means of spreading HIV infection, since, for physiological reasons younger women are more likely to become infected. Each sexual act with an infected man carries a higher risk of infection for a young girl, and older men are more likely than younger men to be infected. Age mixing is a term that refers to sexual activity between two partners that are separated by ten or more years in age. For first partner older by 10 years the percentage for all was less then 5%. The proportion whose first sexual partner was between 5 and 10 years older was 9%, for males and 28% for females as this 268 scenario appeared to be more frequent amongst those surveyed. Forced sex at first sexual encounter By gender, female youths are more likely than young males to have been forced to have sex during their first sexual intercourse. In St. Lucia, this statistic was approximately one in ten respondents who reported being forced at first sex with males reporting 9% and females 12%. Even if females are more likely to have reported forced sex, findings show that both genders experienced this form of violence. In addition, with such a sensitive question, respondents may have been unwilling to report being raped due to feelings of fear and/or shame and so these statistics are likely to be under-reported and may represent just the tip of the iceberg. Additionally, the interpretation of this question was physical force, and so does not represent psychological 269 force (i.e. coercion). 265 CAREC 2007 266 CAREC 2007 267 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 268 CAREC 2007 269 CAREC 2007 293 HIV in the Caribbean: A Systematic Data Review 2003-2008 Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 71% of the males and 56% females were sexually active in the last 12 months. This indirect measure of secondary abstinence can inform on the impact of education and prevention programmes, which encourage 270 young people to abstain from sex after engaging in early sexual activity. Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 48%% of males reported having more than one partner vs 31% of females The range of non-commercial partners in the last 12 months in St Lucia 271 Males 1 – 10 which was the same for Females 1 - 10 272 Commercial and transactional sex for those who have had sex in the past 12 months Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. In Saint Lucia, 8% of males vs 19% of females reported this behaviour. The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?". In Saint Lucia, 7% of males vs 26% of females reported this behaviour Youth reporting giving drugs for sex was very low less then 1% but reports of receiving drugs for sex was higher (males 7% vs females10%). It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr Day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. Among adults the proportion of men who reported engaging in commercial sex was the same for males and females in Saint Lucia 7%. No male who declared having commercial partners were asked if they had received money or gifts in exchange for sex in the 12 months preceding the interview vs 6% for females 273 Non-regular non-commercial sex partners among adults Noticeably more men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than 270 CAREC 2007 271 CAREC 2007 272 CAREC 2007 273 CAREC 2007 294 HIV in the Caribbean: A Systematic Data Review 2003-2008 one non-regular partner in the last 12 months was 21% while among females, 2%. The number of non-regular, non-commercial partners reported by at least half of surveyed men and women was one, Impact of stigma and discrimination 274 Stigma and discrimination The section CAREC BSS uses proxy indicators to assess the level of stigma and discrimination among the target population. Attitudes of the respondents towards people with HIV/AIDS were assessed using a series of questions about willingness to have contact with infected people. By the responses gathered from respondents, the majority of surveyed people seemed willing to care for HIV infected relatives. Similarly, more than half of respondents reported being willing to allow asymptomatic HIV infected students and teachers to continue with their school-related activities. It should be noted, however, when this result is considered alongside relatively low experience with HIV positive people, it is possible that this level of willingness was affected by several things. These include the specification in the questions that the person “has HIV but is not sickâ€?, the degree of contact with the HIV infected person was not specified, and respondents may have a desire to appear compassionate to the interviewer (social desirability bias). Questions that specified closer contact with HIV infected people received less favourable answers. In particular, respondents were much less willing to buy food from an HIV infected vendor or shop keeper, indicating a fear of HIV transmission through food. Respondents with accepting attitudes towards persons with HIV/AIDS based on a composite of 5 questions a-e (u) willingness to care for a close male relative who became sick with the AIDS virus (v) willingness to care for a close female relative who became sick with the AIDS virus (w) willingness to buy food from a shopkeeper or food vendor whom they knew was HIV positive (x) thinks a teacher who is HIV infected but not sick should be allowed to continue teaching in school (y) would not want to keep the HIV positive status of a family member a secret. The denominator for individual proportions and the composites is the total number of respondents who have heard of HIV or AIDS. The results of this indicator showed that among the youth 96% of the males and 95% of the females interviewed would have discomfort having close contact/associations with people living with HIV infection or AIDS Among adults approximately 7 or more out of 10 respondents were willing to care for HIV infected relatives, to allow asymptomatic teachers and students to conduct their school-related activities, and to allow asymptomatic co-workers to continue working. The figures were lower for willingness to share a meal with an HIV infected person, with approximately 6 out of 10 respondents giving positive responses for this question. Strikingly, 2 or fewer out of 10 respondents reported being willing to buy food from an HIV infected vendor. The trends observed were similar among countries, and between genders in each country. Almost half of respondents reported that they would not want the HIV status of a family member to be kept a secret. The composite indicator for accepting attitudes towards people with HIV infection showed low acceptance of HIV infected people. These low scores were heavily influenced by the low willingness to buy food from an HIV infected shopkeeper or food vendor, which may actually be 274 CAREC 2007 295 HIV in the Caribbean: A Systematic Data Review 2003-2008 less a matter of stigma than a reflection that people have fears that HIV can be spread through contact with contaminated food. The results of this indicator showed that most people interviewed (M 4%, F3% 4%) would have discomfort having close contact/associations with people living with HIV infection or AIDS Human Rights A legal assessment entitled St Lucia National Assessment on HIV/AIDS, Law, Ethics and Human 275 Rights was conducted by the NGO AIDS Action Foundation, with funds provided by PANCAP (CIDA). [Report title: Assessment of Laws and Policy related to HIV and AIDS in Saint Lucia published 2007]. . Topics reported on included Disclosure, Testing and Confidentiality, Contact Tracing, Education, Universal Safety Precautions (USP), Condom Availability (including schools and prisons, Sex Education, Homosexuality, Advocacy, Stigma and Discrimination Law Enforcement, SRH services for Minors, Insurance, Economic and Social Issues for PLWHA, Political Leadership and Medical Management Provider Stigma Respondents in St. Lucia also spoke about institutionalized discrimination and said that professionals, civil servants, employers and schools should be compelled to treat PLWA equally. 276 Criminalisation of Sexual Offenses Criminal Code , No. 9 of 2004 (Effective January 1, 2005) Sub-Part C — Sexual Offences Gross Indecency 132. “(1) Any person who commits an act of gross indecency with another person commits an offence and is liable on conviction on indictment to imprisonment for ten years or on summary conviction to five years. (2) Subsection (1) does not apply to an act of gross indecency committed in private between an adult male person and an adult female person, both of whom consent. (3) For the purposes of subsection (2) — (a) an act shall be deemed not to have been committed in private if it is committed in a public place; and (b) a person shall be deemed not to consent to the commission of such an act if — (i) the consent is extorted by force, threats or fear of bodily harm or is obtained by false and fraudulent representations as to the nature of the act; (ii) the consent is induced by the application or administration of any drug, matter or thing with intent to intoxicate or stupefy the person; or (iii) that person is, and the other party to the act knows or has good reason to believe that the person is suffering from a mental disorder. 275 See Annex 5 for a copy of the key findings: 276 Loudon, M., A Study of Child Vulnerability in Barbados, St Lucia and St Vincent and the Grenadines, The United Nations Children’s Fund (UNICEF), November 2006 296 HIV in the Caribbean: A Systematic Data Review 2003-2008 (4) In this section “gross indecencyâ€? is an act other than sexual intercourse (whether natural or unnatural) by a person involving the use of the genital organs for the purpose of arousing or gratifying sexual desire.â€? Buggery 133 “(1) A person who commits buggery commits an offence and is liable on conviction on indictment to imprisonment for — (a) life, if committed with force and without the consent of the other person; (b) ten years, in any other case. (2) Any person who attempts to commit buggery, or commits an assault with intent to commit buggery, commits an offence and is liable to imprisonment for five years. (3) In this section “buggeryâ€? means sexual intercourse per anus by a male person with another male person.â€? This section o the Criminal Code may be used to hamper outreach workers who provide condoms to sex workers. An un-intended consequence Saint Lucia Section 141 of the Criminal Code No. 9 of 2004. take a note of subsection (2) Procuring or aiding and abetting 141. - (1) any person who- (a) procures any female or male under 18 years to have unlawful sexual intercourse or sexual connection with another person withinn or outside this State; (b) procures any male or female to become, either within or outside this State, a common prostitute; (c) procures any male or female to leave this State, with intent that he or she may for the purposes of prostitution, become and inmate of, or frequent, a brothel elsewhere; (d) procures any male or female to leave his or her usual place of abode in this State with intent that he or she may for the purposes of prostitution, become an inmate or fequent a brothel, in any country; is liable on conviction on indictment to imprisonment for seven years. (2) Any person who, knowing that an offence under subsection (1) has been committed by the person, aids or abets the unlawful detention of another person, or oyherwise aids and abets the execution of the intent with which that offence was committed, commits that offence. (3) A police officer may take into custody without a warrant the person whom he or she has reasonable cause to suspect of having committed or attemted to commit, any offence under this section. Human Resource Shortages Although the national response is not confined to the health sector, the Ministry of Health continues to be the leading sector in the response. Staffing involved in the HIV response within the Ministry of Health (MoH) include a Director of the National AIDS Programme, a health educator, secretary, two STI nurses, a Clinical Care Co-ordinator, two STI physicians, VCT/PMTCT co-ordinator, two social workers and community health workers. The country experienced a shortage of health workers, as many of its nurses and other staff obtained more lucrative positions abroad. Approximately half of all nurses and midwives left the service within a year of graduating. The Nursing Council received 297 HIV in the Caribbean: A Systematic Data Review 2003-2008 170 requests for transcripts in 2004, suggesting the departure of substantial numbers of trained 277 nurses . The National Strategic Plan for Health emphasizes the development of measures to retain trained health workers. 277 Saint Lucia Nursing Council, Special Committee on the Migration and Training of Nurses. Final Committee Report, August 2004. 298 HIV in the Caribbean: A Systematic Data Review 2003-2008 References CAREC, the Saint Lucia National HIV/AIDS Strategic Plan 2005-2009 September 2005 Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. Cenac, V., National Assessment on HIV/AIDS, Law, Ethics and Human Rights 2006 Cox, I., Didier, M.G., Clinical Reports for the HIV Programme January – March 2006 March – June 2007 July – September 2007 Day, M., Cocaine and the Risk of HIV infection in Saint Lucia., 2007, CDARI Press Didier, M.G., Clinical Reports for the HIV Programme January– July 2005 Government of Saint Lucia; United Nations Population Fund; Organization of Petroleum Exporting Countries. Knowledge, Attitude, and Practice Survey of Youth regarding HIV/AIDS, 2004. Loudon, M., A Study of Child Vulnerability in Barbados, St Lucia and St Vincent and the Grenadines, The United Nations Children’s Fund (UNICEF), November 2006 Measure Evaluation, PLACE Survey: Identifying Gaps in HIV Prevention in, Saint Lucia, Castries, Gros Islet, and Anse la Raye, 2007 MEASURE Evaluation 2006. Saint Lucia Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. Pan American Health Organization. 2007 Health in the Americas, 2007, Volume II – Countries found at www.paho.org/HIA/vol2paisesing.htm Saint Lucia Nursing Council, Special Committee on the Migration and Training of Nurses. Final Committee Report, August 2004. United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—Saint Lucia 299 HIV in the Caribbean: A Systematic Data Review 2003-2008 SAINT VINCENT AND THE GRENADINES HIV Overview Complied by Dr Marcus Day 10 July 2008 300 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Table of Contents....................................................................................................................... 301 Review......................................................................................................................................... 303 HIV Overview .............................................................................................................................. 303 CARE AND TREATMENT........................................................................................................... 303 Treatment, care and support.............................................................................................. 303 Cultural Constraints to evidenced based care and treatment .............................................. 304 Provision of ARV ................................................................................................................ 304 Data Collection and Country Surveillance System ................................................................ 305 Monitoring and Evaluation (M&E ....................................................................................... 305 TECHNICAL ASSISTANCE AND CAPACITY BUILDING ......................................................... 307 Testing and Diagnosis sites ............................................................................................... 307 Prevention................................................................................................................................... 307 Condom use with a non-regular, non commercial partner.................................................... 307 Condom use with commercial partners .................................................................................. 307 Condom access ................................................................................................................. 308 Condom use at first sexual encounter ............................................................................... 308 Condom use with non-commercial sex partner ................................................................. 308 Condom use with commercial sex partners ....................................................................... 308 Blood Safety....................................................................................................................... 309 PMTCT............................................................................................................................... 309 VCT ................................................................................................................................... 310 PEP .................................................................................................................................... 310 HIV and OI ......................................................................................................................... 310 Self-reported Sexually Transmitted Infections (STIs) ........................................................ 311 Prevalence of HIV co-infection with STIs, TB and hepatitis .................................................. 311 Impact of Caribbean migration on local epidemic ................................................................. 312 Risk Populations ........................................................................................................................ 313 Use of illegal drugs............................................................................................................. 313 Prisoners ............................................................................................................................ 313 Failures to obtain Male-to-male and sex work data ........................................................... 313 Minibus and Taxi drivers .................................................................................................... 314 Youth on the block ............................................................................................................. 314 301 HIV in the Caribbean: A Systematic Data Review 2003-2008 General risk behaviour .............................................................................................................. 315 Alcohol consumption .......................................................................................................... 315 Sexual activity .................................................................................................................... 315 Sexual activity in the last 12 months.................................................................................. 315 Non-regular non-commercial sex partners ........................................................................ 316 Commercial sex ................................................................................................................. 316 Youth Sexual activity ......................................................................................................... 316 Sexual initiation .................................................................................................................. 316 Sex before 15..................................................................................................................... 317 Age-mixing at first sexual encounter.................................................................................. 317 Forced sex at first sexual encounter .................................................................................. 317 Youths sexually active in the last 12 months ..................................................................... 317 Youth with multiple sex partners ........................................................................................ 318 Commercial and transactional sex for those who have had sex in the past 12 months.... 318 Male-to-male sex................................................................................................................ 318 Impact of stigma and discrimination ....................................................................................... 319 Stigma and discrimination .................................................................................................. 319 Human Rights .................................................................................................................... 319 Provider Stigma.................................................................................................................. 319 Criminalisation of Sexual Offenses in Saint Vincent and the Grenadines ......................... 320 Human Resource Shortages..................................................................................................... 320 302 HIV in the Caribbean: A Systematic Data Review 2003-2008 Review The the SVG strategic plan was launched in December 2001 A CAREC/PAHO Team also assisted in the development of the initial plan.. Priority areas for the strategic plan include: Strategy 1 - strengthen intersectoral management, organizational structure and institutional capacity Strategy 2 - develop, strengthen and implement HIV/AIDS/STI prevention and control programmes with priority given to youth and high risk/vulnerable groups Strategy 3 - strengthen care, support and treatment programmes for people living with HIV/AIDS and their families Strategy 4 - conduct HIV/AIDS related research Strategy 5 - upgrade surveillance systems Strategy 6 - Implement advocacy programmes The HIV epidemic is driven by a number of factors including cultural, behavioural and socio- economic. The plan then outlined the following six priority areas: The time frame of the first strategic plan was 2002-2006. It was developed utilizing several working groups who accessed information from relevant institutions, NGOs, private sector personnel, PWLHA, religious organizations, the Chamber of Commerce, teachers, police officers, other public servants and the general public. The GoSVG then began negotiations with the World Bank in 2003 to finance the programme. This necessitated the development of an updated strategic plan to synchronize the time frames of the project and the national strategic plan as well as to expand the plan to encompass a multi-sectoral implementation approach. The revised strategic plan covers the period 2004-2009. The process of updating the strategies was undertaken at a workshop in February 2004 and involved all stakeholders, with technical assistance from the CAREC . This strategic plan maintains the priority areas articulated in the original plan HIV Overview For the UNGASS current reporting period, (2006-2007) a total of 154 new cases of HIV were recorded. Of these, 84 (54.5%) were males and 69 (44.8%) were females. One (1) case was recorded as unknown sex. Seventy-four (74) persons progressed to AIDS with 68 deaths. The age group 20-49 accounted for 74% of the total new case identified in the period, with the 50 years and over accounting for 8%, the under 15 years 3% and the age group 15-19 : 1%. CARE AND TREATMENT 278 Treatment, care and support At the close of 2007 the national protocols for HIV/AIDS care and treatment were being completed and training will be conducted with Health Care Providers. An Adherence protocol and training of trainers programme were completed in December 2007. These are aimed at 278 UNGASS 2008 303 HIV in the Caribbean: A Systematic Data Review 2003-2008 enhancing adherence to medication and subsequent survival. The early warning indicators have been incorporated into the adherence strategy. The patient tracking and monitoring system is being improved, the ART Journal software was installed at the treatment facility and training was conducted. Nutritional assessment and counselling is currently being offered as part of the treatment services. HIV survival/adherence has shown some fluctuations over the years. All the cohorts in the15 and under age group had a perfect record of 12 month survival/adherence. Cultural Constraints to evidenced based care and treatment At a Regional Rastafarian Gathering held in SVG in 2006 the gathering expressed concern regarding the origins of the HIV/AIDS virus, the propagation of several myths about the disease and the refusal of governments and authorities to accept and investigate the holistic, herbal and nutritional treatments that have been developed. This same group is lobbying against vaccines as 279 a requirement for their children to enter school. I include this reference as it is indicative of the attitude of some sub sectors of society toward a modern medical response to HIV and other public health issues. Provision of ARV Treatment with Highly Active Antiretroviral Therapy commenced in St. Vincent and the Grenadines in August 2003. Care, treatment and support to people infected and affected by HV/AIDS is currently being provided at one medical facility located at the main Hospital in the capital Kingstown. The plan is to increase the number of ARV sites by June 2009. It was stated that decentralization of the services is necessary to increase access to high quality care at health facilities within the Health Districts and to ensure sustainability when the World Bank project terminates. To ensure access to treatment and ARV, the Government provides treatment free of charge to all clients. Overall coverall is 68% based on Spectrum projections. This is estimated rather then actual due to the unavailability of data on most at risk populations (MARP) and the reliance on antenatal sero-prevalence data. This also is assumes that the epidemic is indeed a heterosexual one. No gender disaggregation of persons tested to determine the disease burden by gender was offered in the published reports. Data from Private laboratories was also not included until 2007 so while future estimates are projected to be more accurate the lack of published data on gender makes it difficult to collaborate the statement with regard to the heterosexuality of the epidemic. However, in spite of this limitation, the indicator shows “universal ARV coverageâ€? (81.1%) among the male PLHIV population and 57% coverage among the female PLHIV population. Although, the national picture shows a greater burden of HIV prevalence on the male population (265 males and 230 females), the estimation models produced higher values for females in need of ART compared to males in need of ART (74 male, 96 females).From the clinic data, it has been computed that 86 % of all clinic attendees with advanced HIV disease are currently on ART. Of note, all children under 15 years who are in need of ART receive treatment receive that treatment. The survival/adherence of adult male clients on ARV has remained below 50% for most years, while the female survival/adherence has been improving although it is still not at an acceptable 279 Rastafari Reality – Reparations & Repatriation –Empowerment into The New Ethiopian Millennium, Communiqué on the 11th Caribbean Rastafarian Organization Summit St. Vincent & the Grenadines, Dec 2006 304 HIV in the Caribbean: A Systematic Data Review 2003-2008 level. The low survival levels in the males have been attributed to late enrolment in clinic with low CD4 and poor treatment adherence, common throughout the region. These two factors are being addressed by development and implementation of an adherence strategy, decentralization of services and addressing stigma and discrimination. Data Collection and Country Surveillance System Data management from collection to analysis remains a major challenge in St. Vincent and the Grenadines. While cognisance must be given to the high cost and complexities of a fully automated data management system, it must be stated that it becomes extremely difficult to provide detailed and comprehensive analyses for different population groups, using the paper- based system. As a first step to remedial action a patient monitoring and tracking system for HIV was introduced at the care and treatment clinic of the Milton Cato Memorial Hospital in November 2007. This was made possible with assistance from PAHO/CDC and OECS HIV/AIDS Project Unit. This system allows for the collection of all relevant follow-up information for each client in a systematic and standardized way as well as providing feedback on the patient population and indicators. The system is supported by paper forms capturing the OECS Minimum Dataset and customized to facilitate charting of patient clinical staging information, laboratory results, patient encounters, and clinical histories. Members of staff at the care and treatment clinic have already been trained to operate the patient monitoring and tracking system which is currently functional. The Ministry of Health and the Environment is moving towards a fully automated patient management information 280 system within the next two years. The laboratory performs routine services such as CD4+ T cell, Hb/CBC, Liver Function Tests, Glucose, Cholesterol, BUN/Creatinine and electrolytes. HIV viral load capacity is not yet available and samples are sent to CAREC in T&T. Laboratory training has been completed for the diagnosis of Opportunistic Infections and material and supplies are currently being procured to strengthen the capacity. Number of blood units collected and screened – In 2007 884 units were collected and tested for HIV. This is 100% of all blood collected. 281 Monitoring and Evaluation (M&E) The process of designing a Monitoring and Evaluation system for HIV/AIDS programmes commenced in mid 2005 with several activities undertaken towards the development of such a system. Activities included: (a) the development of a monitoring and evaluation framework consisting of 50 programmatic indicators covering output, outcome and impact for 14 service areas; (b) refinement process of the programmatic indicators (c) development of baseline values and agreed targets for indicators to monitor achievements; (d) development of data collection and abstraction forms to collect monitoring and evaluation data; (e) orientation of Stakeholders to the various data collection forms and how to use them; (f) development of a data base to organize and manage M&E data; (g) production of a Newsletter for information sharing; (h) formation of a Monitoring and Evaluation Reference Group (MERG) to provide advice on M&E approaches and practices as well as M&E technical and managerial aspects; 280 UNGASS 2008 281 As reported in the UNGASS 2008 305 HIV in the Caribbean: A Systematic Data Review 2003-2008 (i) production of a Monitoring and Evaluation Plan to improve HIV/AIDS systems and programmes and (j) organizing monitoring and evaluation capacity building workshop for stakeholders to equip them with the basic concepts of monitoring and evaluation, as well as enhancing their capacity to apply those concepts to real life situations. The fourteen (14) service areas under the HIV/AIDS programme selected for monitoring and evaluation include (a) national programme impacts, (b) voluntary counselling and testing, (c) prevention of mother to child transmission, (d) care, treatment and support, (e) Non Governmental Organizations, Community Based Organizations, (f) Behaviour Change Communication/ Behaviour Change Mass Media, (g) Orphans and Vulnerable Children, (h) Condom Distribution, (i) Line Ministries, (j) Partnership Programme Management, (k) Monitoring and Evaluation, (l) Post Exposure Prophylaxis, (m) Stigma and Discrimination and (n) Sexually Transmitted Infections. The Monitoring and Evaluation Framework presents the results that the National Strategic Plan expects to achieve in specified priority areas. The plan also addresses the needs of several Stakeholders Groups such as Ministry of Health and Environment, National AIDS Council, National AIDS Secretariat, Line Ministries, Non-Governmental Organizations, the Global Fund, UNAIDS and the World Bank. It articulates the linkages, reporting relationships and indicators used to measure inputs, outputs, outcomes and impact of national response to HIV/AIDS. The National HIV/AIDS Monitoring and Evaluation Plan will be fully implemented in 2008. In July 2006 the formation of a technical body called the Monitoring and Evaluation Reference Group (MERG) was formed with the primary purpose of providing advice on monitoring and evaluation approaches and practices as well as other technical and managerial aspects of HIV/AIDS Monitoring & Evaluation at all levels. The MERG comprises a 9 member body with representation from the National HIV/AIDS Secretariat, Public Sector Institutions, Civil Society and Non-Governmental Organizations. MERG meetings are convened on a monthly basis. One of the important activities of the MERG in 2006 was the 1-day work session to critically review the contents of National HIV/AIDS Monitoring and Evaluation Plan. 282 CHALLENGES FACED IN THE IMPLEMENTATION OF A COMPREHENSIVE M&E SYSTEM Below are the five areas outlined by the National AIDS programme regarding challenges faced in developing a M&E System. Basically it states that donor driven external indicators that are often revised are the greatest challenge followed by externally provided software systems. Also mentioned was the erroneous view of nationals as to the nature of M&E and its usefulness in planning. 1. The first challenge encountered was the inheritance of a Monitoring and Evaluation Framework template which was pre-designed for the OECS countries in an Excel programme. This presented 282 UNGASS2008 306 HIV in the Caribbean: A Systematic Data Review 2003-2008 much frustration during the first year of the programme. When one tried to alter information within the cells, some words remained legible, while others were reduced to illegible fonts. Eventually the Framework template had to be redesigned into a word document which significantly simplified the problem. 2. It was difficult trying to keep track of the specific indicators that were of particular interest to the various donor agencies. An attempt was made to harmonize these indicators across donors by accepting all the indicators as national indicators and designating those that were for external use. Additionally, Donors have been revising, omitting and including indicators from time to time. When this is done, it also requires revising and updating the national indicator set as well as adjusting the required data collection formats. 3. There was a preconceived notion that monitoring and evaluation was established to highlight the deficiencies and inefficiencies of service providers. This made it difficult to convince persons of the importance and necessity of monitoring and evaluation as a management tool. 4. The establishment of this new system required that a number of data reporting formats for data collection be developed, tested, refined and introduced to Health Care Providers primarily, who were already overburdened. 5. Another challenge is in the area of data management. There is an urgent need for an appropriate Information Technology Platform to manage HIV related information at the national level. The project currently uses statistical software (SPSS) to input routine data; however the software package cannot fulfill the functions of a management information system. TECHNICAL ASSISTANCE AND CAPACITY BUILDING There is urgent need for training at all levels in the following areas: • Information technology • Data and its importance in planning and decision making • Monitoring and Evaluation, (basic concepts and use) Testing and Diagnosis sites, Prevention Condom use with a non-regular, non commercial partner More males than females reported using a condom at last sexual intercourse with non-regular, non-commercial partners. Among males, 70% of the respondents reported using a condom at last sex vs 55% of females. In terms of consistent condom use with casual sex partners, there were similar gender differences across countries. More males than females reported using condoms every time they had sex with non-regular, non- commercial partners in the 12 months preceding the interview. 41% for males vs 32% for females. Condom use with commercial partners Survey participants who reported having any commercial sex partners in the last 12 months were asked about condom use practices. This data is only available for male respondents, due to the negligible number of female respondents for these questions. At least eight out of ten males reported condom use at last sex with a commercial partner. 307 HIV in the Caribbean: A Systematic Data Review 2003-2008 Consistent condom use was reported for 57% of the males. These numbers should be interpreted carefully as the denominator is very small with 21men reporting having had sex with commercial sex partners in the last 12 months. 283 Condom access More than 9 out of 10 interviewees could identify a place where condoms can be obtained. Commonly cited sources were shops, pharmacies, markets / supermarkets and clinics. Questions in this section of the survey instrument asked respondents if they knew of a person or place from which to obtain condoms. Respondents were asked how long it would take to obtain a condom away from their home or workplace, and where they would prefer to get condoms. More than 9 out of 10 interviewees could identify a place where condoms can be obtained Generally, respondents preferred to obtain condoms at shops or pharmacies. There were some common gender differences, for example, in all surveyed countries, more males than females cited ‘shop’ as a preferred place to obtain condoms. 284 Condom use at first sexual encounter In Saint Vincent 27% of males and 42% of females reported using a condom at their first sexual encounter. Less than half of the surveyed youths in St. Vincent and the Grenadines reported using a condom during their first sexual encounter and the proportion of females who reported condom use at first sex was higher compared to males. 285 Condom use with non-commercial sex partner Respondents were asked about sex with different partner types and about the frequency of their condom use with each partner type. Consistent condom use is defined here as using a condom “every timeâ€? with the specified partner type. Across all countries, more than half of the respondents reported using a condom the last time they had sex with a non-commercial partner. However this still shows that there are still significant numbers of young people not using condoms in these potentially high-risk partnerships. Condom use at last sex was consistently higher amongst males compared to females. In Saint Vincent, 68% of males reported condom use last sex compared to 53% of females. 286 Condom use with commercial sex partners 283 CAREC 2007 284 CAREC 2007 285 CAREC 2007 286 CAREC 2007 308 HIV in the Caribbean: A Systematic Data Review 2003-2008 92% of persons in St. Vincent and the Grenadines reported consistent condom use with commercial sex partners. These results should be interpreted with caution as the denominators are quite small (Saint Vincent Males n= 24 / 92%, Females n= 6 F 67). It is expected that there was strong potential for response bias to questions on illegal activities, such as engagement in commercial sex. Internationally, this indicator is usually calculated for males only, but in this BSS, the question was also posed to female respondents. The results are surprising and interesting, with much lower condom use rates reported by females compared to males. Although the question did not specify if the respondent was the client or the commercial sex worker, the assumption can be made that these young women were more likely the recipients of the money and therefore not in a strong position to negotiate condom use. Saint Vincent n= 24 M 92%, n= 6 F 67 287 Blood Safety Laboratory support for HIV prevention and care continues to be a major strength of the HIV/AIDS Programme in St. Vincent and the Grenadines. The Pathology Laboratory of the Milton Cato Memorial Hospital has maintained an excellent record with regard to safety of blood for transfusion. There have been no documented cases of HIV transmission through blood transfusion, since the HIV epidemic began in 1984. The Laboratory ensures that each unit of blood for transfusion is screened for HIV, Hepatitis B and C, HTLV 1 and 2 and VDRL. A standardized set of procedures have been documented to allow for uniformity, reliability and consistency in blood screening. Additionally, laboratory staff members have been trained to use the required standard operating system. The Pathology Laboratory participates in an External Quality Assurance Scheme; this implies that the quality of HIV screening performed is assessed at regular intervals. The HIV Prevalence among blood donors remains low at about 0.2%. PMTCT Prevention Mother to Child Transmission The PMTCT Programme which was initiated in year 2000 is now fully integrated into the Primary Health Care System. Pregnant women are offered the HIV test as part of the antenatal screen and antenatal mothers who are HIV positive are referred to the care and treatment programme and provided with highly active anti-retroviral therapy (HAART). The treatment management for both HIV positive mother and baby are standardized according to WHO Guidelines. There are several treatment options available which are easily accessible. The babies of HIV positive women are closely monitored for the first 18 months of life by a paediatrician. Mothers are counselled regarding the risk of breastfeeding and informed of infant feeding options. A regular supply of replacement feed is provided for all children up 6 months old. The PMTCT programme is managed by a steering committee headed by the HIV/AIDS Nurse Manager and guided by a PMTCT policy manual. The expectation is that all pregnant women will be counselled and tested for HIV. The data revealed that pregnant women counselled and tested for HIV in 2006 was 88 % as compared to 58% during the period 1999-2000. St. Vincent and the Grenadines is one of the OECS countries involved in early infant diagnosis for HIV, using DNA PCR through the Dry Blood Spot method. This intervention was initiated by the Clinton Foundation and will be supported for the next three years. A training programme on the Dry Blood Spot methodology was conducted in 288 early December 2007 for Laboratory Technologists, Medical and Nursing personnel. 287 UNGASS 2008 288 UNGASS 2008 309 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV positive women receiving ARV drugs in the PMTCT programme 289 VCT Voluntary Counselling and Testing (VCT) is one of the intervention strategies used to control the spread of HIV in St. Vincent and the Grenadines. The VCT programme which began in 2003, intensified in 2006/2007. A number of measures were undertaken to ensure adequate functioning of this programme. These included: • Training of personnel at different levels in different areas of VCT • Identification and refurbishing of sites to be used for VCT • Procurement and distribution of VCT equipment and supplies • Preparation of VCT data collection tools • Establishment of a data base to input VCT data • Social marketing for VCT • Piloting of VCT (HIV rapid test) sites • Preparation of a VCT Policy Manual During the period 2006 and 2007, eighteen (18: 46%) Health Centres throughout the country have had civil works done on the physical structure in preparation for the delivery of VCT services. Additionally, a total of 114 stakeholders including health care providers have so far received VCT training and 41 persons have been trained in HIV rapid testing. Seven HIV rapid test sites became operational from June 2007. A ‘parallel’ algorithm is utilized to perform the test, where two different test kits are used. Confirmation of positive results is done at the Milton Cato Memorial Hospital Clinical Laboratory. National Policy Guidelines for Voluntary Counselling and Testing were developed in June 2005 using a multisectoral approach and included key Stakeholders such as Line Ministries, Non Governmental Organizations, PLHIV and Community Based Organizations. The document was developed with 3 objectives in mind. Namely: (1) providing a framework for VCT services and the training of health providers and counsellors, (2) incorporating VCT as part of the comprehensive health care system and (3) to bring about positive behaviour change. This document was widely disseminated to Health Care providers and other HIV Stakeholders. PEP In SVG 2 of the 18 total public facilities reported PEP available but neither had PEP medicines. Further, this access to PEP includes facilities that offer PEP or have a system to refer staff for PEP. If only two facilities report that PEP is prescribed but none has ARVs for PEP, service providers are left without clear referrals for treatment, if necessary. This issue should be addressed as soon as possible. Unfortunately, PEP guidelines are not available in any of the facilities where staff prescribe PEP and records for monitoring records/registers of staff receiving PEP are lacking. HIV and OI AIDS – related deaths which account for approximately 4% of total deaths attributed its main causes to Pneumonia, Wasting Syndrome, Toxoplasmosis, Renal Failure and Meningitis in order 290 of rank. 289 UNGASS 2008 290 UNGASS 2008 310 HIV in the Caribbean: A Systematic Data Review 2003-2008 Self-reported Sexually Transmitted Infections (STIs) Sexually Transmitted Infections (STIs) are transmitted in the same ways as HIV, and can be prevented by the same safe behaviours being promoted by HIV prevention programmes. Therefore, measures of STI prevalence are a relatively good guide to recent trends in sexual risk behaviour. The surveys assessed self-reported prevalence of genital discharges and ulcers among youths in the 12 months preceding the interview. Among male youths, the reported prevalence rates of 2%% for genital discharge while females reported 6% Among male youths, the reported prevalence rates of 1% for genital ulcers/sores while females reported <1% The gender difference in the range of genital discharge may have been due to females reporting normal genital discharge as an abnormal one. These low self-reported rates carry a high likelihood of bias and should not be used to represent national STI prevalence. Prevalence of HIV co-infection with STIs, TB and hepatitis 291 2006: 100 % (2 males 2 females) Co-Management of HIV and TB Treatment Tuberculosis which has been reported as the most common opportunistic infection affecting HIV/AIDS clients world wide has been given considerable national attention over the years. With appropriate drugs and diagnostic technology available in country, the diagnosis and management of TB are done efficiently. All patients diagnosed with Tuberculosis are routinely tested for HIV and all symptomatic HIV infected persons who access medical services are tested for Tuberculosis. The national records illustrate a low incidence of Tuberculosis over the last decade with approximately 13 cases reported annually. Up to year 2005, Tuberculosis / HIV Co-infection documented just 2 cases annually. However in 2006, there were twenty (20) Tuberculosis cases diagnosed with five (5: 25%) co-infected with HIV and in 2007, 16 Tuberculosis cases were recorded with seven (7: 44%) cases co-infection with HIV. Of the 12 co-infected clients, diagnosed over the reporting period, two died shortly after diagnosis and two were defaulters who were previously diagnosed. The Ministry of Health and the Environment has committed itself to continue its efforts to enhance prevention measures, treatment and identification of the two diseases as well as the continuous provision of effective treatment options. Indicator 6 reflected 100% coverage for TB/HIV co-infected clients who received treatment for both tuberculosis and HIV. The reporting period for this data was September 2006 to September 2007. Services Services for Orphans and Vulnerable Children (OVC) The National AIDS Secretariat is aware of 66 HIV/AIDS related orphans and vulnerable children. The definition used here is: “Children aged 0 to 18 years who have lost one or both parents to 291 UNGASS 2008 311 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV/AIDS–related causes, or who have at least one parent who suffers chronic illness due to HIV/AIDSâ€?. Approximately 15% are themselves HIV-infected; five of the HIV-infected children are double orphans. Most of the children (63 or 95%) are of school age. Of these, 92% attend school. Six (6) children reside at an orphanage while the remaining children reside with family. In terms of support, all persons with HIV infection who attend the public clinic for care and treatment are assessed regarding their social and economic situation. Financial assistance is provided via disbursement through the Ministry of National Mobilization Family Services Department. Priority for financial assistance is given to orphans and the elderly. Assistance provided takes various forms, e.g. school lunches, monthly stipends, monthly food packages (mostly for pregnant and post-natal mothers), school supplies and school fees. In 2007, 100 children infected and affected by HIV/AIDS received school-related assistance. Separate and apart from school-related assistance, financial support is provided to the Bread of Life orphanage for general care of the children under their control. Seventy-five percent (75%) of the non-institutionalized OVC also receive financial assistance from the programme. Impact of Caribbean migration on local epidemic With the creation of the CARICOM Single Market and Economy (CSME) in 1989 to advance integration and promote economic growth in the region, there has been an anticipated increase in the migrant labor. Such population mobility is likely to increase the spread of HIV and burden the 292 HIV and AIDS response and treatment of some National AIDS Programs (NAPs) . In terms of provision of ART and PMTCT services to residents of other countries in public facilities in St. Vincent and the Grenadines, One facility reported offering ART to patients who live in another country. The HSPA found that nine public facilities in St. Vincent and the Grenadines offer PMTCT services; six of those facilities reported that they have provided PMTCT services to residents of other countries. Of the facilities that offer PMTCT services, one reported providing ARV prophylaxis to residents of other countries during the last month. It should be noted that due to the way that the question is posed, the response could be capturing residents of other countries who live in St. Vincent and the Grenadines rather than persons who travel there to receive services. Unfortunately, data were not available that specified from which countries the patient(s) came. Further, mechanisms to track movement of PLHIVs around the region are not in place, which makes additional or regular follow-up of these clients difficult. This also makes it difficult to assess the “full pictureâ€? of migration for health services. Nevertheless, this is an interesting finding and might be something to study further and assess whether programs, countries, and the region should address it. It has been reported elsewhere that because of high levels of stigma and discrimination, people often seek services outside their own health districts to remain anonymous. It is well known that people travel long distances, even to other countries, for care and treatment of HIV. This underlines the need not only for urgent measures to reduce 293 stigma but also the importance of having high-quality services available throughout the region. 292 MEASURE Evaluation. 2005. The Implications of a Caribbean Community (CARICOM) Single Market and Economy (CSME) for Population Mobility and the Spread of HIV. Calverton, MD: Macro International Inc As reported in the MEASURE Evaluation 2006. 293 Pan American Health Organization. 2005. Access to care for people living with HIV/AIDS. Provisional Agenda Item 4.15 CD46/20 (Eng.); 46th Directing Council, 57th Session of the Regional Committee. Washington, DC: World Health Organization, September 26–30., As reported in the MEASURE Evaluation 2006. 312 HIV in the Caribbean: A Systematic Data Review 2003-2008 Risk Populations 294 Use of illegal drugs Young males were more likely to report using marijuana than female youths. Among males, marijuana use in the 30 days preceding the interview was 23%. By comparison, marijuana use among females was 6%. However, youth regardless of gender reported low use of crack and cocaine, with usage rates of less than 1% across both genders Compared to females, a higher proportion of adult males reported ever trying marijuana and marijuana-use in the last month. The data indicate that approximately one-third of male interviewees had ever tried marijuana, with a slightly smaller proportion of 16% having used this drug in the month preceding the interview. Adult female marijuana use in the past 30 days was 3% Very few survey participants reported using crack and cocaine, ever and in the last month. These results may not be reflective of reality as it is likely to be under-reported due to the illegal nature of the activity. Life time crack for adults In Saint Vincent was 3% for males and 1% for females Prisoners Prisoners2 (n=344) 4.1% HIV positive Prison inmates In April 2005, 344 male inmates (92% of inmates on the survey days) of Her Majesty’s Prison in St. Vincent and the Grenadines were surveyed for their HIV serological status. The sero- prevalence rate for all inmates tested 4.1%; half of these HIV positive inmates were between the ages of 20 to 29 years. Subsequent to these surveys, the NAS increased their prevention and VCT activities in the prisons. A counsellor with the Secretariat makes regular visits to the prison to conduct HIV education sessions, counselling and voluntary HIV testing for inmates and prison officers. NAS programme data showed that a total of 320 inmates participated in HIV education and/counselling sessions between January and August, 2007. The documented results of such sessions were requests by 97 inmates for HIV testing. Between January and June, 2007, 295 a total of 47 prison officers and/or new recruits attended HIV education/counselling sessions. 296297 Failures to obtain Male-to-male and sex work data The baseline BSS conducted in 2005 did not have an HIV sero-prevalence component. Although questions regarding male-to-male sex, commercial sex and transactional sex were included in the survey questionnaire for the general population sample, the findings did not yield statistically useful information on the proportion of the general population who engage in these activities nor 294 CAREC 2007 295 Report on an HIV seroprevalence survey among male inmates in Her Majesty’s Prison in St. Vincent and the Grenadines conducted on April 12-13, 2005. CAREC, July 2005. 296 UNGASS 2008 297 CAREC 2007 313 HIV in the Caribbean: A Systematic Data Review 2003-2008 their condom use practices. Under-reporting is assumed and was most likely due to the face-to- face interview methodology used where persons are less likely to report highly sensitive and stigmatizing information, especially about an activity that is illegal in St. Vincent and the Grenadines. In an effort to obtain behavioural and sero-prevalence data on two hidden populations namely, MSM and FSW, the Ministry of Health and the Environment worked in collaboration with the Caribbean Epidemiology Centre (CAREC), the International HIV/AIDS Alliance (Caribbean Office), the Caribbean Health Research Council (CHRC) and the Global AIDS Program (GAP) of the US Centers for Disease Prevention and Control (CDC) to implement a Behavioural and Seroprevalence Surveillance Survey in 2006/20075. These surveys, conducted from November 2, 2006 to January 31, 2007, used the Respondent Driven Sampling (RDS) methodology which has been used successfully in many countries for sampling hard-to-reach populations. By the end of the survey period, a total of 7 males and 4 females had been interviewed out of the planned samples of 175 males and 218 females. Information obtained from monitoring visits, survey evaluation and fieldworker debriefing interviews indicated the following key reasons for the failure of the surveys: • issues relating to networking between MSM cliques that are affected by mistrust, fear of disclosure, etc • the network of female sex workers appeared not dense enough for use of the RDS methodology; • potential female participants were not willing to identify themselves as being sex workers; • fear of disclosure and fear of a lack of confidentiality were also cited as barriers • incentives offered were reportedly not worth the risk of disclosure. These issues require further exploration before the implementation of subsequent surveys. There are efforts underway to reach these hidden populations with the assistance of the Caribbean office of the International HIV/AIDS Alliance. Minibus and Taxi drivers The analysis of the data for the minibus and taxi drivers’ population (15-49 years) was done on a collective basis (as an OECS region), not by individual countries. The data revealed that almost all MBTD interviewed had heard of HIV/AIDS (n=388 : 99%). With regard to the ABC of HIV prevention, 73% (n=388) of the respondents mentioned all prevention strategies. Almost all MBTD surveyed (98%) knew that a healthy looking person can be HIV positive, however, only 40% of the respondents rejected all three myths (HIV transmission by a mosquito and sharing a meal, as well as, a healthy looking person can be HIV positive). Approximately 40% of respondents had initiated sexual activity before the age of 15 years. Forty eight percent of the respondents reported that they ever had an HIV test, whereas 17% received 298 HIV test and results in the last 12 months. Youth on the block A total of 388 youths (aged 10 to 19 years) were surveyed in the BSS conducted in St. Vincent and the Grenadines in 2005. Most (86%) were males and the median age was 16 years. Almost all (97%) of respondents had heard of HIV or the disease called AIDS. Of those respondents who had heard of HIV or AIDS, almost all (98%) knew of transmission via sexual intercourse and almost two-thirds (61%) knew of transmission via blood. By contrast, 32% and 36% knew of mother-to-child transmission and injecting drug use, respectively. Only thirty-three respondents 298 CAREC 2007 314 HIV in the Caribbean: A Systematic Data Review 2003-2008 (9%) knew all four routes. More than nine of ten respondents were aware that a healthy looking person can be infected with HIV. Approximately one-fifth (19%) of the youths believed that HIV can be transmitted by mosquitoes, and one-third (31%) believed that HIV can be transmitted by sitting on a toilet seat previously used by an HIV infected person, indicating persisting fears of HIV transmission through body fluids. Overall, only 39% of respondents correctly rejected the two myths and knew that a healthy looking person could be infected with HIV, indicating that three out of five youths aged 10 to 19 in St. Vincent and the Grenadines still have misconceptions about HIV transmission. In terms of HIV prevention, abstinence and faithfulness between uninfected partners were the most identified methods (89% and 90%, respectively). Condom use was identified by 76% of respondents. Approximately seven out of ten respondents correctly identified all three HIV prevention methods. Roughly half of the youths (53%) surveyed correctly identified ways of preventing sexual transmission of HIV and rejected major misconceptions about HIV transmission. Through a list of different questions, willingness of the respondents to interact with persons with HIV was assessed. Eight out of ten (80%) respondents indicated being willing to care for an HIV infected relative in their own household. Empathy was less for HIV infected students and teachers, with 63% being willing to allow an HIV infected student to attend school and just over half (54%) being willing to allow an HIV infected teacher to teach. Overall, half of all respondents gave answers that indicate an accepting or supporting attitude towards persons with HIV infection. In the area of sexual behaviour, almost half (47%) of all respondents reported ever having had sexual intercourse. Forty-four percent (44%) of the sexually active youths reported sexual debut before the age of 15 years. The age range at sexual debut was as early as 6 years old for at least one respondent. For the majority (86%) of respondents who had ever had sex, their first sexual partner was older by ten years or less. Among those who had ever had sex, almost one-fifth indicated that they had been forced during the act that resulted in their loss of virginity. All but one respondent had ever heard of a male condom, however, of the 182 sexually active youths, only 40% had used a condom the last time they engaged in sexual intercourse. 299 General risk behaviour 300 Alcohol consumption There was a notable gender difference for every-day consumption of alcohol, with more males than females reporting alcohol consumption everyday For adults in Saint Vincent 13% of the males vs 3% of the females For youth – daily drinking was not as common with only 8% of the males and 1% of the females aged 15 – 24 reporting daily drinking. The majority of people interviewed reported drinking alcohol less than once a week or never. 301 Sexual activity Sexual activity in the last 12 months 299 CAREC 2007 300 CAREC 2007 301 CAREC 2007 315 HIV in the Caribbean: A Systematic Data Review 2003-2008 This indicator was calculated using all survey participants as the denominator. The findings showed that approximately eight out of ten males and females were sexually active in the last 12 months. Non-regular non-commercial sex partners Noticeably more men reported having more than one non-regular non-commercial sex partner in the 12 months preceding their interview. The percent of males who reported having more than one non-regular partner in the last 12 months was 9% while among females, 2% The number of non-regular, non-commercial partners reported by at least half of surveyed men and women was one, Commercial sex The proportion of men who reported engaging in commercial sex Saint Vincent M 7%, F 1%, Men who declared having commercial partners were asked if they had received money or gifts in exchange for sex in the 12 months preceding the interview. Saint Vincent M 2%, F 1%, There were negligible reports of giving or receiving drugs in exchange for sex. 302 Youth Sexual activity These indicators measure sexual activity among young people. Typically, young people have partnerships that are more often of short duration and perhaps less formal than those of older people. Moreover, they are less likely to live with their sexual partners, and this can often result in one of the partners having additional concurrent partners, thus increasing the risk of infection. Data are presented for indicators around sexual debut (age, age mixing and forced sex) and indicators of recent sexual activity (sexual intercourse, number of partners, commercial sex and sex between men, in the last 12 months). Adult Respondents who reported ever having had sex were asked about their sexual activities in the 12 months preceding the interview. The survey sought information on: (1) sexual activity in the last 12 months (2) number and type of sexual partners (3) commercial sex (4) male-to-male sex (5) transactional sex and (6) forced sex in the last 12 months. 303 Sexual initiation 302 CAREC 2007 303 CAREC 2007 316 HIV in the Caribbean: A Systematic Data Review 2003-2008 In St. Vincent and the Grenadines more female youths were sexually experienced compared to their male counterparts In St. Vincent and the Grenadines, the percent of sexually active respondents was 69% for young males and 75% for females 304 Sex before 15 Saint Vincent M 31%, F 14%, All 22%, 305 Age-mixing at first sexual encounter This indicator measures the proportion of young people having sex with older partners. For young women in particular, sex with older men is often risky because young women lack the power in the relationship to negotiate safe sex. It is also an efficient means of spreading HIV infection, since, for physiological reasons younger women are more likely to become infected. Each sexual act with an infected man carries a higher risk of infection for a young girl, and older men are more likely than younger men to be infected. Age mixing is a term that refers to sexual activity between two partners that are separated by ten or more years in age. For first partner older by 10 years the percentage for all was less then 5% The proportion whose first sexual partner was between 5 and 10 years older was Saint Vincent M 4%, F 28%, as this scenario appeared to be more frequent amongst those surveyed. 306 Forced sex at first sexual encounter By gender, female youths are more likely than young males to have been forced to have sex during their first sexual intercourse. Even if females are more likely to have reported forced sex, findings show that both genders experienced this form of violence. In addition, with such a sensitive question, respondents may have been unwilling to report being raped due to feelings of fear and/or shame and so these statistics are likely to be under-reported and may represent just the tip of the iceberg. Additionally, the interpretation of this question was physical force, and so does not represent psychological force (i.e. coercion). Saint Vincent M 8%, F 9%, All 9%, 307 Youths sexually active in the last 12 months When the data was examined for only those respondents who reported ever having had sex and who were sexually active in the past year, it was observed that 50% of the males and 63% females were sexually active in the last 12 months. 304 This indicator was calculated based on the reported age at first sexual intercourse, a retrospective survey question that is not recommended by FHI or UNAIDS for international comparison. It has been included here as it provides useful information for advocacy around protection of children. 305 CAREC 2007 306 CAREC 2007 307 CAREC 2007 317 HIV in the Caribbean: A Systematic Data Review 2003-2008 This indirect measure of secondary abstinence can inform on the impact of education and prevention programmes, which encourage young people to abstain from sex after engaging in early sexual activity. 308 Youth with multiple sex partners Survey participants who reported being sexually active in the last 12 months were asked how many sex partners they had had during the same period. 64% of males in St Vincent and the Grenadines reported having more than one partner. Among females 20% reported having more than one partner. The range of non-commercial partners in the last 12 months in SVG Males 1 – 12 -Females 1 - 4 309 Commercial and transactional sex for those who have had sex in the past 12 months Respondents who reported sex in the past 12 months who were asked the questions on sex with a commercial partner, where this was defined as “…partners with whom you had sex in exchange for moneyâ€?. Saint Vincent M 11%, F 2%, All 5%, The wording of the question did not allow for differentiation between those who paid for sex versus those who received money. When the same sexually active youth were asked "Have you … been paid or received gifts in exchange for sex in the last 12 months?". Saint Vincent M 8%, F 2%, All 5%, Gave drugs for sex was very low Saint Vincent M 8%, F 0%, And a similar question was also asked who received drugs for sex. It should be noted that the author of this report (not the BSS quoted Dr Marcus Day has interviewed over 300 crack smoking individuals since 2002 and has asked this same question. When asked of females, the general response has been one of amusement with comments such as “me no give rock (drugs) for sex, men give me rock. Dr day is of the opinion that males who receive drugs for sex are generally to be considered male on male sex exchanges. Saint Vincent M 3%, F 2%, All 3 %, This form of transactional sex in the young population involved the receipt of drugs for sex more than the giving of drugs – a clear issue of vulnerability especially since these figures most likely represent an underestimation of the true situation. 310 Male-to-male sex 308 CAREC 2007 309 CAREC 2007 310 CAREC 2007 318 HIV in the Caribbean: A Systematic Data Review 2003-2008 The BSS asked male participants if they had ever had sex with a man. Those who responded in the affirmative were asked (1) if they had had sexual intercourse (defined as oral or anal sex) with a man in the last 12 months; and (2) how many men had they engaged in anal sex with over the same period. The percentage of young men who reported sex with men, ever or in the last 12 months, varied according to country. In St. Vincent and the Grenadines, the proportions of men who reported having had male partner(s) in the last 12 months was 3%, respectively. The proportion of adult men reporting ever engaging in male-to- male sex was one percent (1%) or less. Under-reporting is highly likely to have occurred in all the countries, due to the illegal aspect of homosexuality and the high level of stigma and discrimination in the society toward Men who have Sex with Men (MSM); These findings are most likely a large underestimation of the prevalence of this practice in the Caribbean region, where anal sex between men is illegal and where there is a high level of stigma and discrimination towards men who have sex with men. Due to the small number of respondents for these questions, data for the indicators on number of partners are not presented in this report Impact of stigma and discrimination 311 Stigma and discrimination The area of Stigma & Discrimination was given particular attention. A human rights desk where complaints of stigma and discrimination from HIV positive clients can be lodged and recourse sought, was established in the first quarter of 2007. The national assessment of law ethics and human rights was also completed. Two (2) HIV/AIDS Support Groups were formed, namely SVG +, Friends for Life (St. Vincent and the Grenadines’ Network of Persons living with and affected by HIV/AIDS) and CARE SVG (Care to Assist by Reaching out to Empower SVG). Their total membership to date is 46. Human Rights 312 Provider Stigma To provide an estimate of the proportion of providers of HIV and AIDS-related services reporting accepting attitudes towards PLHIV, a composite indicator was constructed to measure provider stigma. The indicator is derived from providers’ responses (recorded on a 4-point Likert scale) of agreement or disagreement with a series of statements. Respondents with a positive score of 6 out of six questions are considered to have accepting attitudes towards PLHIVs. 1. People who are infected with HIV should not be treated in the same place as other patients in order to protect other patients from infection. 2. People with HIV are generally to blame for getting infected. 3. Providing health services to people infected with HIV is a waste of resources, since they will die soon anyway. 4. Clients who have sexual relations with people of the same sex deserve to receive the same level and quality of health care as other clients. 311 CAREC 2007 312 Measure 2006 319 HIV in the Caribbean: A Systematic Data Review 2003-2008 5. Health providers have to be careful not to get a reputation for treating HIV positive clients, since this might affect who might go to them for other health services. 6. You avoid touching the clothing and belongings of clients whom you know or suspect have HIV for fear of becoming HIV infected. Four of the six items are related to internationally recognized measures of health worker attitudes toward PLHIV (1–4) and health worker comfort working around PLHIV (6)49. Item 5 was adapted locally to further explore health worker stigma. In St. Vincent and the Grenadines, of the 77 public facility providers surveyed, only half (49 percent) showed a positive attitude toward PLHIV. Since this is only a sample of providers in St. Vincent and the Grenadines, one cannot make assumptions about attitudes of all providers, but there appears to be a need to sensitize health providers and better inform them. It has been reported elsewhere that health care providers without an in-depth knowledge of HIV transmission held more stigmatizing attitudes. Criminalisation of Sexual Offenses in Saint Vincent and the Grenadines Male/Male Illegal Female/Female Illegal Criminal Code, 199087 Section 146 Any person who "commits buggery [anal intercourse] with any other person" and any person who "commit buggery with him or herâ€? is "liable to imprisonment for ten years" Section 148 "Any person, who in public or private, commits an act of gross indecency with another person of the same sex, or procures or attempts to procure another person of the same sex to commit an act of gross indecency with him or her, is guilty of an offence and liable to imprisonment for five years." Human Resource Shortages Human resources: In 2000, the medical practitioners' register included 89 doctors and 5 dental practitioners. Of these, 56 doctors work in the public sector (51 per 100, 000 population), and 26 work in the private sector exclusively. Seven physicians were registered employees of Kingstown Medical College . The Nursing Council's register included 398 trained nurses (362 per 100,000 population ). There were 42 registered nursing aides, 45 community health aides, and 7 nursing tutors. Nursing training is provided at the Government's St. Vincent 's School of Nursing . Health care workers also receive training internationally, including in North America and Europe. The Ministry of Health has endorsed continuing medical education to improve efficiency and 313 productivity, and has financed organization and hosting of such activities. Sexual Behaviours that contribute to HIV Infection, Other STI, and Unintended Pregnancy Total Male Female 313 PAHO Basic Health Indicator Data Base found at http://www.paho.org/english/dd/ais/cp_670.htm 320 HIV in the Caribbean: A Systematic Data Review 2003-2008 Percentage of students who have ever had sexual intercourse 30 52 13 Percentage of students who have had sexual intercourse with two or more people during their life time 25 43 8.6 Among students who had sexual intercourse during the past 12 months, the percentage who used a condom the last time they had sexual intercourse 65.7 63.9 321 HIV in the Caribbean: A Systematic Data Review 2003-2008 References Caribbean Epidemiology Center (CAREC). 2007. Behavioural Surveillance Surveys (BSS)in Six Countries of the Organisation of Eastern Caribbean States (OECS) 2005-2006 Final Report. CAREC-SPSTI, Port of Spain. MEASURE Evaluation 2006. Saint Vincent and the Grenadines Caribbean Region HIV and AIDS Service Provision Assessment. Calverton, MD: Macro International Inc. Pan American Health Organization. 2007 Health in the Americas, 2007, Volume II – Countries found at www.paho.org/HIA/vol2paisesing.htm Pan American Health Organization. 2005. Access to care for people living with th HIV/AIDS. Provisional Agenda Item 4.15 CD46/20 (Eng.): 46th Directing Council, 57 Session of the Regional Committee, 26-30 September. Washington, DC: World Health Organization. Pan American Health Organization. 2003. Scaling up Health Systems to Respond to the Challenges of HIV/AIDS—Latin America and the Caribbean. Washington, DC: World Health Organization. Pan American Health Organization. 2001. Saint Vincent and the Grenadines Available at http://www.paho.org/english/SHA/PRFLANT.htm. Pan American Health Organization. Basic Country Health Profile for the Americas: Saint Vincent and the Grenadines Pan American Health Organization. 2001. Health Systems and Services Profile for Saint Vincent and the Grenadines . http://www.lachsr.org/documents/healthsystemprofileofsaintvincentgrenadines-EN.pdf United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2008. Country Report—Saint Vincent and the Grenadines Saint Vincent and the Grenadines HIV/AIDS/STI National Strategic Plan 2004 - 2009 322 HIV in the Caribbean: A Systematic Data Review 2003-2008 TRINIDAD AND TOBAGO Epidemiological Synthesis of HIV/AIDS in Trinidad and Tobago by Eldonna Boisson Caribbean Epidemiology Centre (CAREC/PAHO/WHO) June 5, 2008 323 HIV in the Caribbean: A Systematic Data Review 2003-2008 Acknowledgements Many thanks are extended to the Trinidad and Tobago, Ministry of Health, National Surveillance Unit, particularly Dr. Jay Buensuceso for providing much of the HIV and AIDS surveillance data and graphics. Their contribution to the section on the epidemiology of HIV/AIDS in Trinidad and Tobago was invaluable. Thank you to staff of the Epidemiology Division of CAREC, particularly Dr. Franka Des Vignes and Ms. Sarah Quesnel, who assisted greatly with the data gathering for this document; and Ms. Stacey Grant and Ms. Esther Bissessarsingh for preparing some of the tables and figures. Thank you to the various sites that contributed data to the Trinidad and Tobago HIV/AIDS surveillance system namely, the Central Statistical Office (CSO), the Medical Research Foundation (MRF), the Prevention of Mother-to-Child Transmission (PMTCT) Programme, the Queen’s Park Counseling Center and Clinic (QPCC&C), the Trinidad Public Health Laboratory (TPHL) and all other contributing health care providers and facilities. 324 HIV in the Caribbean: A Systematic Data Review 2003-2008 Table of Contents Acknowledgements ................................................................................................................... 324 Executive Summary................................................................................................................... 327 Introduction ................................................................................................................................ 329 Epidemiology of HIV/AIDS in Trinidad and Tobago ............................................................... 329 Estimates of persons living with HIV/AIDS in Trinidad and Tobago .................................. 329 Trends in HIV infections ..................................................................................................... 329 Trends in AIDS cases ........................................................................................................ 335 Trends in AIDS Mortality .................................................................................................... 339 HIV prevalence among specific populations .......................................................................... 344 Pregnant women ................................................................................................................ 344 Men who have sex with men (MSM).................................................................................. 344 Substance Dependent Persons ......................................................................................... 345 STI clinic attenders............................................................................................................. 345 Persons with HIV positive partners .................................................................................... 346 Homeless persons ............................................................................................................. 346 Tuberculosis (TB) patients ................................................................................................. 347 Other possible high risk groups ......................................................................................... 348 Knowledge, attitudes and practises with respect to HIV ....................................................... 348 Knowledge of and attitudes to HIV..................................................................................... 348 Age at first sex and numbers of sexual partners ............................................................... 349 Condom use....................................................................................................................... 349 Socio-cultural and Behavioural Factors Influencing the HIV/AIDS Situation ...................... 349 HIV Subtypes and Resistance in Trinidad and Tobago ......................................................... 350 Programmatic Response........................................................................................................... 350 Programme Coordination ................................................................................................... 350 The National HIV/AIDS Strategic Plan............................................................................... 351 Prevention Activities........................................................................................................... 353 Prevention of Mother to Child Transmission of HIV Programme (PMTCT) ............. 354 Blood Screening Programme ................................................................................... 354 Counselling and Testing........................................................................................... 355 Prevention Activities by NGOs ................................................................................. 355 Treatment, Care and Support ............................................................................................ 355 National HIV Treatment, Care and Support System ................................................ 355 HIV Care and Treatment Uptake.............................................................................. 356 TB/HIV Care and Treatment..................................................................................... 356 Treatment, Care and Support Activities by NGOs ................................................... 356 325 HIV in the Caribbean: A Systematic Data Review 2003-2008 Advocacy and Human Rights............................................................................................. 357 Surveillance and Research ................................................................................................ 357 The Routine HIV/AIDS Surveillance System............................................................ 357 Recent research ....................................................................................................... 358 Programme Management, Coordination and Evaluation................................................... 358 Main Challenges in Managing and Implementing the National Response ........................ 358 References.................................................................................................................................. 359 326 HIV in the Caribbean: A Systematic Data Review 2003-2008 Executive Summary Trinidad and Tobago is the most southern country in the chain of Caribbean islands, with an area of 5,128 sq km and population of approximately 1.3 million in 2007. The country is composed of seven counties, of which St. George is the most densely populated. Trinidad and Tobago is reported to have a generalised epidemic, with an estimated HIV prevalence in the adult population of approximately 1.5% and approximately 29,000 persons living with HIV/AIDS in 2006. During the period 1983-2007, there has been a cumulative total of 18,735 reported HIV cases, which includes 5,743 AIDS cases (of which 3,548 have died). There were 10,509 (56%) male cases and 7,520 (40%) female cases; with 7% of cases aged less than 15 years and 84% cases aged 15 years old and older. The first cases of HIV/AIDS in Trinidad and Tobago were diagnosed and reported in 1983 and since then the annual number of newly-detected HIV cases increased steadily until the early 2000s, reaching a peak of 1,718 cases in 2003. During 2007, on average, 4 new cases of HIV/AIDS were reported everyday. Women and young adults continue to be disproportionately affected by HIV/AIDS in Trinidad and Tobago. In 2007, for the first time, the number of reported female HIV cases was greater than the number of reported male HIV cases. Sexual exposure, especially heterosexual, is the main mode of HIV transmission. Men who have sex with men, substance dependent persons, STI clinic attenders and homeless people are at higher risk of HIV infection, mostly due to high risk sexual behaviours (e.g. multi-partnering, unprotected sex). In the adult population of Trinidad and Tobago, there appears to be a high level of knowledge of HIV and its transmission and prevention methods, with younger persons appearing to be more knowledgeable in this regard. However, there appears to be few youth friendly HIV testing sites in the country. While HIV/AIDS cases have been reported from all counties in Trinidad and Tobago, county St. George (urban and densely populated) and Tobago (a popular tourist destination) are most affected. HIV-1 subtype, clades B and D have been identified as the most prevalent subtypes circulating in Trinidad and Tobago. There has been no HIV drug resistance identified at this time. The national HIV response in Trinidad and Tobago is multi-faceted and multi-sectoral, and is guided by the National Strategic Plan for the period 2004-2008. The national response is coordinated and managed by the National AIDS Coordinating Committee (NACC), which is under the office of the Prime Minister and has a full range of stakeholders from public and private sectors, civil society and persons living with HIV/AIDS (PLWHA). The two goals of the national plan are to reduce the incidence of HIV infections in Trinidad and Tobago; and to mitigate the negative impact of HIV/AIDS on persons infected and affected in Trinidad and Tobago. There are ii) iii) five priority areas in the national plan, namely Prevention, Treatment, care and support, iv) v) Advocacy and human rights, Surveillance and research, Programme management, coordination and evaluation. In terms of prevention activities, the PMTCT programme has been successful in terms of both uptake of VCT ( 95%) and reduction of mother to child transmission (greater than 3 fold decrease in the past 7 years). All blood is screened and HIV prevalence among blood donors is low. A comprehensive counselling and testing policy has been developed, with VCT and rapid testing available at 7 sites and additional sites are scheduled to come on stream in 2008. Free treatment is available for eligible persons, though an estimated 54% of persons with advanced HIV are receiving ART. Care and treatment for TB/HIV co-infected persons are available, however the country would benefit from an extended surveillance and referral system for 327 HIV in the Caribbean: A Systematic Data Review 2003-2008 opportunistic infections (especially TB) affecting PLWHA. A comprehensive and responsive intervention strategy addressing the improvement of STI screening, diagnosis and management among HIV infected clients is essential for a successful HIV and STI prevention programme. A better and in-depth understanding of the dynamics of the HIV epidemic in the country could be achieved with more routine behavioural surveillance data for specific sub-populations (e.g. men who have sex with men, female sex workers) and better correlation of HIV/AIDS surveillance data, behavioural surveillance data and HIV/AIDS and STI programmatic data. 328 HIV in the Caribbean: A Systematic Data Review 2003-2008 Introduction Trinidad and Tobago is the most southern country in the chain of Caribbean islands, just 7 miles from the Venezuelan coast. It has an area of 5,128 sq km. In 2007, the population of Trinidad and Tobago was approximately 1.3 million, with a crude birth rate of 15 per 1,000 population and crude death rate of 8 per 1,000 population. The country is composed of seven counties, of which St. George is the most densely populated. In 2006 the literacy rate among those aged 15 years and older was estimated to be 99%. Epidemiology of HIV/AIDS in Trinidad and Tobago Estimates of persons living with HIV/AIDS in Trinidad and Tobago Trinidad and Tobago is reported to have a generalised epidemic, that is an HIV prevalence of greater than 1% in the general population (UNAIDS, 2006; CAREC, 2004). UNAIDS estimates HIV prevalence in the adult population to be approximately 1.5% and the number of persons living with HIV/AIDS (PLWHA) to be approximately 29,000. Trends in HIV infections In this report, an HIV case includes persons whose HIV diagnosis is AIDS (i.e. AIDS at first diagnosis) and the year of report is the earliest known date of HIV diagnosis. The first cases of HIV/AIDS in Trinidad and Tobago were diagnosed and reported in 1983. During the period 1983-2007, there has been a total of 18,735 reported HIV infections, with 10,509 (56%) being male and 7,520 (40%) being female. The 18,735 cases consisted of 1,321 (7%) cases aged less than 15 years, 15,693 (84%) cases aged 15 years old and older, 1,225 (6%) with no age recorded and 496 (3%) with no age and gender recorded [Table 1]. In the last eight years, the cumulative total of HIV cases has more than doubled, with the annual incidence increasing from 816 per 100,000 population in 2000 to 1,441 per 100,000 population in 2007. During 2007, on average, 4 new cases of HIV/AIDS were reported everyday. The annual number of newly-detected HIV infections increased steadily from the beginning of the epidemic to the early 2000s, reaching a peak of 1,718 cases in 2003, with a male to female ratio of 1.03:1 [Table 1]. The subsequent decrease in reported cases coincided with the introduction of antiretroviral treatment (ART) that promoted and encouraged HIV testing. During 1983-2006, the larger proportion of newly-detected HIV infections per year occurred in males, though there has been a steady decrease in the male to female ratio over the years. In 2007, for the first time, the number of reported female HIV cases (637 cases, 47%) was greater than the number of reported male HIV cases (624 cases, 46%) [Table 1, Figure 1]. Table 1: Number of Reported HIV Cases by Year and Gender 329 HIV in the Caribbean: A Systematic Data Review 2003-2008 Total reported cases Year of Male to Gender not Male Female Test female ratio reported Cumulative Number cases 1983 8 0 All males 0 8 8 1984 27 0 All males 0 27 35 1985 95 17 5.59 2 114 149 1986 104 31 3.35 1 136 285 1987 136 40 3.40 4 180 465 1988 172 57 3.02 12 241 706 1989 146 84 1.74 18 248 954 1990 188 93 2.02 5 286 1240 1991 280 153 1.83 9 442 1682 1992 401 195 2.06 18 614 2296 1993 442 176 2.51 8 626 2922 1994 382 218 1.75 23 623 3545 1995 424 229 1.85 31 684 4229 1996 507 309 1.64 51 867 5096 1997 571 390 1.46 36 997 6093 1998 551 386 1.43 28 965 7058 1999 625 466 1.34 33 1124 8182 2000 546 331 1.65 39 916 9098 2001 543 434 1.25 85 1062 10160 2002 651 527 1.24 31 1209 11369 2003 852 827 1.03 39 1718 13087 2004 757 635 1.19 53 1445 14532 2005 777 616 1.26 43 1436 15968 2006 700 669 1.04 50 1419 17387 2007 624 637 0.97 87 1348 18735 Total 10509 7520 706 18735 Data source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Figure 1: Reported HIV Cases by Year and Gender (1983-2007) 330 HIV in the Caribbean: A Systematic Data Review 2003-2008 1800 200.0 1600 180.0 160.0 1400 Percentage of HIV cases 140.0 1200 No of HIV cases 120.0 1000 100.0 800 80.0 600 60.0 400 40.0 200 20.0 0 0.0 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year Male Female Total % of Males % of Females Data source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 In 2007, almost 18% (236 of 1,348) of reported HIV cases were among young people aged 15-24 years [Figure 2]. In 2007, there was a disproportionately higher number of infected younger females compared to young males. In 2007, only 25% (60 of 236) of new HIV cases among adolescents and young adults occurred in males, while females accounted for 73% (172 of 236) of these cases (gender was not reported for 2%) [Figure 2]. Additionally, young men accounted for only 10% (60 of 624) of new HIV cases among males overall, while young females accounted for 27% (172 of 637) of new cases among females overall. HIV infections are showing the fastest increase among young adult females aged 15-29 years, increasing from 16% of all newly diagnosed adult female cases in 1983-1987 to 65% in 2003-2007 [Figure 3]. The higher rate of HIV detection among younger females may be partly due to more opportunities for HIV screening in young women (e.g. Prevention of Mother to Child Transmission (PMTCT) programme). Figure 2: Number of HIV Cases Reported in 2007 by Gender and Age Group 331 HIV in the Caribbean: A Systematic Data Review 2003-2008 120 No. of reported cases 100 80 60 40 20 0 <1 1-4 5-9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60+ Age group Male Female Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Figure 3: Reported Female HIV Cases by Age Group and Year (1983-1987) 70 60 Percentage of Female HIV Cases 50 40 30 20 10 0 1983 - 1987 1988 - 1992 1993 - 1997 1998 - 2002 2003 - 2007 Years 15-29 y.o. 30-44 y.o. 45-59 y.o. 60 y.o. above Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 332 HIV in the Caribbean: A Systematic Data Review 2003-2008 Sexual exposure continues to be the main mode of HIV transmission in Trinidad and Tobago. In 1983, all of the eight diagnosed HIV/AIDS cases reported sexual exposure as their risk of having HIV, with five (62.5%) being men who have sex with men (MSM), and three (37.5%) being men who have sex with men and women (MSMW). Starting in the late 1980’s heterosexual exposure became the major risk for both sexes [Figure 4]. It should be noted however, that on average, only 42% of HIV cases reported on their exposure risk. During the period 1983-2007, intravenous drug use and blood transfusions accounted for 0.06% and 0.03% of all HIV cases respectively. This represents 9 cases due to intravenous drug use and 4 cases due to blood transfusions during the period 1998-2002. There were no cases due to either of these two exposures outside of this time period. Figure 4: Reported HIV Cases by Exposure Category and Year (1983-2007) 70 60 Percentage of HIV cases 50 40 30 20 10 0 1983 - 1987 1988 - 1992 1993 - 1997 1998 - 2002 2003 - 2007 Years % MSM % MSWM % MSW % WSM MSM - Men who have sex with Men MSMW - Men who have sex with Women and Men MSW - Men who have sex with Women WSM - Women who have sex with men Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 HIV cases have been diagnosed in all counties in Trinidad and Tobago [Table 2]. During the period 1983-2007, annually and overall, the largest proportion of HIV cases were reported from County St. George (56%), with 51% of these coming from St. George West, 27% from St. George Central and 22% from St. George East [Figures 5-6]. Table 2: Number of Reported HIV Positive Cases by County and Year 333 HIV in the Caribbean: A Systematic Data Review 2003-2008 Total 1983- 1988- 1993- 1998- 2003- County 1987 1992 1997 2002 2007 Numbe /100,000 1 St George 158 716 1295 1487 1713 5369 3469 West St George 66 301 660 950 917 2894 1840 Central St George 47 182 351 681 1019 2280 699 East Total for St 312 1199 2306 3118 4782 11717 1836 George Caroni 22 65 162 271 412 932 405 St Andrew 5 30 87 129 195 446 693 /St David Nariva/ Mayaro 2 13 28 33 35 111 332 St Patrick 8 35 108 140 188 479 260 Victoria 21 106 212 402 400 1141 774 Tobago 20 55 204 340 391 1010 1867 Not stated 116 328 690 843 2096 4073 Total 465 1831 3797 5276 7366 18735 1385² 1 Rate/100,000 County population based on the 2000 census ² Rate/100,000 population using 1,352,369 as denominator. Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Figure 5: Reported HIV Infections by County, 1983-2007 22% 5% 22% 51% 56% 6% 3% 1% 2% 5% Total St. George Caroni 27% St. Andrew/St.David Nariva/Mayaro St. George East St. George Central St. Patrick Victoria Tobago Not Reported St. George West Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Figure 6: Maps of Reported HIV Infections by County, 1983-2007 To be inserted 334 HIV in the Caribbean: A Systematic Data Review 2003-2008 Trends in AIDS cases During the period 1983-2007, there has been a cumulative total of 5,743 reported AIDS cases, of which 3,758 (65%) were males, 1,963 were females and 22 were not categorized according to gender [Table 3]. Since the start of the epidemic the male to female ratio of AIDS cases decreased and in the last 10 years remained at between 1.5:1 and 2.15:1. Over the past ten years, the cumulative number of AIDS cases has almost doubled. The AIDS incidence rate peaked in 1999 at approximately 35 per 100,000 population and subsequently decreased to approximately 8 per 100,000 in 2007. Table 3: Number of Reported AIDS Cases by Year and Gender Total reported cases Year of Male to Gender not Test Male Female Cumulative female ratio reported Number cases 1983 8 0 All males 0 8 8 1984 13 0 All males 0 13 21 1985 32 7 4.57 0 39 60 1986 60 13 4.62 0 73 133 1987 58 20 2.90 0 78 211 1988 97 36 2.69 0 133 344 1989 84 36 2.33 0 120 464 1990 120 57 2.11 0 177 641 1991 160 79 2.03 0 239 880 1992 200 78 2.56 0 278 1158 1993 207 74 2.80 0 281 1439 1994 155 90 1.72 0 245 1684 1995 215 111 1.94 0 326 2010 1996 225 99 2.27 2 326 2336 1997 195 102 1.91 0 297 2633 1998 231 131 1.76 2 364 2997 1999 277 175 1.58 0 452 3449 2000 266 145 1.83 0 411 3860 2001 262 168 1.56 10 440 4300 2002 248 167 1.49 3 418 4718 2003 199 120 1.66 3 322 5040 2004 153 92 1.66 1 246 5286 2005 142 74 1.92 0 216 5502 2006 80 56 1.43 1 137 5639 2007 71 33 2.15 0 104 5743 Total 3758 1963 22 5743 Data source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 The proportion of new cases with AIDS at first diagnosis peaked in the early 2000s and decreased since then in both males and females. In 1983, 100% of all diagnosed HIV were AIDS cases [Figure 7]. In 2002, when the combination ARV became available, the proportion of AIDS cases at first diagnosis decreased to 38% among the males and 32% among the females. 335 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 7: Reported HIV and AIDS Cases by Year (1983 – 2007) 2000 1800 1600 1400 Number of cases 1200 1000 800 600 400 200 0 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year HIV Diagnosis AIDS Diagnosis Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Overall, the cumulative number of cases of AIDS at first diagnosis peaked in the age group 30-34 years (17%), followed by 35-39 years old (15%) [Figure 8]. Recent analysis of 1,512 patients from a resource-poor setting showed that the mean survival time from seroconversion to ART eligibility was 5.67 years (95% confidence interval 2.85-9.96). Given this average period of time from HIV infection to AIDS, Trinidad and Tobago data suggest approximately 20-29 years as the most likely age of HIV infection. It is worth noting that 9% of all AIDS cases at first diagnosis are among those aged 20-24 years, indicating a probable period of infection of younger than 15 years [Figure 8]. Figure 8: Percentage of AIDS Cases as First Diagnosis by Age Group (1983 – 2007) 336 HIV in the Caribbean: A Systematic Data Review 2003-2008 18 16 14 Percentage of AIDS cases 12 10 8 6 4 2 0 <1 1-4 5-9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 + Age group % AIDS Diagnosis Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 During the period 1983-1987, men who have sex with men (MSM) was the largest exposure category among AIDS cases (57%), and this decreased to 5% during the period 2003-2007. Heterosexual exposure however, has increased over time [Figure 9]. Among heterosexual females (WSM), the proportion of AIDS cases rose from 12% in 1983-1987 to 42% in 2003-2007. Among the male heterosexuals (MSW), it increased from 11% in 1983-1987, to 51% in 2003- 2007 [Figure 9]. However, it should be noted, that only 57% of AIDS cases reported on their exposure risk. During the period 1983-2007, intravenous drug use and blood transfusions accounted for 0.1% and 0.06% of all AIDS cases respectively. This was as a result of 5 cases due to intravenous drug use and 3 cases due to blood transfusions during the period 1998-2002. No cases in these exposure categories were reported outside of this time period. Figure 9: Reported AIDS Cases by Exposure Category and Year of Diagnosis 337 HIV in the Caribbean: A Systematic Data Review 2003-2008 60 50 Percentage of AIDS cases 40 30 20 10 0 1983-1987 1988-1992 1993-1997 1998-2002 2003-2007 Years MSM MSWM MSW WSM MSM - Men who have sex with Men MSMW - Men who have sex with Women and Men MSW - Men who have sex with Women WSM - Women who have sex with men Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 As with HIV cases, AIDS cases have been diagnosed in all counties in Trinidad and Tobago, with county St. George having the highest proportion of reported cases, 38% of all AIDS cases reported in the country [Figure 10, Table 4]. Figure 10: Reported AIDS Cases by County, 1983-2007 4% 5% 7% 3% 38% 1% 3% 6% 13% 20% St. George West St. George Central St. George East Caroni St. Andrew/St.David Nariva/Mayaro St. Patrick Victoria Tobago Not Reported Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Table 4: Reported AIDS Cases by County and Year 338 HIV in the Caribbean: A Systematic Data Review 2003-2008 1 Rate/100,000 County population based on the 2000 census Total County 1983- 1988- 1993- 1998- 2003- 1987 1992 1997 2002 2007 Numbe /100k 1 r Pop St George West 93 444 598 691 324 2150 1389 St George 43 179 315 454 185 1176 748 Central St George East 31 99 169 305 167 771 236 Total for St 167 722 1082 1450 676 4097 642 George Caroni 11 49 78 117 72 327 142 St Andrew/ St 4 22 43 68 30 167 260 David Nariva/ Mayaro 0 12 12 16 3 43 128 St Patrick 3 25 47 59 24 158 86 Victoria 14 65 105 174 52 410 278 Tobago 2 23 53 100 53 231 427 Not stated 10 29 55 101 115 310 Total 211 947 1475 2085 1025 5743 425² ² Rate/100,000 population using 1,352,369 as denominator. Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Trends in AIDS Mortality In 2004, HIV disease was the fifth leading cause of death in Trinidad and Tobago overall, and the leading cause of death among those aged 25-44 years [Table 5, Figure 11]. Table 5: Ten leading causes of death in Trinidad and Tobago in 2004 Rank Cause of Death Number Rate 1 Ischaemic heart diseases 1633 122.8 2 Diabetes mellitus 1372 103.1 3 Cerebrovascular diseases 948 71.3 4 Hypertensive diseases 418 31.4 5 Human Immunodefiency virus (HIV) Disease 311 23.4 6 Assault (homicide) 293 22.0 7 Influenza and Pneumonia 260 19.5 8 Malignant neoplasm of prostate 239 18.0 9 Land transport accidents 202 15.2 10 Certain conditions originating in the perinatal period 187 14.1 Note: The total deaths for Trinidad and Tobago in 2004 was 9,873 339 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 11: Leading Causes of Death Among 25 - 44 Year Olds in Trinidad and Tobago in 2004 Human Immunodefiency Virus Disease (HIV) Assault (Homicide) Land Transport Accidents Intentional Self-Harm (Suicide) Ischaemic Heart Disease 0 20 40 60 80 100 120 140 160 180 CRUDE RATES PER 100, 000 POPULATION During the period 1983-2007, there were 3,548 reported AIDS deaths, 2,374 (66.9%) males, 1,163 (32.8%) females and 11 (0.3%) with gender not reported [Table 6, Figure 12]. This may be a reflection of a gender-related issue with respect to ART services. The number of reported AIDS deaths peaked in 1998. During the ten year period 1997-2006, the male to female ratio of AIDS deaths varied between 1.4:1 and 2.0:1. In 2007, there was a much smaller proportion of female deaths, with a 3:1 male to female ratio [Table 6]. Data were not available on the number of AIDS cases or deaths that were receiving ART. Thus it is only assumed that the introduction of ART is related to the decreasing number of AIDS deaths in recent years. Table 6: Number of Reported AIDS Deaths by Year and Gender Total reported cases Year of Male to Gender not Test Male Female Cumulative female ratio reported Number cases 340 HIV in the Caribbean: A Systematic Data Review 2003-2008 1983 6 0 All males 0 6 6 1984 10 0 All males 0 10 16 1985 25 4 6.25 0 29 45 1986 30 12 2.50 0 42 87 1987 48 8 6.00 0 56 143 1988 48 17 2.82 0 65 208 1989 52 19 2.74 0 71 279 1990 71 34 2.09 0 105 384 1991 101 32 3.16 0 133 517 1992 129 43 3.00 0 172 689 1993 150 50 3.00 0 200 889 1994 125 69 1.81 0 194 1083 1995 137 69 1.99 0 206 1289 1996 177 80 3.46 1 258 1547 1997 129 68 1.90 0 197 1744 1998 170 96 1.77 1 267 2011 1999 151 95 1.59 0 246 2257 2000 147 75 1.96 0 222 2479 2001 143 86 1.66 6 235 2714 2002 142 95 1.49 3 240 2954 2003 102 64 1.59 0 166 3120 2004 85 43 1.98 0 128 3248 2005 65 36 1.81 0 101 3349 2006 66 47 1.40 0 113 3462 2007 65 21 2.95 0 86 3548 Total 2374 1163 11 3548 Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 Figure 12: AIDS Cases and Deaths in Trinidad and Tobago, 1983-2007 341 HIV in the Caribbean: A Systematic Data Review 2003-2008 500 450 400 AIDS Deaths AIDS Cases 350 300 Reported Cases 250 200 150 100 50 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year The largest proportion of all AIDS deaths (17%) were reported among those aged 30-34 years, followed by those aged 35-39 years (16%). Among younger adults, approximately 14% of all AIDS deaths were in the age group 25-29 years old and approximately 9% were in the age group 20-24 years [Table 7]. The majority of AIDS deaths in the less than 15 years age group were females (54%), while almost (68%) of the AIDS deaths in the 15 years old and above were males. Table 7: Reported AIDS Deaths by Age Group and Year (1983-2007) Age group in Total 2003- years 1983-1987 1988-1992 1993-1997 1998-2002 2007 N° % 1 Children < 15 7 34 79 37 7 164 5 342 HIV in the Caribbean: A Systematic Data Review 2003-2008 15-19 4 8 28 17 6 63 2 20-24 21 77 71 90 38 297 8.5 25-29 30 89 144 144 64 471 13.5 30-34 21 114 199 191 77 602 17 35-39 18 73 162 214 90 557 16 40-44 13 50 124 160 103 450 13 45-49 6 48 91 141 83 369 11 50-54 12 17 70 89 51 239 7 55-59 1 15 34 57 46 153 4 >60 3 16 38 40 23 120 3 Not reported 7 5 15 30 6 63 2 354 Total 143 546 1055 1210 594 8 1 Percentages based on total number minus reports for which age group was not reported. N=3,485 2 Totals include 11 AIDS deaths for which gender was not reported. Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 As with HIV and AIDS cases, all counties in Trinidad and Tobago report AIDS deaths, with the largest proportion of deaths reported from county St George West (41%), followed by St. George Central (21%) and St. George East (14%) [Figure 13]. Figure 13: Reported AIDS Deaths by County, 1983 – 2007 3% 4% 6% 2% 1% 3% 41% 5% 14% 21% St. George West St. George Central St. George East Caroni St. Andrew/St.David Nariva/Mayaro St. Patrick Victoria Tobago Not Reported Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 During the period 1983-2007, the county with the highest mortality rate was St. George West (931/100,000 population), while county St. Patrick had only 46 deaths per /100,000 population. County Nariva/Mayaro and county St. Patrick did not have any reported AIDS deaths in 2007 [Table 8]. Table 8: Reported AIDS Deaths by County and Year 343 HIV in the Caribbean: A Systematic Data Review 2003-2008 County 19 83- Total 1988-1992 1993-1997 1998-2002 2003-2007 1987 N° /100k Pop 1 St George West 62 235 459 450 234 1440 931 St George Central 26 103 224 282 114 749 476 St George East 24 72 114 173 95 478 147 Total for St 112 410 797 905 443 2667 418 George Caroni 7 26 55 68 34 190 83 St Andrew/St 3 16 27 32 20 98 152 David Nariva/Mayaro 0 7 5 10 0 22 66 St Patrick 1 22 25 27 10 85 46 Victoria 9 37 72 75 31 224 152 Tobago 1 14 33 38 24 110 203 Not stated 10 14 41 55 32 152 All Counties 143 546 1055 1210 594 3548 262² 1 Rate/100,000 County population based on the 2000 census ² Rate/100,000 population using 1,352,369 as denominator. Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008 HIV prevalence among specific populations Pregnant women Three major national HIV seroprevalence surveys conducted among women attending antenatal clinics at government health facilities in 1990, 1991/1992 and 1996 showed an increasing prevalence over time of 0.28%, 0.62% and 1% respectively (Lewis M. et al 1994; CAREC, 2004). In the 1996 survey, among the women aged 15-24 years, the HIV prevalence was even higher at 1.5%. HIV prevalence among pregnant women attending antenatal clinics in public health facilities appeared to have peaked in 2000 at 1.9%. It subsequently decreased to 1.4% in 2002 and increased slightly to 1.6% in 2005 and 1.5% in 2006 (CAREC, 2004; PAHO/WHO, 2006; Ministry of Health, 2006). HIV prevalence among pregnant women in Tobago appears to be higher than in Trinidad. In 2004, a survey conducted in Tobago among delivering women found a prevalence rate of 2.6% overall and 3.8% among those under 25 years old (Duke et al, 2004). Men who have sex with men (MSM) Early in the epidemic, in 1984, Bartholomew and Cleghorn found a 40% prevalence rate among a cohort of MSM recruited primarily from STI clinics in Trinidad. 344 HIV in the Caribbean: A Systematic Data Review 2003-2008 A study in Trinidad and Tobago in 2004, found an HIV prevalence of 20% among MSM, 25% of whom said they also regularly had sex with women. The majority of respondents were over 30 years of age. Younger men (those aged less than 30 years) reported more behaviours that reduce HIV exposure (reduction in the number of sexual partners, condom use, HIV testing, low reported drug use). Men reported having sex with older men at sexual initiation, often in situations of coercion or exploitation. Bisexual respondents reported a lower knowledge of HIV and its transmission and prevention, as well as more negative attitudes towards persons with HIV/AIDS than respondents who reported male partners exclusively. There was a high reported percentage of unprotected sex, pointing to continued high transmission of HIV among this population and their female partners. The limitation of this study is that it did not aim to reach a representative sample of MSM. The snowballing method was used, so only those who had disclosed their sexual preference to their social network could be recruited. Additionally, out of a sample size of 307 respondents, test results were unavailable for 72 (23%) respondents, with 62 samples being inadequate for testing and 10 respondents declining to give a sample. (Lee et al, 2006) Substance Dependent Persons A study conducted on a group of 318 cocaine dependent persons, who were classified as heavy users, found 9 (3.3%) of the 276 males addicts and 6 (14.3%) of the 42 female addicts to be HIV positive. The HIV positive addicts reported having > 10 sexual partners during the previous year, which was more that the number reported by those who were HIV negative. Thirty-three percent (33%) of the female addicts were prostitutes, compared to 28% of those who were HIV negative. Cocaine users, especially females, may be more likely to be at increased risk for HIV infection through sexual behaviour such as multiple partnering and prostitution. (Lewis P.D and Hospedales C.J) During September 1992 - October 1993, a cross-sectional survey was conducted on 192 HIV positive index cases recruited from the Queen’s Park Couselling Centre and Clinic (QPCCC), the main STI clinic in the country, and 50 partners. In this survey cocaine use itself was not associated with being HIV positive, but was significantly associated with a history of STIs and genital ulcer disease, and may play an indirect role in HIV transmission. (de Gourville E et al). Another survey among 1,227 persons admitted to a psychiatric hospital and deemed to be at high risk of HIV infection found HIV prevalence to be highest among those with substance abuse problems, particularly those who abused cocaine (p< 0.001) (Hutchinson and Simeon 1997). Injecting drug use is not common in Trinidad and Tobago, as evidenced by low HIV transmission rates due to injecting drug use (< 0.1% of HIV positive cases). STI clinic attenders In the de Gourville study on STI clinic attenders in 1992-1993, being HIV positive was found to be significantly associated a history of STIs and prostitution in the past 2 years (p<0.05). (de Gourville E et al). In 1997, the Hutchinson and Simeon survey among psychiatric hospital patients found that those who were VDRL positive were also more likely to be HIV positive than other patients (p<0.001). 345 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV prevalence among STI clinic attenders, while higher than that among the general population, has been decreasing. Serosurveys conducted on patients with STIs at QPCC&C in 1991, 2002 and 2006, found prevalence rates of 13.6%, 5.99% and 2.2% respectively. This showed a 6 fold decrease in the HIV seroprevalence rate among STI patients over the 14 year period (CAREC, 2004; Government of Trinidad and Tobago, Ministry of Health, 2006). In 2006, among the HIV positive clinic attenders at QPCC&C, 84 (51%) were male and 81 (49%) were female. This compares to 58% being male and 42% being female in 2005 and higher male to female ratios in previous years. Women were infected at a younger age than men, starting at 15-19 years and peaking at 25-29 years. Among males, the peak incidence was in the age group 35-39 years. The majority of the clients came from St. George West, St. George Central, St. George East and Victoria Counties. It is worth noting that 38% of all positive test results were not collected by clients. Hence persons may not be aware of their status and could put their partner(s) at risk of HIV infection. Hence field interviewers continue to visit defaulting clients. (Government of Trinidad and Tobago, Ministry of Health, 2006) In 2005-2006, a survey of 180 newly diagnosed HIV cases that were tested for STI infections found a STI prevalence rate of 42%, with 25% among males and 17% among females. Herpes, syphilis and gonorrhoea were significantly more likely to be seen in males. Patients who were unemployed or the partner of already diagnosed HIV clients were significantly more likely to have an STI than those who were employed or did not have an HIV positive partner (Buensuceso JI, 2007). Persons with HIV positive partners Available data suggest that the HIV transmission rate from HIV positive partners to their partners is slightly higher than 50%. The limitation of the available data was that the dates of infection of the index case and their partner was not always available, thus it was not possible to determine who infected whom. In the de Gourville study on STI clinic attenders in 1992-1993, an HIV prevalence of 54% (27 of 50) was found among partners of index HIV positive patients. Partners of women in the PMTCT Programme are encouraged to do an HIV test, particularly if the pregnant client is found to be positive. However, in 2006, only 38 of 206 male partners were referred for testing, 32 (84%) were tested for HIV and 17 (53%) were positive (Ministry of Health, 2006, NACC, 2008). Homeless persons A convenience sample of 88 homeless persons in the capital, Port-of-Spain, showed that they had many risk factors for HIV infections, namely engaging in unprotected sex with multiple partners, exchanging sex for money and regularly smoking crack cocaine. Females were significantly more likely to be sex traders, to engage in bisexual behaviour and to have a history of psychiatric illness. (Reid S, 1999). Homeless persons appear to be at risk of HIV due to their mobility, sex-trading, psychiatric disorders and substance abuse, particularly crack (Day M et al 2004) 346 HIV in the Caribbean: A Systematic Data Review 2003-2008 Tuberculosis (TB) patients TB/HIV co-infection rates have been increasing over the years. During 1990-1996, of 987 reported TB cases, 122 (12.4%) were found to be positive for HIV. Eighty percent (80%) of these 122 patients were of African descent and 11% were of East Indian descent. Out of a total of 74 paediatric TB cases, 6 (8%) were HIV/TB co-infected (Ovid et al 1998). During the period 1998 to 2006, with the exception of 2001, TB patients were screened for HIV. While co-infection rates varied over the years, the average co-infection rate was 38%. The incidence of TB/HIV co-infection decreased between 1998 and 2000, from 50% to 32%. It increased to 53% in 2002, decreased again to 20% in 2005 and then increased to 32% in 2006. It is worth noting that the percentage of TB cases evaluated for HIV varied between 51%-100% over the years [Figure 14]. The incidence of TB/HIV co-infection follows the same geographic pattern as HIV/AIDS, with the highest number of cases being diagnosed in county St. George. 347 HIV in the Caribbean: A Systematic Data Review 2003-2008 Figure 14: TB/HIV Co-infection, 1998-2006 120 250 100 200 Number of New Tb Cases 80 Percentage (%) 150 60 100 40 50 20 0 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year % Evaluated for HIV-Antibody % Positive for HIV-Antibody No. of New TB cases Other possible high risk groups Other possible high risk groups are commercial sex workers and prisoners, but no data were available on these groups. Knowledge, attitudes and practises with respect to HIV Knowledge of and attitudes to HIV In 2006, a national survey of Knowledge, Attitudes, Practices and Beliefs (KAPB) was conducted on a representative sample of 1,798 persons in the general population aged 15-49 years. The survey revealed that there were high levels of awareness of HIV/AIDS throughout the population, with 98% of the sample reporting that they had heard of HIV or AIDS, though only 69% knew that there was a difference between HIV and AIDS. The survey revealed that the impact of HIV/AIDS on the general population has been quite widespread, as about 37% of those surveyed indicated that they knew someone who had HIV or had died from AIDS. There was variation by geographic location with Tobago and Port of Spain having the highest number of respondents knowing someone who had HIV or had died from AIDS, while Victoria, St. Andrew and San Fernando had the lowest percentages. It is to be noted that 63.3% of the respondents declined to indicate if they had a close friend or relative who is HIV-positive or who died from AIDS. This appears to be consistent with a population in which stigma and discrimination against those living with and affected by HIV/AIDS remains pervasive. 348 HIV in the Caribbean: A Systematic Data Review 2003-2008 The survey found quite high levels of knowledge regarding ways to curb the transmission of HIV with no noticeable differences by age group. Approximately 90% of those surveyed were able to identify six key measures which can reduce the transmission of HIV. Though all blood collected by the Blood Bank is screened for HIV, 74.5% of respondents identified refusing a blood transfusion as one way of preventing the transmission of HIV. Close to two thirds (65%) of the respondents indicated that they had heard of the NACC’s “What’s your positionâ€? (WYP) campaign. The main target of the WYP campaign, youth (15-24 years) did indicate more widespread knowledge of the WYP campaign with 73.3% of youth indicating that they had heard of the campaign. Seventy-eight (78%) of men and 82.6% of women in the sample revealed that the information received from the WYP campaign had led them to adjust their HIV risk behaviour. With regard to knowledge of the location of an HIV testing site, 65.9% of those surveyed, stated that they were aware of a site where testing was done. A slightly higher percentage of females (67.9%) than males (63.3%) responded that they knew a site where HIV testing was done and that only 54.7% of youth 15-19 years knew where testing was available. This becomes all the more important in the context of the findings of the HIV/AIDS Service Provision Assessment (Measure Evaluation Project: University of North Carolina, Chapel Hill, NC and Macro International, Calverton, Maryland, 2006), which reported that there were no youth friendly testing sites in Trinidad and Tobago. Age at first sex and numbers of sexual partners The national KABP survey in 2006 found that the median age for initiating sexual activity was found to be 18 years and 11.6% of young women and men aged 15-24 years reported to have had sexual intercourse before the age of 15 years. Further research is needed to determine if, during the most recent decade of the epidemic young persons have begun to delay the initiation of sexual activity. Eighty-five percent (85%) of young women and men aged 15-49 years had had sexual intercourse with more than one partner in the last 12 months. Condom use The national KABP survey in 2006 pointed to the greater probability of youth 15-24 years (62.2%) using a condom during their first sexual encounter as compared to 38.5% for adults 25-49 years of age (Ali et al, 1997). In 2004, 47% of men reported the use of a condom the last time they had anal sex with a male partner (Lee et al, 2005) Socio-cultural and Behavioural Factors Influencing the HIV/AIDS Situation A Situational and Response Analysis was conducted for the island of Tobago in 1999 and for Trinidad in 2001. These reports both highlight the fact that the HIV/AIDS epidemic is firmly rooted among the youth in the country, while continuing to impact significantly on the older age cohorts (25-39 years). They also confirm the epidemiological data which demonstrates that women are particularly affected. The specific sociocultural and behavioural factors that act as driving forces behind the spread of the epidemic in both islands are shown in the boxes below. 349 HIV in the Caribbean: A Systematic Data Review 2003-2008 BOX 1: Factors Influencing the HIV/AIDS BOX 2: Factors Influencing the HIV/AIDS Situation in Tobago Situation in Trinidad Unemployment among the youth; Multiple partnering; Increasing substance abuse problems; High use and abuse of alcohol, drugs and Commercial sex practices; other illegal substances; High stigma and discrimination of PLWHAs; Increased incidence of violence among males Powerlessness among women to change and between men and women; cultural norms around multiple partners and Inconsistent use of condoms among the child rearing; sexually active population; Increasing expatriate population; and Gender inequalities among poorer groups; Absence of an organised, coordinated Regional and extra regional migration intervention programme based on Tobago’s particularly around the festive seasons; situation and norms. An environment in where men having sex with men remains illegal; Discrimination and stigmatisation against PLWHAs; and Commercial sex practices. Source: The University of the West Indies, Health Economics Unit, Report of Consultations for the National Strategic Plan Source: Health Economics Unit, The University of the West Indies on HIV/AIDS for Trinidad and Tobago: Rapporteur Report, (2001). Situation and Response Analysis of HIV/AIDS in Trinidad. 2002 HIV Subtypes and Resistance in Trinidad and Tobago Studies in Trinidad and Tobago found that the prevalent HIV type is HIV-1 subtype B, the most common subtype in North America and Western Europe (Cleghorn et al, 2000). In 2002, a study found that there were no HIV drug resistant strains circulating in the region and HIV-1 subtype B was still the most prevalence serotype, with clades B and D being isolated (Vaughan H, Tedder R, 2002). Programmatic Response Programme Coordination 350 HIV in the Caribbean: A Systematic Data Review 2003-2008 Trinidad and Tobago’s HIV response is coordinated and managed by the National AIDS Coordinating Committee (NACC), comprised of representatives of the full range of stakeholders from the public and private sectors, civil society and PWLHA. The NACC was established under the aegis of the Office of the Prime Minister and performs a coordinating, monitoring and advisory role with respect to the national expanded response to HIV/AIDS. The key areas of focus for the NACC are policy formulation, programme management, coordination, monitoring, evaluation and finance. NACC’s key areas of responsibility include: • Definition of national policies • Setting of national targets • Establishment of national standards • Evaluation and monitoring of the programme at the national level With respect to Tobago, the Tobago House of Assembly (THA) ensures that the implementation of the expanded response in Tobago is consistent with the national policies, sectoral plans and standards set out by NACC. Hence the THA is represented on NACC. NACC is divided into five sub-committees consistent with the five priority areas identified in the National Strategic Plan (NSP) 2004-2008. Several of the Sub-Committees have formed working groups which co-opt ad-hoc members as required. The Chairs and Vice-Chairs of the various committees comprise the Executive Committee which meets regularly to examine critical issue and make key policy decisions. Non-governmental Organisations (NGOs) continue to provide critical prevention, treatment, care and support services and are important partners of the NACC. Some of these NGOs facilitate access to the most at risk groups including CSW, MSM, PLWHA and orphans and vulnerable children. The NACC funds a range of proposals from NGOs and also provides technical assistance in support of the implementation of proposals. NGOs have been involved in the implementation of projects and activities which support some of the priorities of the NACC. The National HIV/AIDS Strategic Plan The Trinidad and Tobago HIV/AIDS national response is a multi-faceted, multi-sectoral response, guided by the National Strategic Plan (NSP) 2004-2008. This plan is the instrument for initiating the required expanded response to HIV/AIDS in the country. The two overarching goals of the National Strategic Plan are: • To reduce the incidence of HIV infections in Trinidad and Tobago • To mitigate the negative impact of HIV/AIDS on persons infected and affected in Trinidad and Tobago There are five priority areas of the National Plan as follows: 1. Prevention. The goal of this priority area is to reduce the susceptibility of the population of Trinidad and Tobago to HIV. The six strategic objectives to achieve this goal are to: • Promote safe and healthy sexual behaviours among the general population • Promote healthy sexual attitudes, behaviour and practices among vulnerable/high risk populations • Reduce mother to child transmission • Increase the population’s knowledge of its serostatus 351 HIV in the Caribbean: A Systematic Data Review 2003-2008 • Reduce the probability of post exposure infection • Improve the management and control of conventional sexually transmitted infections (CSTIs) 2. Treatment, Care and Support The goal of this priority area is to provide adequate treatment, care and support services for the infected and affected. The two strategic objectives to achieve this goal are to: • Improve access to treatment and care for HIV/AIDS • Create an environment that supports the infected and affected 3. Advocacy and Human Rights The goal of this priority area is to heighten national interest in HIV/AIDS issues and to ensure the upholding of human rights principles as they relate to PLWHA, CSW, MSM, families of PLWHA and other affected groups. The two strategic objectives to achieve this goal are to: • Reduce stigma and discrimination against PLWHA • Ensure human rights for PLWHA and other groups affected by HIV/AIDS 4. Surveillance and Research The goal of this strategic objective is to provide effective data reporting and monitoring. The two strategic objectives to achieve this goal are to: • Strengthen the surveillance systems for CSTI/HIV/AIDS • Undertake and participate in effective clinical and behavioural research on HIV/AIDS and related issues 5. Programme Management, Coordination and Evaluation The goal of the strategic objective is to ensure successful implementation of Trinidad and Tobago’s National Strategic Plan. The three strategic objectives to achieve this goal are to: • Achieve national commitment, support and ownership of the expanded strategic response to HIV/AIDS • Monitor the implementation of the expanded response • Build capacity among key stakeholders in the expanded response The total cost of the National Strategic Plan is an estimated US$90.33 million over five years. Placing the plan within the economic context of the country, the first year’s implementation cost of US$15.61 million represents 0.20% of the country’s income. This translates into a per capita cost of US$12.20. The largest proportion of funds is targeted at the first two priority areas, namely Treatment, Care and Support (65%) and Prevention (23%). The Prevention component of the Strategic Plan is expected to avert 3,864 new infections over the period 2004-2008, decreasing the incidence rate to 30% of its 2003 value at the end of the Plan’s period. Table 9 outlines the strategies employed to achieve the objectives of the national plan. Table 9: Priority Areas and Strategies in the NSP 2004-2008 Priority Areas Strategies Prevention • Heighten HIV/AIDS education and awareness • Improve the availability and accessibility of condoms. • Extend the responsibility for the prevention of HIV to all sectors of government and civil society. • Introduce behavior change intervention programmes targeted to young females. • Introduce behavior change interventions targeted to youths in and out of school. • Support behavior change programmes targeted to 352 HIV in the Caribbean: A Systematic Data Review 2003-2008 MSM. • Implement a nationwide MTCT programme. • Develop a comprehensive national VCT programme. • Promotion of VCT services. • Ensure the availability of adequate post exposure services. • Increase knowledge and awareness of the symptoms of STIs • Ensure effective syndromic management of STIs. • Provideâ€?youth friendlyâ€? sexual and reproductive health services. Treatment, Care • Implement a national system for the clinical and Support management and treatment of HIV/AIDS • Improve access to medication, treatment and care for persons with opportunistic infections. • Provide appropriate economic and social support to the PLWHA and to the affected. Advocacy and • Promote openness and acceptance of PLWHA in the Human Rights workplace and in the wider community. • Creation of a legal framework that protects the rights of the PLWHA and other groups affected by HIV/AIDS. • Monitor human rights abuses and implement avenues for redress. • Mobilize opinion leaders on HIV/AIDS and related human rights issues. Surveillance and • Understand the linkage between psychosocial issues Research and vulnerability to HIV/AIDS. • Conduct effective epidemiological research and clinical trials Programme • Develop an appropriate management structure for the Management, national expanded response. Coordination and • Gain wide support for the NSP. Evaluation • Mobilize adequate and sustained resources to support implementation of the NSP • Monitor the implementation of policies and programmes as outlined in the NSP. • Strengthen the key constituents of NACC. • Strengthen support groups for PLWHA to better respond to the epidemic and increase the number of these support groups. In the final quarter of 2007, the NACC Secretariat initiated discussions with the Health Economics Unit of the University of the West Indies, St. Augustine with regard to a review of progress made on attaining the objectives of the current NSP, and preparation of terms of reference and a schedule for the development of the new NSP. Prevention Activities 353 HIV in the Caribbean: A Systematic Data Review 2003-2008 Prevention of Mother to Child Transmission of HIV Programme (PMTCT) The Government of Trinidad and Tobago implemented the Prevention of Mother to Child Transmission of HIV Programme (PMTCT) in 2000 and it is now operating in all public antenatal and delivery service facilities. Pregnant women are offered Voluntary Counselling and Testing (VCT) services for HIV and if tested positive are eligible to receive free ART. The goal of the programme is to reduce transmission rate by 50% by 2010. The objectives of the programme are to: • Increase the testing of HIV exposed infants in order to determine their status • Revise PMTCT policy for submission to the Directorate Quality Management • Complete drafts of Standard Operations Procedures, Guidelines for the PMTCT Programme • Increase nutritional replacement feeding for HIV exposed infants from 6-18 months • Train health providers in testing and counselling utilising JHPIEGO Model VCT or Provider Initiated Testing and Counselling (PITC) based on programmes for implementation. The programme has achieved some success in terms of both in uptake of VCT by pregnant women and the reduction of mother to child transmission. VCT services among pregnant women attending public antenatal facilities are well accepted, with at least 95% of women accepting VCT services annually (Kuruvilla A et al, 2000; (PAHO/WHO, 2006). In 2000, 19% of HIV exposed children tested positive; in 2005, 6.8% tested positive; and in 2006, 5.6% tested positive. It should be noted however, that in 2006, 22% of pregnant women did not attend public health facilities for ante-natal care and no data are available on prevention of mother to child transmission practises in the private sector. Some of the challenges faced by the PMTCT programme are: • Adherence of mothers who are HIV positive to the recommended treatment regime due to factors such as stigma and discrimination, provision of incorrect addresses, non- disclosure to partner/family regarding HIV status, migration within districts in Trinidad and Tobago etc. • The quantity of formula for Nutritional Replacement feeding for HIV exposed infants was inadequate and appropriate requirements should be considered. It was suggested that formula should be offered up to age two (2) years. This component of the programme is being reviewed • Lack of coordination between doctors at the treatment centres and the doctors at the antenatal clinics • Low uptake in the testing of exposed infants • Shortage of human resources • The absence of definitive and documented guidelines for health providers to follow resulting in inconsistencies in the management of HIV infected pregnant women, exposed infants, partners and families affected • Non-adherence to all components of antiretroviral prophylaxis A comprehensive review of the PMTCT programme was undertaken during the first quarter of 2007, the review paid specific attention to the issues highlighted above and this has resulted in some measures being put in place to address these issues. (Source: Ministry of Health, 2006; NACC, 2008) Blood Screening Programme 354 HIV in the Caribbean: A Systematic Data Review 2003-2008 All blood is screened for HIV by the National Blood Transfusion Unit. In 2006, 19,771 units were screened and the seroprevalence rate was 0.21%. (NACC, 2008) Counselling and Testing During 2006-2007, the Ministry of Health took several steps to develop a comprehensive counselling and testing policy to include, not only VCT, but rapid testing and Provider Initiated Counselling and Testing. (PITC). As a result, rapid testing is now available at seven sites with several more sites scheduled to come on stream in 2008. As of September 2007, 7,842 rapid tests had been completed at the various sites with all positive tests being referred to the Trinidad and Tobago Public Health Laboratory for confirmation. Patients testing positive for HIV are referred to a treatment centre for a CD4 count and viral load confirmation. Treatment is provided if patients are eligible for it. Prevention Activities by NGOs NGOs have played a key role in prevention interventions directed at schools, youth and work places. They have also played critical roles in the dissemination of information on sexual and reproductive health, STIs and distribution of condoms. In 2006, 21 NGOs undertook 1,293 prevention outreach activities directed at the general population. Treatment, Care and Support National HIV Treatment, Care and Support System The Ministry of Health is responsible for developing and managing care and treatment programmes for persons living with HIV infection and its complications. An essential aspect of this programme is the acceleration of training for caregivers. A small number of health care providers from Trinidad and Tobago have benefited from HIV/AIDS-related training by attending Caribbean HIV and AIDS Regional Training (CHART) Network’s activities elsewhere in the Caribbean and to a lesser extent outside of the region. The recent launch of the Trinidad and Tobago Training Centre should impact on the number of health care workers who are able to provide care and treatment services to PLWHA. The Medical Research Foundation (MRF) is the main national centre providing comprehensive treatment and care to adults with HIV/AIDS. Other care and treatment delivery sites are the Cyril Ross ‘Nursery’, which provides residential and out-patient care for less than 100 children with HIV/AIDS, the Paediatric Hospital at Mt. Hope, the San Fernando General Hospital, the Scarborough Regional Hospital and the Health Promotion Clinic. During 2006-2007 treatment support services at the various delivery sites were enhanced with the provision of CD4 machines at four of the treatment sites. 355 HIV in the Caribbean: A Systematic Data Review 2003-2008 HIV Care and Treatment Uptake During the period April 2002 – December 2007, there was a total of 5,075 persons (4,896 adults and 179 children) receiving HIV care and treatment; and a total of 2,592 persons (2,460 adults and 132 children) receiving ART. Using the UNAIDS estimates of the number of PLWHA in Trinidad and Tobago, it was estimated that in 2007, 54% of persons with advanced HIV infection are receiving antiretroviral treatment. In 2006, the percentage of HIV positive women who received ART to reduce the risk of mother-to-child transmission was reported to be 86%. (NACC, 2008) Also, wider access to ART (available free of charge to persons requiring it) has helped reduce the number of AIDS-related deaths by 53% between 2002 and 2006 (Ministry of Health, Trinidad and Tobago, 2007). TB/HIV Care and Treatment TB is one of the most common opportunistic infections linked to HIV/AIDS and is one of the main causes of death in HIV-infected persons. TB diagnosis and treatment is viewed as an essential component of care for persons who are HIV positive. All suspected cases of TB, TB/HIV are referred to the Caura Hospital. However, in order to improve TB and TB/HIV data collection there is a need to develop an extended surveillance system linking all other departments e.g. MRF, QPC&C, VCT centres, private hospitals and laboratories. Table 10 presents information on treatment outcomes for TB/HIV patients. In 2004, the high default and death rates (29.4% each) reflect the non-existence of a comprehensive direct observed treatment short course (DOTS) programme. An even higher death rate of 42% was recorded in 2005, though there was some reduction in the default rate (19.4%). The issue of adherence requires urgent attention. In this regard the Ministry of Health will need to pay particular attention to existing referral systems for the opportunistic infections which affect HIV/AIDS patients. Table 10: TB/HIV Treatment Outcomes Year 2004 2005 Cured 7 20.6% 4 11% Comp. Rx 7 20.6% 10 28% Died 10 29.4% 15 42% Defaulted 10 29.4% 7 19% Total New TB Cases 34 100% 36 100% Treatment, Care and Support Activities by NGOs During 2006, NGOs conducted various interventions such as PWLHA counselling, home based care of PLWHA, training in home based care, community based treatment adherence counselling and peer education. In the third quarter of 2007, the Caribbean HIV/AIDS Alliance collaborated with the NACC, Ministry of Health, South West Regional Health Authority and South AIDS Support, on a review of users’ perceptions of the quality of care at Ward 2 of the San Fernando General Hospital. Users 356 HIV in the Caribbean: A Systematic Data Review 2003-2008 reported general satisfaction with the quality of care provided and made suggestions with regard to more flexible clinic hours to facilitate employed PLWHA and the need to sensitize health care workers in other wards and service delivery sites at the hospital in order to address stigma and discrimination (NACC, 2008). Advocacy and Human Rights A Human Rights desk has been established to document discrimination and infractions against the rights of PLWHA. A legislative assessment to determine how the existing legal framework facilitates the enjoyment of the human rights of those living with and affected by HIV/AIDS has been undertaken and the report is being finalized (NACC, 2008). Surveillance and Research The Routine HIV/AIDS Surveillance System Surveillance data come from case reports of HIV infection from the Trinidad Public Health Laboratory (TPHL), and AIDS diagnoses are classified by the medical epidemiologist at the National Surveillance Unit (NSU) using the CAREC’s AIDS case definition. Both active and passive surveillance systems are used in collecting case reports. Health clinics submit reports to the NSU and NSU surveillance nurses collect data on AIDS cases from five public hospitals and HIV treatment centres. Data are also collected from VCT sites and Hospices (for advanced HIV disease when appropriate). National data on the HIV status of infants exposed perinatally to HIV infection are collected through the (PMTCT) programme. There are two sources of national information on the number of deaths due to HIV/AIDS, namely the NSU (based on reports from public clinics and hospitals), and the Central Statistical Office (which collects vital registration data). The collection of data on TB/HIV co-infected cases is the responsibility of County Health Visitors. All information is fed into the National Register (not the NSU) from the following sources: • Caura Chest Hospital • Medical and Surgical Thoracic Units Eric Williams Medical Sciences Complex • Chest Clinics i.e. 3 diagnostic and treatment centres (San Fernando General Hospital, Port of Spain General Hospital, Scarborough General Hospital. Data limitations in the national HIV/AIDS surveillance system are: • Reporting delays between the time when a person tests positive for HIV or is given a diagnosis of AIDS and the time when the NSU receives the report • Under-reporting of the number of HIV and AIDS cases due to reports not being sent to the NSU • Incomplete reporting forms - There are a large number of cases for which key information regarding gender, socio-economic status (education and occupation) and co-factors for 357 HIV in the Caribbean: A Systematic Data Review 2003-2008 exposure (sexual contacts, partner information, condom usage, crack/cocaine use, etc) is not available • Changing testing patterns (i.e. who presents for testing and when) • Duplicate HIV positive test reports due to the non-identifying nature of HIV reporting in some jurisdictions. Where possible, counties and regions periodically review and assess the presence of duplicate reports in their positive HIV test data • False positive HIV reports in infants aged less than two years of age due to an initial positive test result, but a negative HIV status at their final HIV test. Infants with positive HIV test reports have proven very difficult to follow up due to the fact that they are initially reported as “infant + mothers’ name and/or surnameâ€? and when these infants are tested later on they are reported under his/her own name. • Surveillance data are collected from the public sector, not the private sector. • Under-reporting of AIDS deaths due to AIDS cases being under-reported thus deaths in unreported AIDS cases cannot be recorded. Also, death is not a mandatory reportable variable in the HIV/AIDS surveillance system, so there are significant reporting delays and under-reporting of deaths among AIDS cases. In some situations, even though an attending physician may list AIDS as a cause of death, laboratory confirmation of HIV infection from the TPHL may not be available, thus this case may never be reported as an AIDS death. Recent research During 2006-2007, two major studies were conducted and reported on, namely a KAPB study of a representative sample of the population aged 15-49 years, and an HIV/AIDS Service Provision Assessment. These studies have provided critical baseline data on a wide range of indicators relating to knowledge, attitudes, beliefs and actions taken to reduce risk, the volume, quantity, quality and range of services currently being provided, availability of policies and guidelines at service delivery sites and capacity gaps. This information will inform the development of the NSP for 2009-2013. Programme Management, Coordination and Evaluation A Programme Officer, Strategic Planning was recruited and commenced work in May 2007 to enhance the coordination efforts of the NACC and to provide critical support to the HIV/AIDS Coordinators assigned to the eight ministries. Main Challenges in Managing and Implementing the National Response The main challenges in managing and implementing the National Response are: i. Stigma and Discrimination remains pervasive (including among health care-providers) particularly against persons living with AIDS and most at risk groups and thus create barriers to accessing testing, treatment and care services ii. Interventions tend to be targeted to the general population with limited one specifically designed and directed at high risk groups iii. Limited sites provide youth friendly services 358 HIV in the Caribbean: A Systematic Data Review 2003-2008 iv. Limited availability and willingness of clinicians to provide HIV/AIDS care and treatment services v. Insufficient training opportunities to update the skills of all members of the treatment team vi. Different departments report on HIV infections, AIDS morbidity, AIDS mortality and TB/HIV infection vii. Lack of reporting of surveillance data and services provided in the private sector viii. Limited participation of the medical professional associations in supporting reporting ix. Inadequacies of existing reporting forms which exclude critical data x. Record-keeping and documentation of services provided are not routine xi. Policy guidelines for service delivery are not readily available nor diligently adhered to xii. Limited absorptive capacity of several civil society organisations which have key roles to play in the national response xiii. Lack of monitoring and evaluation culture and capacity (Source: NACC UNGASS Report 2006-2007, 2008) References 1. Buensuceso JI. Sexually transmitted infections among diagnosed cases of HIV-1 at Queen’s Park Counselling Centre and Clinic, Port of Spain, Trinidad and Tobago. 2007. Unpublished Report. 2. CAREC/PAHO/WHO. Status and Trends: Analysis of the Caribbean HIV/AIDS Epidemic, 1982-2002. Published 2004. 3. Cleghorn FR, Jack N, Carr, JK, Edwards J, Mahabir B et al. A distintivve clade B HIV type 1 is heterosexually transmitted in Trinidad and Tobago. 2000. Proc. Natl. Acad. Sci.AS Vol 97, No. 19; 10532-10537. 4. Day M, Devieux G, Reid SD, Jones JJ, Meharis J, Malow RM. Risk behaviours and healthcare needs of homeless drug users in Saint Lucia and Trinidad. ABNF J. 2004. Nov-Dec; 15(6):121-6 5. de Gourville E, Mabey D, Quigley M, Furlonge C, Jack N, Mahabir BS. Heterosexual transmission of HIV in Trinidad and Tobago: a sexual partner study. 1994 WIMJ 43 (Suppl 1)23: Apr. 6. Duke V, Kitson-Pigott, Lee R, Remy D, Wagner U. Seroprevelence of HIV, HSC1 and HSV-2 among delivering women in Tobago – A core blood based survey. CAREC Surveillance Report Vol 24. No. 3 Nov 2004. 7. Government of Trinidad and Tobago. National HIV/AIDS Strategic Plan 2004-2008 and National AIDS Coordinating Committee. 8. Government of Trinidad and Tobago, Ministry of Health, V.D. and Yaws Division, Queen’s Park Counselling Centre and Clinic. 2006 Annual Report. 9. Hutchinson G, Simeon DT. HIV infection rates and associated factors in high risk patients admitted to a psychiatric hospital in Trinidad and Tobago. WIMJ 1999; 48(3):129-131 10. Lee RK, Poon King C, Legall G, Sameil S, Trotman C. Many partnered men: A behavioural and HIV seroprevalence study of men who have sex with men. 2006 Unpublished. 11. Lewis P.D and Hospedales C.J HIV Study of cocaine dependent persons. 1991. WIMJ 40 (Suppl 1) 25; Apr. 12. Lewis M, Mitchell P, Thomas C, Holder Y, de Gourville E. HIV seroprevalence trends among antenatal clinic attenders in Trinidad and Tobago. WIMJ 43 (suppl 1): 35, Apr. 359 HIV in the Caribbean: A Systematic Data Review 2003-2008 13. Kuruvilla A et al. Antenatal screening for HIV in North Trinidad. Demographic characteristics of patients, acceptability of testing and the rising prevalence of infection. 2000. WIMJ 49(Suppl 2): 53: Apr 14. Ministry of Health, Trinidad and Tobago (2007). HIV/AIDS morbidity and mortality report. Quarter 1. Report. 22. May 15. National AIDS Coordinating Committee. UNGASS Country Progress Report, Trinidad and Tobago. Reporting period: January 2006-December 2007. 2008. 16. Ovid T, Chadee DD, Persad A. Assessment of the impact of the IV epidemic on the incidence of tuberculosis in Trinidad and Tobago. 1998. WIMJ 1998 47(Suppl 2) 56: Apr. 17. Republic of Trinidad and Tobago, Ministry of Health, National Surveillance Unit. HIV and AIDS in Trinidad and Tobago, Surveillance Report to 31 December, 2007. Published May 2008. 18. PAHO/WHO (2006) Assessment report for the evaluation of national services for the prevention of mother to child transmission of HIV and syphilis, 2000-2005. Washington DC. 19. Reid SD. Drug use, sexual behaviour and HIV risk of the homeless in Port-of-Spain, Trinidad. WIMJ 1999; 48(2): 57-60 20. Sandy-Robinson C. Ministry of Health, Prevention of Mother to Child Transmission of HIV Programme, 2006 Final Report 21. UNAIDS/WHO AIDS epidemic update. November 2006 22. Vaughan H, Tedder R. Characterization of HIV-1 subtypes circulating in the Caribbean region. 2002. Caribbean Epidemiology Centre (CAREC) and the University College of London, London School of Hygiene and Tropical Medicine. Unpublished. 360 HIV in the Caribbean: A Systematic Data Review 2003-2008 TURKS AND CAICOS ISLANDS The Turks and Caicos Islands (TCI) is an archipelago of approximately 40 islands and cays located between the southeastern tip of the Bahamas archipelago and Hispaniola island of Haiti and the Dominican Republic. The eight major islands are dispersed between the two groups of islands, the Turks Islands and the Caicos Islands: Grand Turk, Salt Cay, South Caicos, East Caicos, Middle Caicos, North Caicos, Providenciales and West Caicos. The TCI is a United Kingdom Overseas Territory in the English speaking Caribbean and has for long time been a salt production and export until 1964 when that economic activity was stopped and is now replaced by fishing, tourism and offshore banking as major pillars of its economy. Economic growth is fast and so is the population growth, indeed in 2007 the total population was 34 862 inhabitants a 57% increase when compared to the population of the island in 2001. The majority of the increase is due to an influx of migrants (legal or illegal), many of whom are from Haiti and the Dominican Republic, in search of economic opportunities. 1. Summary of National Strategic Plan Actually, there is no national strategic plan in implementation in TCI; the National AIDS program which is advisory to the Ministry of Health and Human Services is implementing a national response based on four strategic directions: 1. Advocacy, policy development and legislation 2. Treatment, acre and support for PLHIV 3. Prevention, especially among young people and vulnerable groups 4. Coordination, program design, implementation, monitoring and evaluation National budget of the National AIDS Program to mount a national response to HIV/AIDS was USD 958 000 in 2006 and USD1 108 000 in 2007. The country has a national multisectoral strategy/action framework to combat AIDS including the following sectors: Health, Education, Women, Young People and PLHIV. Civil society participation is promoted especially in dealing with issues re PLHIV. 2. Data Collection Procedures and surveillance systems The primary source of information for the surveillance programs within the National AIDS Program is the laboratory where all HIV tests are done which represents a challenge because essential information such as demographics and mode of transmission is lacking. It is also admitted by national authorities that in the TCI it is very difficult to know or estimate the exact number of PLHVI and equally difficult to track HIV+ persons diagnosed in the health care system for the following reason: 1. The majority of the PLHIV are from the migrant population who apply for a work permit. Hence the numbers may fluctuate markedly from year to year. In many instances, once an HIV+ result is communicated to an immigrant, the individual returns to his/her homeland or go underground to evade health and immigration authorities. 2. Some persons on receiving an HIV+ test result challenge the accuracy of the test and repeatedly get retested by the National Lab and the private laboratories thereby leading to duplicate counting 3. It is reported on anecdotal basis that the TCI nationals, in order to preserve their anonymity, if they are financially able, they will avoid the national health systems for testing and/or treatment. Hence these cases will never get reported to the national TCI surveillance system. 361 HIV in the Caribbean: A Systematic Data Review 2003-2008 3. Prevention efforts: past and present, successful and unsuccessful Through Information, Education and Communication (IEC) programs, primary prevention programs have targeted the following groups and strategic areas: young people (school based and out –of school based programs), condom promotion, promotion of testing, risk reduction among MSM, reduction of stigma and discrimination, and the workplace. Integration of STI in reproductive and sexual health services was promoted as a way to prevent HIV transmission and to treat STI. Blood safety is a preventive measure which is fully implemented for 2006 and 2007; all blood donors were tested for HIV antibodies and universal precautions measures are observed in all health facilities. During the two year-period 2006 and 2007, a total number of 12 pregnant women have received ART to reduce mother-to-child transmission of HIV in TCI. However, the number of 6 infants and 3 children on ART in TCI (see care and treatment chapter) may suggest that the national PMTCT programs are not as effective as they should have been. That is a real challenge to be studied, understood and addressed. 4. Graphs with Trends re epidemiological status From 1985 when the first case of AIDS was reported to the end of 2007 the total cumulative of HIV/AIDS cases reported in the TCI was 344. Of this number, 79 are under ART in 2007, 88 died. During the period 2000-2007, the reported number of new cases of HIV has increased from 19 in 2000 to 58 in 2007. This could be explained by the improvement of VCT services and /or the flux of new immigrants applying for work permits. However with 79 TCI islanders living with HIV on ART, it cannot be excluded that TCI is facing a major HIV epidemic influenced by immigrant population. Graph 1 Number of Reported New Cases of HIV in Tuks and Caicos Islands:2000-2007 70 60 58 50 40 Number 33 30 27 20 22 22 22 19 10 12 0 2000 2001 2002 2003 2004 2005 2006 2007 Year Source: 2008 UNGASS Country Report, TCI. During the period 1995-2007 a total number of 50 deaths due to AIDS related illness were registered in the TCI. The overall male-female ratio is approximately 1:1. The majority of deaths occurred among people aged 25 years and older as expected. From 1986 to 2007, as a 362 HIV in the Caribbean: A Systematic Data Review 2003-2008 proportion of total TCI deaths, the number of AIDS related deaths peaked at 23.1% in 1999 and thereafter has declined, only 3 deaths were reported in 2006 and 2 in 2007. 5. Care and treatment programs In 2006, the total number of persons on ART was 54 adults, 2 infants and 3 children (59 in total) and in 2007 there were 70 adults, 3 children and 6 infants i.e. a total number of 79 PLHIV on ART (see graph 2). The reported number of persons alive 12 months after initiating ART was 96% a result of a well organized care and treatment delivery system and that may explain the increase in number of PLHIV on ART between 2006 and 2007. Indeed the system is led by a visiting clinical supervisor who does all ART prescriptions and visits TCI on bi-monthly basis but who is continuously accessible by a group of internists and general practioners who ensure the day-to- day management of PLHIV in TCI. That approach coupled with the periodic support of professionals from the Bahamas Ministry of Health and the free provision of ARV drugs have ensured that TCI-National AIDS Program provides and sustains quality ART to PLHIV in needs of these drugs. The ART process is taking place in an environment which is pushing for the strengthening of national health systems. Graph 2 Number of PLHIV Adults, Infants and Children on ART in TCI: 2006-2007 Adults Infants Children 100 80 Number of Cases 60 40 20 0 2006 2007 Years Source: 2008 UNGASS Country Report, TCI. 6. Influence of migration The majority of immigrants in TCI are from Haiti and the Dominican Republic where HIV prevalence are the highest in the Caribbean and they are home of ¾ of the total population living with HIV in this region. HIV Screening among applicants for work permit and pregnant women has shown that nationals of these two countries feature prominently in the HIV/AIDS profile of TCI. 7. Data in specific groups: MSM, FSW, Bisexual, pregnant women, DU (injection and non Injection), etc. There is no specific data regarding HIV prevalence among specific groups. A shortcoming to be addressed rapidly because annual cohorts of pregnant women are tested for HIV and result could be used to determine at least HIV prevalence among that group. 8. Co-infection STI/HIV, TB/HIV and HepB/HIV 363 HIV in the Caribbean: A Systematic Data Review 2003-2008 There is no information on co-infections; however national authorities have put in place programs that integrate STI services into sexual and reproductive health programs. 9. Data on human resources issues Focus is put on clinical care in terms of immediate need for human resources. However, it will be urgent for TCI to reorganize its health information and HIV/AIDS surveillance systems to collect and analyze a core set of information which can help guide the national responses to HIV. This strengthening of surveillance of HIV/AIDS could be achieved with the help and support of PAHO- Bahamas or CAREC. 10. Issues surrounding Stigma and Discrimination AIDS and the work place were identified as a priority because of stigma and discrimination against PLHIV. However another issue is the discriminatory practice of testing people who apply for a work permit because the one found HIV+ positive are not allowed to stay and work in the TCI. That approach could hinder the effectiveness national responses to HIV, because it could drive the HIV epidemic underground. 11. Assessment and recommendations for programmatic response to HIV epidemic: new strategies and new priorities a. Strengthening national HIV/AIDS surveillance systems is a priority and could be done with the support of PAHO-Bahamas or CAREC. b. National response to HIV should be data driven and focused on the most-at risk populations and data from treatment programs should be used also for decision making and planning. c. National monitoring and evaluation systems should be put in place to measure regularly outcome, outputs, and impact achieved by the national responses to HIV. d. Work with neighboring countries of Haiti, and the Dominican Republic should be intensified because these are the two main country of origin for the migrant populations e. Work with the Ministry of Health of the Bahamas should be sustained and diversified to replicate best practices achieved in that country . 364 HIV in the Caribbean: A Systematic Data Review 2003-2008 365