H N P D I S C U S S I O N P A P E R HIV/AIDS in Latin America The Challenge ahead Anabela Garcia-Abreu, Isabel Noguer and Karen Cowgill March 2003 HIV/AIDS IN LATIN AMERICA The Challenges Ahead Anabela Garcia-Abreu, Isabel Noguer and Karen Cowgill March 2003 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network (HNP Discussion Paper). The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. 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ISBN 1-932126-72-4 © 2002 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper HIV/AIDS in Latin America The Challenges Ahead Anabela Garcia-Abreua, Isabel Noguerb and Karen Cowgillc aSector Manager, South Asia Region, Health Nutrition and Population, The World Bank, Washington DC, USA bConsultant, LCSHH, The World Bank, Washington DC, USA cConsultant, The World Bank, Washington DC, USA Paper prepared as part of Advisory and Analytical Activities on HIV/AIDS in the Latin America and the Caribbean Region Abstract: Information on HIV/AIDS epidemics in Latin America is disperse and lacks comprehensiveness. Sound and timely policies can limit the current and future impact of the epidemics but good policies are built on a strong epidemiological base and according to the countries' needs. The aim of this study was to assemble all the information available on the epidemiological pattern of the epidemics in Latin America and to gather information on current national surveillance capacity, national responses of the health sector to identify key areas where specific interventions are needed. Through national statistics, data published by international organizations, and databases searches, we collected data on the extent, trends and patterns of HIV/AIDS epidemic in 17 Latin American countries. Data on national surveillance systems and national responses from the health sector were gathered through questionnaires applied to managers of the national HIV/AIDS surveillance system, director of the National HIV/AIDS program, NGOs, and physicians. Despite relatively high rates of HIV infection in most countries, many Latin American countries have not yet faced a full-scale AIDS epidemic. HIV/AIDS falls within the framework of a low endemic setting; in the majority of the countries the epidemic is still concentrated in high-risk populations. Latin America has the necessary infrastructure to efficiently and effectively confront the HIV/AIDS epidemic. However, the capacity to respond has been limited by political, technical and social problems. Several key problems on the areas of prevention, access to health and social services, human rights and national capacity were identified. The results of our study suggest that the main challenges to meeting the current needs are (i) availability of resources; (ii) institutional capacity to provide training in all areas; and (iii) cultural, social and religious factors. Keywords: HIV/AIDS; Latin America, Prevention; Surveillance; Multi-sectoral collaboration. Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Anabela Garcia-Abreu; The World Bank, 1818 H Street NW, Mail Stop MC 11-1114; Tel: (202) 458-7763; Fax: (202) 202-522-2955; Email: aabreu@worldbank.org; Web: www.worldbank.org iii iv Table of Contents Abbreviations and Acronyms...................................................................... vii Foreword............................................................................................. ix Acknowlegements................................................................................. xi Background.....................................................................................................xiii Executive Summary.............................................................................. xvii CHAPTER 1: EPIDEMIOLOGICAL OVERVIEW AND ECONOMIC IMPACT Summary.................................................................................... 1 Quantifying the Epidemic................................................................. 3 Mexico....................................................................................................................8 Central America............................................................................10 Brazil........................................................................................15 Andean Region.............................................................................17 Southern Cone..............................................................................22 The Economic Impact of HIV/AIDS in Latin America...............................26 CHAPTER 2: EPIDEMIOLOGICALSURVEILLANCE Summary.................................................................................... 31 Introduction.................................................................................33 Resources for HIV/AIDS Surveillance.................................................................34 HIV/AIDS Information Systems and Reporting...................................... 34 Sentinel Surveillance of HIV............................................................ 40 HIV Testing and Diagnosis Policies.................................................... 42 Blood Supply Safety.......................................................................44 What do the Countries Identify as Basic Needs for Improving Epidemiological Surveillance of HIV/AIDS?..............................................................45 Conclusions: Strengths and Challenges................................................ 46 Annex 2.1: HIV/AIDS Case Definitions Annex 2.2: Countries/Sub-Regions with Reporting Forms for Case Notification Annex 2.3: Legislation Regarding Confidentiality Issues Annex 2.4: Under-reporting and Delays in Notification Annex 2.5: Systematization of Records of HIV and AIDS Annex 2.6: Results of HIV Sentinel Surveillance Studies Annex 2.7: People Living with HIV Annex 2.8: Cost of HIV Testing in Public and Private Health Centers v CHAPTER 3: NATIONALRESPONSES TO THEEPIDEMIC Summary.................................................................................... 65 Introduction.................................................................................67 National Agreements and Multisectoral Coordination..........................................68 Interventions for the General Population and Specific Groups..................... 71 NGOs' Contributions to HIV/AIDS Control in Latin America.....................78 The Population's Level of Knowledge of Methods of Transmission and Prevention of HIV/AIDS................................................................. 82 Prevention of Mother-to Child Transmission......................................... 85 Health and Social Services...............................................................86 Collaboration with International Agencies............................................. 94 Principal Barriers and Needs for More Effective Control of the HIV/AIDS Epidemic.................................................................................... 95 Annex 3.1: Additional Tables Annex 3.2: Legal Restrictions to Homosexuality CHAPTER 4: KEY INTERVENTIONS ANDCHALLENGES AHEAD Summary................................................................................... 109 Introduction................................................................................111 National Response to the Epidemic: Prevention..................................... 112 Access to Health and Social Service....................................................117 Human Rights............................................................................ 120 National Capacity: Structure and Management.......................................121 Conclusions................................................................................124 APPENDIX 1 Country Fact Sheets APPENDIX 2 Collaborators in the Study vi ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Antiretrovirals CDC Centers for Disease Control and Prevention CSW Commercial Sex Worker HAART Highly Active Antiretroviral Therapy HIV Human Immunodeficiency Virus IBRD International Bank for Reconstruction and Development IDUs Injecting Drug Users IFA Immuno-Florescence Assay INH Isoniazide MoH Ministry of Health MSM Men who have Sex with Men NGOs Non-Governmental Organizations PAHO Pan American Health Organization PLWHA People Living with HIV/AIDS STIs Sexually Transmitted Infections UNAIDS Joint United Nations HIV/AIDS Program WB Western Blot WHO World Health Organization vii viii FOREWORD Compared to most countries in Africa, and to the nearby islands of the Caribbean, many Latin American countries have not faced a full-scale AIDS epidemic. On average, Latin American countries estimate HIV prevalence among 15- to 49-year-olds at 0.5 percent. Around 130,000 adults and children were newly infected with HIV during 2001, and 80,000 died. However, AIDS accounts for only a fraction of all adult deaths in most Latin American nations, altought in the most productive years of life. This positive appearance is offset by worrisome signs: in several countries in the Region, the disease appears to be evolving, from affecting virtually only the highest risk groups, such as men who have sex with men (MSM) and injecting drug users (IDUs), to becoming an increasingly generalized problem. Throughout the Region, many behaviors associated with the spread of HIV/AIDS (young age at first intercourse, violence against women, injecting drug use) are commonplace yet, and with the exception of a small number of countries, the response to the threat of HIV/AIDS has been slow, small-scale and largely supported by external agencies and international programs. If these warning signs are heeded, and appropriate prevention measures are taken in the very near future, Latin America has the opportunity to avoid the sad histories seen in other parts of the world. Sound and timely policies can limit the current and future impact of HIV/AIDS on Latin American health care systems, economies and societies. Good policies are based on understanding the scope and special nature of the HIV/AIDS problem, and confronting it in a way that respects human rights. This report: (a) presents new and updated information about the extent and trends of the HIV/AIDS epidemic in Latin America; (b) evaluates current national surveillance capacity; (c) assessess national responses of the health sector to the epidemic on a country-by-country basis; and (d) identifies key areas in which specific interventions are urgently needed, and the challenges ahead. Rich in information, and based on both analyses of secondary information and a full set of newly collected country-level data, this report is intended to be the basis for discussions within and across countries, and between countries of the Region and their development partners. Alexander S. Preker Chief Editor, HNP Publications World Bank ix x ACKNOWLEDGEMENTS This study was prepared by Anabela Garcia-Abreu (Task Team Leader), Isabel Noguer and Karen Cowgill (consultants), Girindre Beharry, and Ruth Levine (LCSHD), Paloma Cuchí (UNAIDS/PAHO), José Izazola-Licea (SIDALAC) and Nicolas Noriega-Portilla (economist) have also provided written contributions. Pilar Ramón tabulated the data collected through questionnaires. Special thanks to Marian Kaminskis for her substantial input, editorial and logistics assistance, as well as to Natalia Moncada her follow-up on the final phase. Our thanks also to Madalena Cabeçadas for her technical input. Julia del Amo, Maria José Belza, James Cercone, Fiorella Salazar, Laura Altobelli (consultants), Claudia Macías, Magdalena Colmenares, Sandra Cesilini (World Bank) and María Etelvina Barros (UNAIDS) administered the questionnaires. Peers reviewers of the study include: Charles Griffin, and Martha Aisworth (World Bank), Fernando Zacarías (PAHO), Luis Loures and Enrique Zelaya (UNAIDS), and Richards Keenlyside (CDC). Peers reviewers of the questionnaires were: Sandra Rosenhouse, Gerard la Forgia, Michele Granolatti (World Bank) and José Izazola-Licea (SIDALAC). Special thanks to all who took the time to complete the questionnaires. They are truly the key people who made this study possible ­ the national program directors, NGOs, and physicians (listed in Appendix 2). The team would like to extend its gratitude to UNAIDS and PAHO, in both headquarters and local offices, for their help in identifying the key informants and arranging the logistics of the distribution of the questionnaires, helping with data collection, and for providing pertinent bibliographic sources. Our thanks also to Spanish cooperation for helping with data collection, especially in Latin America Countries. The authors of this Report are also grateful to The World Bank for having published the Report as an HNP Discussion Paper. xi xii BACKGROUND Compared to most countries in Africa, and to the nearby islands of the Caribbean, many Latin American countries have not faced a full-scale AIDS epidemic. On average, Latin American countries estimate HIV prevalence among 15- to 49-year-olds at 0.5 percent. Around 130,000 adults and children were newly infected with HIV during 2001, and 80,000 died, however, AIDS accounts for only a fraction of all adult deaths in most Latin American nations, but in the most productive years of life. This positive appearance is offset by worrisome signs: in several countries in the Region, the disease appears to be evolving, from affecting virtually only the highest risk groups, such as men who have sex with men (MSM) and injecting drug users (IDUs), to becoming an increasingly generalized problem. Throughout the Region, many behaviors associated with the spread of HIV/AIDS (young age at first intercourse, violence against women, injecting drug use) are commonplace, and with the exception of a small number of countries, the response to the threat of HIV/AIDS has been slow, small-scale and largely supported by external agencies and international programs. If these warning signs are heeded, and appropriate prevention measures are taken in the very near future, Latin America has the opportunity to avoid the sad histories seen in other parts of the world. Sound and timely policies can limit the current and future impact of HIV/AIDS on Latin American health care systems, economies and societies. Good policies are based on understanding the scope and special nature of the HIV/AIDS problem, and confronting it in a way that respects human rights. This report attempts to: (a) present new and updated information about the extent and trends of the HIV/AIDS epidemic in Latin America; (b) evaluate current national surveillance capacity; (c) assess national responses of the health sector to the epidemic on a country-by-country basis; and (d) identify key areas in which specific interventions are urgently needed, and the challenges ahead. Rich in information, and based on both analyses of secondary information and a full set of newly collected country-level data, this report is intended to be the basis for discussions within and across countries, and between countries of the Region and their development partners. This study was conducted in 2001 and included 17 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Venezuela and Uruguay. It will be worthwhile for the Bank, as well as the countries, to conduct a form of self-evaluation in terms of the achievements, obstacles and challenges ahead. It would be very useful to have this information available to all actors involved. In the future, this study could become a point of departure for comparing this year's results to others. The report would be publicly available, so that countries and institutions could use it for their own evaluation. The Bank is participating in activities related to public health, health services, general social services, etc., and this study would support an evaluation of the response from each of these areas to the HIV/AIDS epidemic, as well as provide value-added input for additional areas of involvement. For purposes of analysis some countries were aggregated in sub-regions, according to: (a) similarities in socioeconomic level, health system and epidemiological pattern of the epidemic; (b) geographical proximity; (c) economic, cultural and politic interests; (d) cultural roots; and (e) frequency of internal migrations. xiii Three sub-regions are analyzed: Central America (Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica and Panama); the Andean Region (Venezuela, Ecuador, Colombia, Peru and Bolivia) and the Southern Cone (Argentina, Paraguay, Uruguay and Chile). Brazil and Mexico are analyzed individually. Both countries possess much higher resources; their national programs have reached a high level of development, and the epidemic's epidemiological pattern presents some characteristics seen in industrialized countries. The study uses primary and secondary data. Primary data were collected using four survey instruments designed specifically for this study. The surveys were designed to assess surveillance systems and national responses to the epidemic from the health sector. Before distribution to the target group of respondents, the survey instruments were reviewed by experts working in the field, with knowledge of the Latin America region*. Data on surveillance systems were collected through a self-administered, semi-structured questionnaire applied to those managing national HIV/AIDS surveillance systems in seventeen Latin American countries (technicians from the National AIDS Program or from the departments of epidemiology, depending on the countries). The survey instrument included questions assessing, among other items, case definition, reporting procedures, type of surveillance, sources of information, and feedback of the surveillance information. All countries surveyed sent their questionnaires, but the level of completion of the questionnaires was variable. Data on the institutional capacity to fight the epidemic were collected using three questionnaires applied to the heads of national HIV/AIDS programs, and to key respondents from non- governmental organizations (NGOs) and physicians working in the field. Most physicians and NGOs questionnaires were completed face-to-face by trained interviewers. In each country, a questionnaire was given to the director of the national HIV/AIDS program. The following aspects were explored: (i) description of the program; (ii) multisectoral coordination and legislation; (iii) sensitization/prevention interventions directed to the general population and adolescents; (iv) interventions targeting high-risk groups; (v) interventions for preventing mother-to-child transmission; (vi) access to the health system and prevention methods; (v) financing and relations with NGOs; (vi) characteristics/coverage of health and social services provided; (vii) relations with international agencies; and (viii) main problems faced in controlling the epidemic in the country. NGOs were selected according to the following criteria: (a) years of experience and level of integration in the countries, favoring those with larger history in the fight against HIV/AIDS; (b) community-based, working with high-risk groups or people living with HIV/AIDS (PLWHA); and (c) implementation of various HIV/AIDS-related activities (prevention, psychological, legal and social support). Eighty-four NGOs were selected from a pool of more than 900. Among the NGOs surveyed, the average time of experience working with HIV/AIDS is eight years; 60% of these NGOs work at the national level, serving over 500,000 people in the Region. In all, 4,000 * These experts included HIV/AIDS specialists, a former national HIV/AIDS coordinator, a population and health specialist, a demographer, a public health specialist and an epidemiologist. The questionnaires were administered to the target group of respondents, preceded by a letter presenting the study and explaining the methodology. xiv people work for the NGOs surveyed (this includes fulltime and part-time workers and volunteers). The NGO questionnaire was designed to cover the following aspects: (i) characteristics of the NGOs (level of integration, resources, work environment, target populations, involvement in networks and objectives of the organization); (ii) activities over the last year regarding HIV/AIDS, specifying target populations, budget, flow of funds and coverage and impact of the interventions; (iii) level of coordination with governments and national plans; (iv) status of the epidemic and those affected from the perspective of NGOs; and (v) main problems and obstacles (present and future) for controlling the epidemic. Physicians were selected according to the following criteria: (a) significant experience in clinical management of patients with HIV/AIDS; and (b) working on large health settings. It was decided to select 5 physicians from each country, which were recommended by national HIV/AIDS programs and by experts from the Region. Sixty-four (75.3 %) agreed to contribute information and opinions for this study. These 64 physicians surveyed have, on average, 13 years of experience in the clinical management of patients with HIV/AIDS, more than half (59 %) in both public and private practice and serve a total of 50 patients per month, approximately. Physicians' questionnaires focused on: (i) characteristics (i.e. years of experience in the current health sector and level of professional experience); (ii) conditions under which s/he practices (good-practice protocols, conditions for diagnosing and treating patients); (iii) level of coverage of basic services for diagnosing and treating patients; (iv) level of knowledge of HIV/AIDS in the population; and (v) main problems with infrastructure and health care resources for effectively controlling the epidemic. Secondary data were drawn from national statistics and complemented by data published by international organizations (WHO/PAHO, UNAIDS and SIDALAC) and data from studies conducted in the Region and identified through databases, as well as from national strategic plans. National surveillance systems provided data on incidence and prevalence of HIV and AIDS. From the same sources, the study used data on incidence and prevalence of STIs and HIV in different sentinel populations (blood donors, CSWs, MSM, IDUs and others). Certain countries are not included in certain tables and charts, which indicates that the corresponding relevant data were not available for this study. This document touches upon the broader context in which the response to the HIV/AIDS in Latin America is taking place, however it focuses more specifically on how the health-sector response is seen by different country players. Results and conclusions drawn from this study represent the views and opinions of a group of key respondents selected from the national HIV/AIDS programs, NGOs and physicians, supplemented with information from other sources. Therefore, these cannot be and were not extrapolated or generalized to the overall national response of a country. xv xvi EXECUTIVE SUMMARY Although the risk behaviors and biological markers that fuel the epidemic are widely widespread, many Latin American countries have not yet faced a full-scale AIDS epidemic. On average, Latin American countries estimate HIV prevalence among 15- to 45-year-olds at 0.5%. Around 130,000 adults and children were newly infected with HIV during 2001 and 80,000 died. HIV/AIDS in Latin America falls within the framework of a low endemic setting - in the majority of the countries, the epidemic is still concentrated in high-risk populations - men who have sex with men (MSM), injecting drug users (IDUs), commercial sex workers (CSWs), prisoners and people with sexually transmitted infections (STIs). Exceptions are Honduras and southeastern Brazil, where the epidemic has reached the general population. Heterosexual sex is the primary mode of transmission in Central America, with sex between men predominating in South America and injecting drug use playing a significant role in the Southern Cone. Survey respondents also identified other populations with increased vulnerability in which interventions would be crucial ­ young people and women. Although the number of men living with AIDS outweighs the number of women in all countries, the gender gap is closing, and in some countries, the effect of AIDS on rural communities is increasing rapidly. In low endemic settings, the main priority are the highest risk groups and activities to address HIV/AIDS should be focused on (i) strengthening efforts to prevent new infections in these populations; and (ii) providing care and support strategies which in turn create incentives for early detection of infection and/or risky behavior. Epidemiological surveillance plays a key role in the control of the epidemic through the measurement of the frequency, distribution and evolution of HIV/AIDS among populations, identification of high-risk groups, and evaluation of the effectiveness of prevention efforts. In Latin America, epidemiological surveillance of HIV/AIDS at the national level began in the first half of the 1980s. Since then, allocation of resources and personnel has steadily increased, leading to well-established surveillance systems based on AIDS cases notification. Presently, in every Latin American country reporting of AIDS cases is mandatory. However there are persistent high levels of under-reporting and delays in reporting. The epidemic in Latin America is likely to include around 30% more cases of AIDS and 40% more cases of HIV than currently estimated. Since the late 1980's Latin American countries have demonstrated capacity to confront the HIV/AIDS epidemic, developing new structures and the groundwork needed for community responses. At the global level, over the past years there have been continuous efforts on mobilizing political leadership at the highest levels of national, regional and global governance. At the country level, much has been achieved. By the end of 2001, almost all countries in Latin America had their national strategic frameworks finalized or in the process of completion. In most cases, the plans were developed with participation from a broad range of stakeholders (including various government ministries, civil society, associations of people living with HIV/AIDS, bilateral and multilateral partners) and they now serve as the common reference for action. The national strategic plan process also resulted in a clear shift in the perception of the epidemic from a health- only to a broader social and developmental approach. xvii Latin America has an excellent basis for effective interventions with multilateral and /or bilateral organizations. The resources infrastructure and professionals are in place to implement a variety of interventions, evaluate their impact and sustain them over time. However, the capacity to respond has been limited by political, technical and social problems. The challenge ahead is to tackle some of the chronic problems that affect the national response. Results from this study bring to light many aspects of the health sector response to the HIV epidemic that could be improved to a greater impact and provide feasible prioritized solutions. The study unravels the gains from an expanded response by engaging much more closely the community and social movements around HIV/AIDS. In terms of the health sector, this study identified several key problems: Prevention Key Problems In the national response there are insufficient interventions targeting high-risk groups, worsened by a substantial lack of information on the magnitude and trend of the epidemic. These include MSM, CSWs, IDUs and other groups such as prisoners. Health and sexual education programs for adolescents and young people are widespread but skill to build the skills to prevent HIV infection in these groups may be lacking from its content. Levels of multisectoral coordination are unequal among countries in the Region. Although there are structures in place to foster multisectoral coordination in almost all countries, the level of true collaboration is still low, lacking resources and adequate coverage for coordinated execution of interventions. At the same time, there is limited coordination between NGOs and governments in interventions for specific populations. NGOs are much more likely to have access to marginal populations, or those that lack health services, yet governments and most NGOs dedicate the majority of their efforts to groups with "variable risk" for infection (i.e. the general population, young people, women, etc.). A stronger and continuous involvement from civil society needs to be ensured, since it may be the only way to expand the response to AIDS in the near future. How to Address them? · Enhancing approaches focusing on social mobilization and on building up of community responses. · Improving multisectoralcoordination. · Intensifying interventions for high-risk groups, where HIV infection reaches the highest levels. · Promoting gender policies that strengthen and build equitable relationships. Access to Health and Social Services Key Problems In Latin America, a substantial number of people infected with HIV do not have access to adequate and comprehensive health care. The reasons for this are diverse, including limited access to services and below quality standards. Insufficient medical training is one of the main deficiencies impacting healthcare along with lack of appropriate clinical management xviii guidelines. Finally, access to new antiretroviral therapies is hindered due to cost and health infrastructure. There are general deficiencies, such as the need to strengthen resources infrastructure, especially the network of HIV diagnostic laboratories, labs for determining CD4 levels and viral load, as well as infrastructure needed for diagnosis and follow-up for coinciding infections and other disease processes associated with HIV. According to national programs, the network of laboratories is insufficient, especially in Central America and the Andean Region (although this is characteristic of all Latin America). Access to services is limited by the payment required. Substantial proportions of people are unaware that they are infected by HIV. Barriers that prevent greater coverage and have implications for supply and demand (such as discrimination, confidentiality, etc.) prevent people from coming early to the services. There is also the need to play more attention to those interventions for decreasing mother-to-child transmission of HIV in health centers. How to Address them? · Improving health and social services through multisectoral collaboration. · Promoting HIV test, especially among high-risk populations. · Universal offering of HIV testing to pregnant women. · Strengthening health infrastructure and laboratory networks. · Training physicians and nurses in clinical management and treatment of HIV and other STIs. Human Rights Key Problems Lack of information, stigmatization, homophobia and social prejudices regarding sexual orientation or behavior prevent access to prevention and clinical care in Latin America, which are some of the obstacles that people at high-risk or infected face when trying to access services. These also hinder access of the people living with HIV and AIDS, which impedes fair and equitable treatment. How to address them? · Fighting against ignorance and promoting human rights. · Preserving the right to access to health, social and psychological care. · Promoting programs addressing the issue of schooling for HIV+ children. · Promoting the right to work and integration or re-integration in the workforce. · Involving people living with HIV/AIDS in all strategies for prevention and control of the epidemic. CD4 count refers to a measure of "helper" T cells which help B cells produce antibodies. The number of CD4 cells is an important measure of an individual's immune system capabilities. Viral load test is a measure of the amount of HIV in the blood to determine how far infection has progressed. xix National Capacity: Structure and Management Key Problems The multiplicity of health problems affecting Latin America and the health sector reforms are part of the circumstances that have prevented Latin America from given a more articulated response to the epidemic. Although most of the countries have multisectoral plans with the participation of multi-partners, however, the actual functionality and capacity for a collaborative response has been mediated by the technical and political capacity of national programs and by limited resources available for HIV/AIDS control. It is critical a stronger involvement from civil society, communities and associations of people living with HIV/AIDS as the basis of the response to AIDS in the Region. Surveillance systems in Latin America are in need to be strengthening to provide opportune and accurate data for decision making. Availability of systematized information on the incidence of newly diagnosed HIV infections and sentinel surveillance coverage (especially among the most affected groups) is scarce throughout the Region. Registries of AIDS cases, which have the greatest tradition and permanence, show high levels of under-reporting in certain sub-regions, especially Central America. Currently, these systems don't provide a clear picture of the magnitude and trends of the epidemic and they are also weak in capturing early signs of alarm given by the dissemination of the epidemic. These systems should include a behavioral component. How to address them? · Consolidating multisectoral responses to the epidemic and bringing national strategic plans into a reality. · Strengthening epidemiological surveillance systems. · Establishing guidelines for prevention interventions, consolidating the interventions that have been most cost-effective · Blood safety policies should be revised, to achieve universal testing of donated blood, and acceptance of only voluntary, altruistic, non-remunerated donations. · Continuous capacity building of human resources. · Increasing available resources. · Overcoming cultural, social and religious factors that obstruct good technical proposals or government decisions. · Encouraging and supporting NGOs networks. · Increase synergy and coordination among different actors in the Region. xx CHAPTER 1 EPIDEMIOLOGICAL OVERVIEW AND ECONOMIC IMPACT Summary Accurate numbers of people living with HIV/AIDS in Latin America are lacking. Under-diagnosis and underreporting contribute to inexact HIV/AIDS statistics. The Joint United Nations on HIV/AIDS (UNAIDS), Pan American Health Organization (PAHO), and World Health Organization (WHO) best estimate of the number of people living with HIV/AIDS in Latin America at the end of 2001 was 1.4 million, or approximately 0.50% of the entire Latin American population. In Latin America, 130,000 adults and children were newly infected with HIV during 2001, and 80,000 died. WHO reports that HIV in 1999 ranked second as a cause of disability-adjusted life years (DALYs) in the World. For the most part, the HIV/AIDS epidemic in Latin America is concentrated in specific high-risk groups. Although the epidemic in Latin America is still largely concentrated in males, the so-called "feminization" of the epidemic is evident in decreasing male:female ratios among those with AIDS. Injecting drug use is an important route of HIV transmission in parts of South America, especially countries in the Southern Cone, Brazil, and Colombia. Commercial sex workers (CSWs) are also at high-risk of acquiring and transmitting HIV, and men who have sex with men (MSM) account for a substantial amount of HIV transmission. Patients with sexually transmitted infections (STIs) represent another high-risk group, however, the incidence is not well-documented in many countries. In Mexico, the epidemic is still largely concentrated in MSM. AIDS is the third most common cause of death in males and the sixth in females 25-44 years of age. On the other hand, HIV transmission in Central America is overwhelmingly due to heterosexual sex, making it more similar to the Caribbean than to South America or Mexico. The situation in this region is serious and expected to worsen, as we see new infections in the youngest population and especially increasing among females. The HIV/AIDS epidemic is most heterogeneous in Brazil, where HIV has been detected in all population groups. The number of people living with HIV/AIDS (PLWHA) is increasing due to the wide coverage of antiretroviral (ARV) therapy. The number of PLWHA in Brazil was estimated in 540,000, at the end of 1999. The Andean region presents evidence of high prevalence of risky sexual behaviors, as this region has the highest estimated incidence of STI infection (15%) in all of Latin America. Over 40% of reported AIDS cases are attributed to sex between men, with a nearly equal number attributed to heterosexual sex. Underreporting of HIV/AIDS is probably substantial in this region, with scarce resources and weak surveillance systems. In the Southern Cone, Argentina has the highest prevalence of HIV infection in South America, one of the highest percentages of infected children, and HIV infections are on the rise. Among reported AIDS cases, injecting drug use plays the largest role, closely followed by sex between men. While there is probably a great deal of underreporting, as in the other regions, the Southern Cone has the lowest percentage of cases with an unknown or unclassified mode of transmission of all the regions There are significant additional health care and societal problems caused by HIV/AIDS. For example, tuberculosis (TB) is a major problem in Latin America, and the HIV epidemic has exacerbated it. Thirty to 50% of adults in Latin America are believed to have latent TB, which often takes the opportunity of decreased immunity to manifest itself. The HIV/AIDS epidemic has also had a heavy macroeconomic impact due to the high costs of treatment and lives lost, which divert resources from productive investments. 1 2 QUANTIFYING THE EPIDEMIC There are wide variations in the availability and reliability of HIV testing, identification of people who have progressed to AIDS, completeness and timeliness of cases reported, and epidemiological surveillance throughout the Region (see Chapter 2). Many identified HIV infections and AIDS cases are not reported to Ministries of Health (MoHs) due to inefficiency and/or lack of resources. Apart from the underreporting problem, the majority of people living with HIV/AIDS (PLWHA) have not been tested and do not know they are infected. Some avoid being tested for fear of stigma, while others encounter barriers to testing1 such as high cost, lack of local availability, or bureaucratic impediments. Some simply do not realize or will not acknowledge that they are at risk. Data regarding the magnitude of under-diagnosis are lacking, but it exists to varying degrees in all countries. Table 1. HIV prevalence, AIDS incidence, and mortality from AIDS by country, 1999 Reported AIDS Estimated AIDS Country Estimated HIV Reported Incidence per Estimated Mortality per Prevalence in 15- AIDS Million Deaths from Million 49-year-olds (%) Cases Inhabitants AIDS Inhabitants Mexico 0.3 4,372 42 4,204 48 Guatemala 1.4 730 66 3,600 325 El Salvador 0.6 425 69 1,300 211 Honduras 1.9 1,136 180 4,200 665 Nicaragua 0.2 36 8 360 73 Costa Rica 0.5 215 58 750 191 Panama 1.5 534 190 1,200 427 Brazil 0.6 18,288 109 18,000 107 Venezuela 0.5 no data no data 2,000 84 Colombia 0.3 547* 13 1,473 35 Ecuador 0.3 325 26 1,400 113 Peru 0.4 1,009 40 4,100 163 Bolivia 0.1 21 3** 380 47 Argentina 0.7 1,401 38 1,800 49 Paraguay 0.1 49 9 220 41 Uruguay 0.4 172 53 150 45 Chile 0.2 518 34 1,000 67 TOTAL 0.5 29,325 62 46,860 99 * This figure is approximately ½ that reported in previous years; ** This figure is 6 according to the country report Source: Adapted from PAHO and UNAIDS Under-diagnosis and under-reporting make it difficult to interpret HIV/AIDS statistics. Statistics reported by MoHs and PAHO/UNAIDS/WHO are based on reported case reports, which substantially underestimate the true number of cases. The interpretation of statistics and comparisons between countries can be misleading because reporting completeness varies, and due to differences in reporting practices/protocols over time and within countries. In some countries both people who are infected with HIV but have no Prevalence is the percentage of people infected, out of the entire population at risk. Incidence is the rate of new cases in a specified population over a defined time period. 3 symptoms of illness and people whose condition has progressed to AIDS are reported to the MoH, while in other countries only people who have progressed to AIDS are reported. In addition, the definition of AIDS may vary within and between countries. Some countries have well-developed epidemiological surveillance systems and are able to capture the dynamics of the epidemic by actively testing sentinel populations such as pregnant women at prenatal visits or high-risk groups like commercial sex workers (CSWs), while others with fewer resources rely on reports that trickle in from field offices. Data are generated by research studies undertaken by government, non-government, or academic institutions in many countries in the Latin American region. While these studies may be valid for the populations in which they are conducted, applying the results to the general population may be problematic. If such studies are carried out in urban areas and among groups at high-risk for HIV infection, they are likely to overestimate the true number of cases. Given the difficulties in quantifying the HIV/AIDS epidemic from these data, PAHO/ UNAIDS/WHO have been working on estimates of the number of people living with HIV/AIDS in Latin America. These estimates of the prevalence of HIV and AIDS by country are the mid-points of ranges obtained from projections that incorporate assumptions about the incidence and progression of HIV infection. While these estimates are not necessarily accurate in an absolute sense (they are likely to overestimate the true prevalence), combined with the classification of the epidemic's status they provide the best relative measure of the HIV/AIDS epidemic in each country. The uncertainties inherent in the figures reported here do not make them invalid. The HIV/AIDS epidemic is constantly evolving, and cannot be quantified in precise, static terms. UNAIDS/WHO/PAHO have developed guidelines for characterizing the status of the epidemic2, and have published estimates of HIV prevalence by country.3- 193 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 , , , , , , , , , , , , , , , , The guidelines classify epidemics as low-level, concentrated, or generalized based on HIV prevalence in pregnant women and in high- risk sub-populations such as injecting drug users (IDUs), men who have sex with men (MSM), and CSWs. The purpose of this chapter is to describe, within the limits of the available data for this study, the current status of the HIV/AIDS epidemic, particular groups affected, and the adoption of prevention and treatment efforts in each of 17 Latin American countries, the Latin America region as a whole, and the sub-regions of Central America, the Andean Region, and the Southern Cone. This chapter and the accompanying country fact sheets draw heavily on estimates generated by PAHO/UNAIDS/WHO, as well as on other UNAIDS documents, MoH strategic plans and assessments, published reports in medical literature, conference abstracts, and the results of an unpublished World Bank survey. The figures given in this report should be taken as relative indicators of the magnitude and severity of a dynamic epidemic. 4 HIV/AIDS IN LATIN AMERICA The PAHO/UNAIDS/WHO's best estimate of the number of people living with HIV/AIDS in Latin America at the end of 2001 was 1.4 million, or approximately 0.50% of the Latin American population20. 130,000 adults and children were newly infected with HIV in 2001, and 80,000 died. WHO reports that HIV was the second leading cause of disability-adjusted life years (DALYs) in the world in 199921. A 1990 estimate of the burden of HIV/AIDS in Latin America and the Caribbean put total DALYs in males at 233,000 and at 850,000 for females22. For the most part, the HIV/AIDS epidemic in Latin America is concentrated in specific high-risk groups. Exceptions are Honduras and southeastern Brazil, where the epidemic has reached the general population§. Heterosexual sex is the main mode of transmission in Central America, in South America sex between men dominates, and injecting drug use plays a significant role in the Southern Cone. The number of males living with AIDS exceeds the number of females in all countries, but the gender gap is closing. The so-called "feminization" of the epidemic is evident in decreasing male: female ratios among those with AIDS and increasing rates of HIV infection in pregnant women and children. Increasing cases of AIDS and HIV infection identified among women in their 20s suggest that adolescent girls are at high-risk. The majority of both boys and girls report their first sexual encounters in their teens, or in some cases pre-teens. Boys are at lower risk of infection from this early sexual activity because they tend to have partners nearer their own age who are less likely to be infected with HIV. Encouraging reports indicate that youth in some countries in the Region are increasingly likely to have used a condom during their first sex act23. However, almost half of the females and a quarter of the males in a sample of over 600 adolescents and young adults in Lima reported being coerced into having sexual relations. Those who were coerced at their first encounter were more likely to have a sexually transmitted infection (STI) and to have been younger at sexual initiation24. A sub-group of youth that is particularly vulnerable to HIV infection is street children25. An estimated 40 million children, mostly boys, live on the streets of Latin America; both boys and girls frequently survive by sex work, and drug use in this population is high. This group does not have access to, or does not use, mainstream health services. They are focused on short-term survival, and the dangers of HIV/AIDS seem remote and abstract to them. They are often targets of local vigilantes, gangs, and police26. Projects that have successfully increased risk-reduction behaviors among street children require intense efforts over a long time to achieve results27, and there is a great need for additional work in this area. Injecting drug use, particularly cocaine, is an important route of HIV transmission in parts of South America, especially countries in the Southern Cone, Brazil, and Colombia. §Caribbean countries are not included in this study, but in many Caribbean countries the epidemic is generalized. 5 Access to clean needles and syringes is limited, and sharing of "works" used to inject drugs is common. In addition to the risk of HIV transmission associated with injecting drug use, IDUs may exchange sex for drugs or money, putting them at risk for sexual acquisition of HIV. CSWs are also at high-risk of acquiring and transmitting HIV. Their clients frequently do not use condoms, and sex workers often do not insist on their use, either because they underestimate the risk of infection, do not have access to condoms, or stand to earn more money by providing unprotected sex28,29. In some countries, sex workers are required to register and undergo periodic HIV testing. However, this is not an effective prevention strategy, as it tends to drive sex workers at highest risk underground; sentinel studies, STI surveillance, and condom use studies should be pursued to shed light on this marginalized group30. Clients of CSWs act as a bridge between high-risk groups and the general population. This is especially true of men who have sex with male sex workers, and are married or have sex with other female partners. Homosexual behavior is common in Latin America, and accounts for a substantial amount of HIV transmission. The countries where HIV/AIDS has been concentrated primarily among MSM are Mexico, Costa Rica, and many of the South American countries. Anal intercourse between men and women is also common in Latin America. However, heterosexual anal intercourse is rarely mentioned specifically as a behavior that carries high-risk for HIV transmission. Many people are unaware that HIV can be passed this way, and reports of condom use during heterosexual anal intercourse are consistently lower than during vaginal intercourse31,32. High rates of STIs are documented in some countries, and suspected in others. The estimated annual incidence of STIs among 15-49-year-olds in Latin America is around 13%33. A person with an STI is at greater risk of HIV infection, both behaviorally and biologically. Since HIV is sexually transmitted, the unsafe sex practices that caused a STI could permit infection with HIV, and the infection itself causes changes in the urogenital tract that can facilitate HIV's entry into cells. 6 Table 2. Incidence of curable sexually transmitted infections (STIs), prevalence of HIV/AIDS and incidence of AIDS by country/sub-region, 1997 & 1999 Central Andean Southern Mexico America Brazil Region Cone Estimated number of new cases of curable STIs, 1997 6,948,000 2,248,000 12,239,000 8,895,000 3,834,000 Syphilis 538,000 173,000 948,000 795,000 165,000 Gonorrhea 1,399,000 435,000 2,465,000 1,487,000 800,000 Chlamydia 1,681,000 550,000 2,961,000 2,212,000 962,000 Estimated STI incidence in 15-49-year-olds, 1997 134 130 131 152 126 (/ 1,000) Estimated number of people living with HIV/AIDS, 1999 150,000 196,900 540,000 204,200 154,000 Estimated HIV/AIDS prevalence in 15-49-year- 0.3% 1.1% 0.6% 0.3% 0.5% olds, 1999 Reported new cases of 4,372 3,166 18,288 1,727 2,140 AIDS, 1999 Reported AIDS incidence in 15-49-year-olds, 1999 84 183 195 30 70 (/1,000,000) Source: PAHO, 2001 Tuberculosis (TB) is a major problem in Latin America, and the HIV epidemic has exacerbated it. Thirty to 50% of adults in Latin America are believed to have latent TB34, which often takes the opportunity of decreased immunity to reawaken. Three to 5% of all active TB cases in Latin America are attributed to HIV infection, and 20% of people living with HIV/AIDS are believed to have active TB34. Therefore, increased detection, prevention, and treatment efforts are crucial23,34. Medications can help reduce the impact of opportunistic infections in people living with HIV/AIDS (PLWHA). Easily-obtained, affordable drugs such as antibiotics can prevent infection with common disease-causing organisms. Peru reports that provision of these drugs has substantially lowered morbidity and mortality from opportunistic infections35. Antiretroviral (ARV) therapy, which directly inhibits proliferation of HIV, can strengthen the immune system, prolonging lives and significantly improving quality of life. In addition to TB and the opportunistic infections that are common in people living with AIDS in developed countries, tropical diseases caused by parasites endemic to the Region are also a serious concern36. Several Latin American countries, most notably Brazil, have begun providing ARV drugs to PLWHA at no cost to the patient, and without reducing prevention activities. However, preliminary results of a study sponsored by the Regional Initiative on AIDS for Latin America and the Caribbean (SIDALAC) indicate that most HIV/AIDS budgets in Latin America are directed toward curative services, to the neglect of preventive efforts37. 7 ARV therapy accounts for most of these expenditures, although it currently reaches only a fraction of those who need it. Rather than shift funds away from prevention, additional funds should be allocated for treatment. If the proper regimen of ARV therapy is taken on the right schedule, levels of HIV in the blood of an infected person can be reduced to the point that he or she is far less likely to transmit the virus, even during unprotected sex. Moreover, the potential benefits in decreased morbidity and mortality, greater economic productivity, and parenting of children could be substantial. MEXICO Modes of Transmission of Reported AIDSCases, Mexico (1983-2000) In Mexico, the trend in AIDS incidence has recently leveled Heterosexual off somewhat, with a shift in 1% Transmission affected populations toward 2% 13% Sex between Men IDUs and women. However, 3% 34% Mother-to-Child the epidemic is still largely Transmission concentrated in MSM. Among Contaminated Blood Products 25-44-year-olds, AIDS is the 47% Injecting Drug Use third most common cause of death in males and the seventh Unknown in females23. A study of over 7,500 MSM between 1991 and 1997 found that more than 15% were HIV-positive23,13. Eighty-five percent of bisexual Mexican men never used condoms during anal sex with their female partners, and 69% never used them during vaginal sex. As of 1994, 0.6% of pregnant women were HIV-positive13, but a 1996-98 study found only 0.09% infected23. Whether this represents a true decline or not is hard to tell. Initially, women were most often infected by contaminated blood products§§, but this mode of transmission has decreased and sexual transmission is on the rise38,39. Although it is reported that 100% of donated blood is screened, historically 7% of reported AIDS cases have been attributed to HIV transmission through contaminated blood or blood products40. Along with the "feminization" common to many Latin American countries, there is a phenomenon of "ruralization" of the epidemic in Mexico. The epidemic is growing rapidly among rural populations who have precarious living conditions. Migrant agricultural workers who acquire HIV in the United States may infect their partners after returning to their home communities41. As of mid-1994, 25% of rural AIDS cases had a history of temporary migration to the U.S., as opposed to 6% of urban cases42. Only 14% of AIDS cases in urban areas occur in women, but in rural areas, women account for 21% of cases42. §§ In 1985, Mexico passed a law ensuring the safety of blood, after which the incidence of cases due to contaminated blood decreased dramatically. 8 Studies of female CSWs have reported a low HIV prevalence - below or just at 1%23,145 ,43, while a study of male CSWs found 4.4% infected, and several studies conducted by the national program between 1988-1997 reported 12% infected. A wider disparity between HIV prevalence in male and female sex workers was found in another study: 12% percent of 104 male CSWs and 0.35% of 2,340 female CSWs were positive for HIV44. Syphilis rates were similar in the two groups, indicating that they shared behavioral risk factors. High rates of syphilis and other STIs in female sex workers Blood Safety indicate low rates of condom One of the most fundamental steps of HIV prevention is ensuring a use and high potential for HIV safe supply of blood and blood products for medical use. A 1999 to spread PAHO report stresses the importance of quality of donors among the among these workers and their first steps toward attaining blood safety. Unpaid volunteer donors are less likely than paid donors to be infected with bloodborne pathogens, clients23. Condom use among including HIV45. However, unpaid, volunteer donations are rare in female Mexican CSWs is Latin America. Instead, blood is either obtained when a friend or associated with higher family member "replaces" the blood a patient is given in the hospital, or through paid donors. education, greater experience Latin American governments have recognized that unpaid, voluntary in sex work, and younger age44. donation is strongly preferred, but the actual administration of blood bank services lags behind this recognition. Most Latin American A study of teenagers entering countries have between 30 and 300 blood banks, except Brazil (1,928), high school and university Mexico (59746), and Argentina (551). Blood banks are not centrally administered, and the quality of their services may vary widely even found that, among those who within a single country. Some are administered publicly, some by the were sexually active, 42% of Red Cross or other Non-Governmental Organizations (NGOs), and males and 36% of females had others by private companies. used condoms for their first Countries have recognized the need to address the issue of blood safety by creating coherent public policy at the national level. As of intercourse. These students 1999, PAHO estimated that 99% of all donated blood was screened for had a later age at first HIV. This translates into approximately 50,000 unscreened units per intercourse than that reported year. A study of 12 Latin American countries in the early 1990s reported that 100% of donated blood was screened for HIV in 9 by other Mexico City countries, making the probability of transfusion-transmitted HIV close teenagers. A study in Mexico to zero in those countries47. In Colombia, 98.8% of donated blood was City found limited access to screened, and the probability of transfusion-transmitted HIV was estimated to be 0.27/10,000. In Ecuador, 89.5% of donated blood was condoms in health clinics and a screened for HIV, with a probability of transfusion-transmitted HIV of failure of health care workers 1/10,000, and in Bolivia, only 36.2% of donated blood was screened, to promote condom use for with a probability of transfusion-transmitted HIV infection of 0.6/10,000. Bolivia continues to report that only about 40% of HIV and STI prevention, rather donated blood is screened for HIV. than solely as contraceptives49. In southern Brazil, the risk of transfusion-transmitted HIV decreased from 1/5,000 in 1991-94 to 1/48,777 in 1997-9948. However, despite Injecting drug use almost this nearly 10-fold reduction, the risk remains 10 times higher than in certainly plays a bigger role developed countries. Much is yet to be done to secure the Latin than reflected in official American blood supply. reports, although even in this population, sex between men is associated with higher risk than injecting drug use alone50. Among male IDUs, those who reported sex with men were more than three times as likely as those reporting sex only with women to be HIV-positive24. Among IDUs in 16 Mexican cities, up to 6% of males and 2% of females were found to be HIV-infected, and 70% of IDUs share "works"51. 9 In the early 1990s, up to 2% of TB patients in 17 states were HIV-positive52. High rates of latent TB infection in some parts of Mexico suggest that the number of active TB infections will skyrocket when HIV reaches them53. A study in a suburban community in southern Mexico found that nearly a quarter of TB cases were resistant to drugs, and that among people with TB, those with HIV were 31 times more likely to die54. CENTRAL AMERICA Modes of Transmission of Reported AIDSCases, Central HIV transmission in America (1983-2000) Central America is 1% overwhelmingly due to 1% heterosexual sex, making it more similar to the 5% 3% 5% Heterosexual Transmission countries of the Caribbean Sex between Men 13% than South America or Mother-to-Child Transmission Other Mexico. The exception is Unknown Costa Rica, where sex Injecting Drug Use between men is the leading 72% Contaminated Blood Products mode of transmission. The three countries with the highest reported HIV prevalence in the Latin American region (Honduras, Panama, Guatemala) are in Central America. The situation in this region is grim, and the ability of national health services to address it is inadequate. Costa Rica is the notable exception, as discussed below. In most Central American countries, like the rest of Latin America, HIV/AIDS care is confined mainly to capital cities and a few other major urban areas, and competes for scarce resources with other pressing health needs. Guatemala In Guatemala, the HIV/AIDS epidemic appears to be growing rapidly. It is concentrated in urban areas, especially those along the Panamerican and International Pacific Highways55,56. The percentage of cases due to heterosexual transmission is unusually high, even when compared to other Central American countries. In the absence of any sentinel studies of HIV prevalence in Guatemalan MSM or IDUs, it is difficult to assess whether this is accurate, or whether it reflects under-reporting of homosexual behavior. HIV rates greater than 1% have been reported among pregnant women in urban lowland areas145, although a single study conducted in the highlands suggests HIV was still absent among pregnant women and CSWs as of 199923,11. CSWs in Guatemala City and Puerto Barrios had HIV levels of 5% and 11%, respectively23,11. Only 8% of female respondents to a 1997 Demographic Health Survey reported ever having used a condom11, but another study11 found that 15% of women reported using condoms with their regular partners, and 26% used them with other partners. Men in this 10 study were more likely to report using condoms, with about 35% using them with both regular and non-regular partners. AIDS patients account for Gender Distribution of Reported AIDS Cases about 5% of The HIV/AIDS epidemic in Latin America started primarily in men who had hospitalizations in sex with men (MSM), and in the early years reported AIDS cases were overwhelmingly male. However, there is a general trend in Latin America Guatemala11, and as many toward "feminization" of the HIV/AIDS epidemic, as more females are as half do not know their infected, tested, and reported as AIDS cases. While there is likely to be both infection status before under-diagnosis and under-reporting of AIDS cases, and while reported symptomatic AIDS cases lag up to 10 years behind asymptomatic HIV arriving at the hospital. infections, the changes in the male:female AIDS case ratios over time give an About half of AIDS indication of the course of the epidemic. patients at one hospital in Table 3 shows the ratio of reported AIDS cases in males to AIDS cases in 1998 and 1999 were co- females for each of the Latin American countries in 1994 and in 2000 (or 1999, if 2000 data were not available). It is striking that in every country with infected with other STIs, available data, with the exception of Chile, the gap in reported AIDS cases which indicates that between males and females is closing. (In fact, the current figure for Chile is high-risk sexual behavior likely to be between 6 and 8, based on previous years' data; at the time the continued after HIV 1999 ratio was calculated, only about 1/3 of the previous years' totals had been reported.) infection11 and the onset of In Central America, where the epidemic is predominantly heterosexually AIDS, and that education propagated, the male:female ratios for 2000 are low, approaching 1:1 in the about safer sex is needed. case of Honduras. The exception is Costa Rica, which, like Mexico, has an epidemic driven by sex between men. A clinic in Guatemala City, In the Andean Region and Southern Cone, although ratios have decreased, which does 60% of HIV there is still a higher male:female ratio than in Central America. This reflects the greater importance of sex between men in the HIV/AIDS epidemic in South tests in Guatemala found America, and also a possible tendency for males to use more injecting drugs. that people who lived Cultural factors undoubtedly play a role in the feminization of the HIV/AIDS farther from the clinic were epidemic in Latin America. For example, females are relatively disempowered less likely to return for in negotiating whether, when, and how to have sex, and thus are more their results. Only 60% of vulnerable to infection through involuntary unsafe sex. Males are more likely than females to have multiple partners of either sex, and, if infected, may those tested returned; transmit HIV to multiple female partners. In general, females are also less adoption of a rapid test educated than males, and may have less access to AIDS information and protocol improved the prevention messages. Adolescent girls are at especially high-risk because they are more likely than their male age-mates to be involved with older partners return rate57. who may transmit HIV to them. The balance of power in such partnerships favors the male; youth, inexperience, and economic inequality are compounded with traditional "machista" values to make women more vulnerable to sexual In one Guatemalan exploitation and behaviors that put them at higher risk for AIDS and other hospital, the percentage of STIs. Fortunately, education and empowerment programs have had some people hospitalized for success in changing attitudes and practices of both men and women, although tuberculosis that also tested widespread social change will take years. positive for HIV rose from 1% in 1991 to 9.3% in 199811. A law mandating testing of donated blood is in the books, but has yet to be fully implemented11. 11 El Salvador Table 3. Ratio of male to female reported AIDSCountry cases (1994 and 2000) 1994 2000 As in Guatemala, the number of Mexico 6.4 5.6 people living with HIV/AIDS in El Central America 2.3 1.8 Salvador continues to rise. The total Guatemala 2.4 1.9 El Salvador 2.8 2.4* number of people infected from the start of Honduras 1.7 1.2 the epidemic to the end of 1999 was estimated to be between 25 and 50,00058. Nicaragua 11.7 1.8 Costa Rica 8.6 4.1 Through 2000 3,481 cases were reported; Panama 3.3 2.2 80% of reported cases are urban, with 75% Brazil 3.3 1.9 of those reported from San Salvador10. Andean Region 6.5 3.2 Venezuela 7.1 no data Surveillance data from El Salvador are Ecuador 4.3 4.2 fairly sparse. CSWs in San Salvador had Colombia 11.7 5.3 HIV rates from 2% to 7%, and one study Peru 4.6 2.7 reported 6% of STI clinic patients were Bolivia 3.5 no data infected with HIV. By contrast, fewer Southern Cone 4.1 4.1 than 2% of IDUs tested were HIV- Argentina 3.8 3.0 positive10. Percentages of seropositive Paraguay 5.8 2.6* pregnant women ranged from 0-1%, and Uruguay 3.4 2.9* 0.15% of blood donors tested from 1996- Chile 9.6 10.9** 1997 had HIV10. The government estimates that the average time between HIV Source: Data as of December 2000, from PAHO/WHO report AIDS Surveillance in the Americas infection and onset of AIDS is 5-7 years, * 1999 data ** 5.82 in 1999 and that 23 years of productive life are lost for each infection10. Little information on preventative behavior is available, although at least 20% of adolescents are estimated to be sexually active. About 3% of El Salvadoran TB patients are HIV positive. Honduras Honduras has the highest prevalence of HIV in all of Latin America, excluding the Caribbean. Although it accounts for just 17% of Central America's population, Honduras has reported over 11,000 cases, or 60% of Central America's HIV/AIDS cases. The high rates may be due in part to better surveillance. HIV/AIDS is the second leading cause of hospitalization and death in Honduras, after injuries due to violence. AIDS has been the leading cause of death in women of childbearing age since 1997. Although it has the lowest per capita income of any country in Central America, Honduras was the first to implement national surveillance and to provide free HIV testing for all59. HIV prevalence is highest in the cities of San Pedro Sula and Tegucigalpa, among the Afro-Carib Garífunas on the Caribbean coast, and along the central corridor between Tegucigalpa and the coast. "Ruralization" of the epidemic is suspected, but data documenting this are not available12. 12 Special Considerations for Indigenous Populations Honduras has the lowest The Latin American population and culture are amazingly diverse, comprising many male to female ratio of indigenous groups and some African-Caribbean populations, as well as the dominant people living with mestizo/criollo population. The risk for, prevalence of, and level of knowledge about HIV/AIDS is under-studied in many of these groups. In general, indigenous HIV/AIDS in all of Latin populations suffer from excess morbidity and mortality related to poverty. For America, approaching example, over 70% of 179 Native Americans surveyed in the Peruvian Amazon had 1:1. Nationwide, 1.4% of no access to a physician. Use of prenatal services was low in this group. In Chiapas, Mexico, indigenous people were among those most likely to present with advanced pregnant women are TB, or not to seek treatment at all60. infected with HIV24; 2- Many indigenous populations have so far been spared from HIV/AIDS because of 5% of prenatal clinic their geographic and cultural isolation, but available data on traditional STIs and patients in San Pedro Sula other human viral and retroviral infections make it clear that behavioral risk factors for HIV transmission exist in these populations. Thus, there is a need for appropriate are infected145. HIV/AIDS services targeted to these groups. In a few cases, indigenous or minority populations have higher rates of HIV In 1997, military recruits infection than the general population. For instance, the Garífunas along the Atlantic were reported to have an coast of Honduras, have rates of HIV infection that are six times higher than the HIV prevalence of 6.8%, general Honduran population, despite the fact that their knowledge of risk factors for HIV and preventive measures are reportedly very high. A study in El Salvador not far behind MSM points out that people may correctly identify HIV risks when asked, but may also (8%)23. As many as 21% have incorrect knowledge about HIV risk. If incorrect ideas are given the same of CSWs have been found weight as correct ones, perceptions of personal risk and adoption of preventive behaviors may not be appropriate. These findings may account for some of the positive for HIV23,145, but discrepancy between knowledge and practice61. a 1998 study suggests the For the most part, the indigenous peoples of the Central American and Andean true rate among urban highlands have very low rates of HIV infection. Guatemala is a case in point: HIV CSWs is about 10%12. infection in pregnant women exceeds 1% in some urban lowland areas, but is Preliminary results of a virtually absent in the highlands, which are predominantly populated by Maya Indians. A study found that only 47% of 210 rural Mayan women had heard of study of female CSWs in AIDS; 81% of these knew that a woman could be infected, and 79% did not know Tegucigalpa and San where to buy condoms. A Guatemalan NGO is working to indirectly increase Pedro Sula found 7.7% HIV/AIDS awareness in these communities by providing HIV/AIDS education to young men, many of whom are Mayan, during their obligatory military service62. HIV positive, with new HTLV-1 and HTLV-2, human retroviruses related to HIV, are endemic among cases appearing at a rate native American groups in South America63. The presence and transmission of of 3.2% per year in these viruses, which are spread by the same routes as HIV, indicate the potential for Tegucigalpa and 0.8% per HIV to spread if it were to gain a foothold. The archaeological record indicates that HTLV-1 and HTLV-2 have been in those populations for millennia, probably year in San Pedro Sula72. carried from Asia by the first settlers of the Americas 64. Likewise, hepatitis B and hepatitis D viruses are endemic and have caused outbreaks among Native Americans Nearly 7% of a in northern South America and the Amazon Basin65,66,67,68. A study of over 1,000 members of 18 different American Indian tribes in Colombia found no HIV population of mostly male infections, although other retroviruses were found in this group69. Among 276 prisoners were HIV- female and 94 male Quechua Indians in Cuzco and Quillabamba, Peru only one was positive, compared with HIV-positive, but 5% were infected with HTLV-I70. The one person infected with HIV was a man who had sex with men and was probably infected outside the 0.5% of a sample of community. HIV had not been introduced among the heterosexual population, but males more closely infection with HTLV-I was associated with risky sexual behaviors and history of resembling the general STIs. In a study in Manaus, in northeastern Brazil, 31 indigenous people were infected with a strain of HIV that was linked to the urban HIV epidemic in population. High-risk southeastern Brazil71. The trafficking of cocaine in remote regions and the sexual behavior was associated rise in drug-related HIV infection suggests that all but the most isolated common among truck groups may soon be at risk of HIV infection. drivers studied in 4 cities, but those who had sex with other men had six times the risk of HIV infection as those who reported sex exclusively with women145. Forty percent of these truck drivers said they never used a 13 condom with a CSW, and over 60% never used a condom when having sex with domestic workers. Domestic workers appear to be at particular risk of having unwanted unprotected sex: nearly 70% of a sample of Honduran night watchmen reported sex with domestic workers, and only 4% always used a condom in this situation23. Injecting drug use is reported to be low in Honduras12. Sexually transmitted infections (STIs) are common in Honduras, and condom use in risky sexual encounters is variable. Garífunas have HIV infection rates six times the national average, with 8.2% of men and 8.5% of women infected. Sixteen percent of Garífunas in their 20s were HIV positive, despite high levels of knowledge about HIV transmission and prevention (see Special Considerations for Indigenous Populations). About 3% of Honduran tuberculosis patients are co-infected with HIV, and about 23% of AIDS patients have TB12. Nicaragua Nicaragua was sheltered from the early years of the HIV/AIDS epidemic due to the Contra war in the 1980s, the U.S.-led embargo, low rates of injecting drug use, and no importation of blood products before the ousting of the Sandinistas in 199073. As of September 1999, 476 HIV/AIDS cases, of whom 209 had AIDS, had been identified in Nicaragua74. Over half of all reported cases in Nicaragua are concentrated in Managua. Surveillance data on HIV levels in pregnant women are not available. A study of Managuan MSM found 2% HIV positive, and another of CSWs in Managua from 1990- 91 reported a seroprevalence of 1%14. Blood donors had HIV prevalence rates of 0.05- 0.07%. STIs, especially gonorrhea and syphilis, are reported to be "out of control" in Nicaragua, but specific data on prevalence are unavailable. Knowledge of proper condom use is low. An intervention in Managua succeeded in increasing condom use somewhat, from 9% to 16% in women, and from 31% to 41% in men75. In a study in Managuan hotels used for commercial and non-commercial sexual rendezvous, condom use in commercial encounters was 60% and in non-commercial, 20%76. Prevention messages are primarily delivered in Spanish and aimed at the mestizo population, neglecting the English-speaking indigenous population on the Atlantic Coast. However, condom use doubled from 35% to 71% between 1991 and 1997 among Atlantic Coast men who had sex with more than one partner in the year prior to the survey23. Costa Rica Costa Rica is unique among Central American nations in the predominance of MSM among people living with HIV/AIDS. The prevalence of HIV in MSM has been reported to be between 10-16%145. Studies of pregnant women in Costa Rica as late as 1997 14 found HIV in 0.5% or less8. Between 1% and 4% of STI clinic patients in San Jose from 1990-94 were infected with HIV, and seropositivity in CSWs tested between 1989 and 1997 ranged from 0.1% to 2%8. HIV/AIDS infections are concentrated in urban zones. Costa Rica is also unique in that its social security system covers all citizens, and provides comprehensive HIV/AIDS care. CD4 cell counts, viral load testing, medications to treat tuberculosis and other opportunistic infections, and antiretroviral drugs are all available77. A decrease in progression to AIDS and death from AIDS has been reported among Costa Ricans receiving ARV therapy. Literacy is extremely high in Costa Rica, and the population is well-informed about HIV/AIDS prevention8. In 1995 WHO estimated that 96% of people had access to condoms, and PAHO reported in 2000 that approximately 75% of 15-19-year-old males, 55% of 20-29-year-olds, 47% of 30-39-year-olds, and 37% of 40-49-year-olds used condoms with casual partners23. In another study, 55% of males and 42% of females reported using a condom for their last risky intercourse8. Panama Panama has the second-highest rate of HIV/AIDS in Central America after Honduras. Very few data are available on HIV prevalence in specific high-risk groups in Panama. HIV prevalence in both pregnant women and CSWs has been reported to be as high as 0.9% in major urban areas23,15; no information on HIV among MSM or IDUs is available. A 1991 study may give a more accurate glimpse of the true penetration of HIV into Panama's population, reporting that 5.8% of military recruits were infected with HIV. Indications are that both HIV and traditional STIs like gonorrhea are increasing in Panama78. BRAZIL Modes of Transmission of Reported AIDSCases, Brazil (1983-2000) PAHO/UNAIDS/WHO estimate that the number of people living with HIV/AIDS Heterosexual Transmission in Brazil at the end of 1999 Sex between Men was 540,000 people. 2% 19% 27% Mother-to-Child The government's unique Transmission Unknown and ambitious program to 19% provide affordable, locally 3% 30% Injecting Drug Use produced antiretroviral (ARV) therapy means that Contaminated Blood Products this number will continue to grow as people with AIDS live longer, despite the leveling off of new cases. One clinic in São Paulo reported a 15 reduction in AIDS-related mortality from 42.2/100 in 1996, when ARV therapy was introduced, to 15.9/100 in 199979. The negative side of widespread ARV use is that resistance to these drugs is appearing in some people infected with HIV, meaning that they are no longer effective in fighting the virus. Nearly a fifth of all reported AIDS cases in Brazil are not assigned to an exposure category; the remainder is nearly evenly divided between sex between men and heterosexual sex, with injecting drug use accounting for nearly 20% of the total cases of AIDS5. The HIV/AIDS epidemic is most severe in the cities of the south and southeast. Sixty percent of Brazilians living with HIV/AIDS are in Rio de Janeiro and São Paulo. While sex between men was initially the major mode of transmission, heterosexual transmission has been the dominant mode of transmission since the mid-90s. This may be due in part to the relative popularity of anal intercourse among heterosexuals. Fifty to 60% of women in general surveys, and 32-41% of HIV-negative female partners of HIV-positive men reported practicing anal intercourse. Reported condom use in heterosexual anal intercourse is consistently less than in vaginal intercourse31,32. At the same time, condom use in general has taken off in Brazil, with sales more than quadrupling between 1993 and 1999145. In Rio de Janeiro, men who had anal sex with men increased condom use from 34% in 1989 to 69% in 1995145. A study of 16-25-year- olds reported that 87% used condoms with casual partners, while another study in 1999 found that close to half of young men reported having used a condom for their first sex act, with condom use higher among more educated men. Condom use is not universal; in areas where the HIV epidemic is just picking up, such as Fortaleza, in the northeast, it is less common145,80. Researchers visiting health centers in São Paulo found inadequate condom supplies81, possibly a consequence of the concentration of resources on treatment rather than prevention. In northeastern Brazil, HIV infection has remained concentrated among MSM, although a growing number of women are infected by sex with these men. Nationwide, the number of HIV infections among MSM is estimated to be increasing by 1.5-3% per year82. HIV prevalence among pregnant 13-24-year-olds in the country as a whole was 0.4% in 1998, but prevalence in the same age group in the southeast was 1.7% in 1997. Among women delivering at a facility for high-risk pregnancies in São Paulo, 1.5% were HIV- positive. In Vitória, 0.6% of 600 pregnant women were HIV-positive83, but the highest prevalence among pregnant females is in the city of Porto Alegre in Rio Grande do Sul, where HIV prevalence in 1996-97 was 2.6-3.3%84. This number may be somewhat inflated because some providers reported testing for HIV selectively, despite a policy that HIV testing should be offered to all pregnant women. HIV/AIDS is affecting younger and poorer segments of Brazil's population, but the epidemic is not limited to youth. A study of AIDS in the state of Rio found 3% of people living with HIV/AIDS (PLWHA) were over 60 years old85. As survival increases due to treatment with antiretroviral drugs, more people with AIDS can be expected to live longer. 16 Injecting drug use has emerged as a major factor in the HIV/AIDS epidemic in Brazil. IDUs in Santos reported that their drug-related risk behavior was decreasing more quickly than their sex-related risk behavior86. Likewise, one-third of IDUs in Rio reported sharing needles, but twice that number (63%) said they never used condoms with casual sex partners, and one-third have traded sex for drugs145. IDUs with AIDS were at higher risk for tuberculosis than MSM with AIDS87. A small study of IDUs in Porto Alegre and Rio found higher HIV prevalence in Porto Alegre, where higher incomes allowed IDUs to inject more frequently88. Needle exchange programs have recently been approved in Brazil145, which hopefully will increase access to clean needles and decrease transmission among IDUs. Brazil has 7-8 million street children between the ages of 5 and 18 who are at high-risk for HIV through drug use and unprotected sex25. Most drugs used by these children are smoked or inhaled, but in a study in Belo Horizonte, 10% admitted to injecting drugs. Another study by an NGO working with street children in Belo Horizonte over the course of 10 years found that exchanging sex for money, not using condoms, injecting drugs and smoking crack were associated with HIV27. Youth in prisons, a population that overlaps with street children, are also at high-risk for HIV. HIV prevalence in the general prison population in Brazil is between 12-17%. Among 121 adult female prisoners in Vitoria, 10% were HIV-positive, and many had other STIs89. A 1998 study found that 18% of CSWs in São Paulo were infected, and 3.7% of men and 1.2% of women attending STI clinics were HIV-positive5. ANDEAN REGION Modes of Transmission of ReportedAIDSCases, Andean There are signs that the epidemic in Region (1983-2000) the Andean region is growing. There is strong evidence of risky sexual behavior, as this region has Heterosexual Transmission the highest estimated incidence of Sex between Men STI infection (15%) in all of Latin America33, which indicates that the 3% Mother-to-Child 15% HIV/AIDS epidemic may be worse 1% Transmission 38% than what the epidemiological 2% Contaminated Blood Products surveillance systems detect. Over Other 40% of reported AIDS cases are attributed to sex between men, with Unknown a nearly equal number attributed to 41% heterosexual sex. Injecting drug use makes a negligible contribution; about 15% of cases with unknown sources of exposure may actually be associated with injecting drug use. 17 Information from sentinel surveillance, seroprevalence and behavioral studies is limited. Under-reporting of HIV/AIDS is probably substantial in this region, with scarce resources and weak surveillance systems in the Venezuela, Ecuador, and Bolivia. Venezuela Venezuela has the highest estimated HIV prevalence in the Andean region, but without data on high-risk groups, the epidemic is classified as low-level. Over 8,000 AIDS cases were registered by the Ministry of Health and Social Development90 and PAHO/UNAIDS/ WHO estimates that about 62,000 people were living with HIV/AIDS at the end of 1999. In 1996, AIDS was the sixth most common cause of death in 25-44- year-olds. HIV rates are Sex between Men and HIV/AIDS in Latin America higher on Margarita Island As of the end of 2000, sex between men accounted for a third of all reported AIDS cases in Latin America. Because of the particular vulnerability of men and Venezuela's other who have sex with men (MSM) to HIV infection as a consequence of Caribbean islands than on behaviors such as unprotected anal intercourse, relations with multiple the mainland. Among partners, and sex work, it is important to understand the dynamics of behavior in this heterogeneous group. residents of mining communities, prevalence Male homosexual behavior is generally clandestine and occurs on the margins, e.g., late at night in discos or bars outside the mainstream. Separate was 1%23. Very little gay-identified communities, such as those found in the United States in San information about the Francisco or New York, are virtually unknown in Latin America. As long as HIV/AIDS epidemic in it is not explicitly discussed, homosexual behavior is tacitly accepted or ignored by family members and social contacts. For instance, in Nicaragua, Venezuela is available, but MSM are integrated into family and neighborhood life and are described as it appears to be increasing being "known about" rather than "recognized"91. MSM who have a more in tourist, industrial, and public gay identity are frequently the targets of hostility and violence, and social and cultural stigma remains associated with homosexuality. Gay- mining areas90. identified men in Guatemala City report being profoundly marginalized; they feel disenfranchised and have no recourse if they are abused92. Surveys of pregnant women The silence and marginalization that MSM in Latin America endure in Venezuela in 1996 found contribute to their susceptibility to HIV infection. With little sense of no HIV infections19, and community among MSM and few activist groups, it is difficult to spread the AIDS prevention message and create a culture of safe sex practice. In Lima, prevalence in CSWs in Peru, MSM reported that they had insufficient information about AIDS and Caracas has ranged from that safer sex was inconsistently practiced, especially in commercial sex94. 0% to 6%19. Of 400 Likewise, among MSM in Fortaleza, Brazil, 43% did not have the fundamental information needed to protect themselves from HIV. Only half prisoners tested in 1996, had ever been tested, and 44% reported engaging in unprotected anal sex. 2.5% were HIV positive23. This differs from the situation among MSM in southern Brazil, where sexual These data suggest that the and cultural norms are more relaxed and gay culture is described as "out of the closet for good"93. HIV epidemic in Venezuela To control the HIV/AIDS epidemic in Latin America, and especially in those is more advanced than is countries where sex between men is the dominant mode of transmission (i.e. indicated by official Mexico, Costa Rica, and much of South America) it is imperative that health statistics. care and prevention messages be provided to MSM in safe, respectful contexts. While Latin American societies still have a long way to go in granting recognition and basic rights to MSM, advances are being made. 18 Colombia In Colombia, sex between men is the primary mode of transmission in the highlands, and heterosexual transmission plays a larger role in the Atlantic Coast region, Orinoquia and the Amazon region. Studies of Colombian CSWs have found HIV prevalence in the range of 0.2%-0.9%, but among one sample of over 100 male and female teenage sex workers, 11% were HIV positive. Nearly 20% of the group also had syphilis. A 1991 survey of university students found that 17% of males and 3% of females had a history of an STI94, and a 1999 study of male and female STI clinic patients found 1.1% HIV positive23; four out of twelve departments reported prevalence rates of 2% or more among STI clinic patients. Between 0.1% and 0.7% of pregnant women in Colombia have been reported to be HIV- positive23. Men who have sex with men (MSM) are the group with the highest reported HIV prevalence in Colombia, with 18% of MSM tested in Bogotá in 1999 positive for the virus23. Interestingly, a study from Bogotá published in 2001 reported that heterosexuals were significantly more likely than homosexuals to engage in risky sexual behavior. Only 2% of the 553 men in the study knew their HIV serostatus, and only 20% of those who practiced anal sex and 5% of those who had sex with women during menses reported consistent condom use23. In contrast to the recent study noted above, an earlier survey reported higher condom use. Fifty-five percent of men surveyed claimed they always used a condom with casual anal sex partners, and in another survey of men with no steady partner, 75% reported having used a condom in their last sex act. Condom use among women was much lower: the 2000 Demographic and Health Survey reported that only 19% of women surveyed had ever used a condom7. In Cucuta, a region where heterosexual transmission dominates, a behavioral intervention among 93 women increased condom use, especially during anal sex95. In another study, only 6% of 700 women representative of the general population, but 67% of 412 female CSWs, reported consistent condom use. Over half the respondents in both groups were not aware of the increased risk of HIV transmission associated with sex during menses96. Six to 9% of tuberculosis patients tested in the mid- 1990s were HIV-positive23. Injecting drug use, although not reported in current official statistics, probably accounts for a substantial proportion of AIDS cases; eight years ago, official statistics reported IDU prevalence at 0.1%. Ecuador Data on the current status of the HIV/AIDS epidemic in Ecuador are very scarce. A document generated internally reports a total of 2,668 HIV/AIDS cases from 1984 to 1999, of which 1,457 had progressed to AIDS at the time of report30. Three-quarters of 19 Ecuador's AIDS cases have been reported from the province of Guayas, largely because Guayas is the site of the infectious disease hospital, where many AIDS cases are first diagnosed after patients make their way there for treatment30. The proportion of females infected with HIV is increasing in Ecuador, although the prevalence of HIV among pregnant women in 2001 was reported to be just 0.05%. An earlier study from Guayaquil reported 0.3% of pregnant women were HIV positive9. No estimates of HIV prevalence among MSM, IDUs, or CSWs were found. A survey of CSWs found 80% had a STI, and a sharp increase in STIs among 14-19-year-olds has been reported. Studies of STI clinic patients in Quito in 1992 found 0.5% HIV positive, and a study in Guayaquil in 1993 found 3.5% HIV positive23. In 2000, 0.26% of blood donors were infected. In a study of 870 secondary school students at 4 schools in Quito and 4 schools in the Amazon region, sexual activity was reported by 41% of urban and 52% of rural respondents. Of those sexually active, 50% never used condoms, and 70% had not used a condom in their last risky intercourse97. Condom supplies are reported to be low. An assessment of Ecuador's epidemiological surveillance system concluded that HIV/AIDS surveillance and prevention activities have decreased in relation to an increase in dengue and malaria control activities following a World Bank grant focused on these mosquito- borne diseases30. Peru As of December 2000, over 11,000 HIV/AIDS cases were reported in Peru. Another 75,000 are believed to be HIV-positive, but have not been tested. In Peru, HIV infection is concentrated among the poor in coastal cities ­ 2/3 of reported cases are in Lima and the adjoining Callao area35. The highest rates of infection have been reported in MSM, although the proportion of females is increasing. HIV prevalence varies widely by region: in one study, 14% of MSM in Lima and 5% of MSM in the provinces tested positive for HIV145. In another study of close to 5,000 MSM conducted in 1998, HIV was detected in 12.2% of those in Lima, 14.5% in Iquitos and 7.5% in Pucallpa (both cities in the Amazonian region); 2.7%-5.3% in coastal cities; and 1.4% in the Andean city of Cuzco. In the entire sample, consistent condom use was reported by only 12%, and 46% of MSM also reported sex with women. Among transvestites in this sample, HIV prevalence was 35%98. A study of MSM in Lima estimated that new cases occurred at the rate of 3.3/1000 per year99. Other areas with increasing rates of HIV incidence are the northern coastal city of Chiclayo and the Amazon city of Iquitos, where homosexual tourism contributes to the epidemic100. Other high-risk populations had lower HIV prevalence. Nationwide, 0.6% to 2% of CSWs are positive for HIV, although levels as high as 5% have been reported in urban areas, and between 1986 and 1990, 10% of unlicensed CSWs were HIV-positive. Among 100 female CSWs in Lima, regular condom use was reported by 87%, although only 29% 20 of those who had a regular partner used condoms with him28. Seven percent of STI patients tested in 1995 were HIV positive35. HIV rates in pregnant women are still well below 1% in Lima, and lower still in the provinces35. Sentinel surveillance among 15-24-year-olds at maternity hospitals in Lima found 0.23%-0.58% HIV positive between 1996 and 199923. AIDS cases are increasing in 20-24-year-olds, indicating that HIV infection is occurring in teenagers35. The role of injecting drug use in the Peruvian HIV epidemic is difficult to evaluate because no data on the prevalence of HIV among IDUs are available after 1990. A nationwide serosurvey conducted between 1986 and 1990 reported that 13% of IDUs were HIV-positive101. In 1998, 0.23% of blood donors in Peru were infected with HIV23. STIs are common in Peru, although exact frequencies are hard to come by. In one survey of young adults, more than 10% had an STI; in another survey of men in their 20s, 12%- 16% reported STI symptoms in the previous year, but as many as two-thirds sought no treatment23. Positive syphilis serology among pregnant 15-24-year-olds in Lima ranged from 8%-17% between 1996-9817. In the 1986-90 serosurvey, 10% of STI clinic patients were HIV-positive. Since 1995, the government has provided drugs to prevent some opportunistic infections associated with HIV/AIDS, resulting in a decrease in those infections35. Bolivia Bolivia's risk factors are similar to its neighboring countries. PAHO/UNAIDS/WHO estimates indicate that about 4,200 people were living with HIV/AIDS at the end of 1999. As of March 2000, 498 HIV/AIDS cases had been reported, nearly half of which presented with AIDS at the time of report4. Only 3% of identified AIDS patients survive more than three years102, a figure that attests to lack of access to and/or the reluctance of people to seek testing and treatment until late in the course of illness. Virtually all reports of HIV and AIDS in Bolivia come from urban areas, primarily from the central corridor of La Paz, Cochabamba, and Santa Cruz, where there is a lot of traffic and where internal migrants tend to settle103. Bolivia lacks data on the prevalence of HIV among MSM and IDUs, but has good STI surveillance data. Syphilis, primarily detected in prenatal screening programs, has increased over the past decade, and congenital syphilis has increased, as well. Rates of gonorrhea, primarily detected in 20-29-year-old males, more than doubled between 1984 and 1998102,104. Despite high rates of traditional STIs in pregnant women, between 1990- 1997, no HIV infections were detected in prenatal screening in two Bolivian cities. However, in 1997, 0.5% of pregnant women tested in Cochabamba were HIV positive4. Females are believed to represent a third of those living with HIV/AIDS in Bolivia102. Among STI clinic patients surveyed in 2000, 0.03% were HIV positive. An estimate of 0.3% HIV prevalence among CSWs was obtained from a study in 1998 in which CSWs 21 volunteered to be tested, but this is likely to underestimate the true prevalence, as those most at risk may have been less likely to volunteer for testing. The estimated true prevalence in CSWs is 0.5%. An HIV prevention project targeted at female sex workers in La Paz increased reported condom use in this group from 36% in 1992 to 73% in 1995, with concomitant decreases in STIs diagnosed. In 1995, HIV seroprevalence in this group of about 500 female CSWs was 0.1%105. In a 1998 survey, 46% of women of childbearing age believed that using a condom prevents AIDS, and 3% of women and 19% of men reported that they began using condoms as a means of AIDS prevention. In another survey, 65% of males and 33% of females reported having used a condom during their last risky sex act. SOUTHERN CONE Modes of Transmission of Reported AIDSCases, Southern Cone (1983-2000) In the Southern Cone the Heterosexual epidemic is persistently growing Transmission Sex between Men in the marginalized populations and spreading to the general Mother-to-Child population. Argentina has the 2% 23% Transmission highest prevalence of HIV 33% Other infection in South America, one Unknown of the highest percentages of infected children, and HIV 4% Injecting Drug Use 32% infections are on the rise. 0% Contaminated Blood Among reported AIDS cases, 6% Products injecting drug use plays the largest role, closely followed by sex between men3. While there is probably a great deal of under-reporting, as in the other regions, the Southern Cone has the lowest percentage of cases with anunknown or unclassified mode of transmission. HIV infection resulting from injecting drug use is particularly high in Argentina and Uruguay, but much less common in Chile, where sex between men is the primary mode of transmission. Very few cases have been reported from Paraguay, and the majority of these were heterosexually acquired. However, other data indicate that injecting drug use may play a role in HIV transmission in Paraguay. Argentina Ninety percent of AIDS cases in Argentina are reported from urban areas, with Buenos Aires accounting for 36%, followed by cities in the southern and western regions106. In Rosario, 0.5% of 11,000 volunteers were HIV-positive, with the highest prevalence among 30-40-year-olds107. Nationwide, HIV prevalence in pregnant women is estimated to be between 0.6-0.7%, but rates in major urban areas may be as high as 2%3. The mean 22 age and educational level of women with AIDS were substantially lower than those of men, and one-third of women with AIDS acquired it through injecting drug use106. Among 130 maternity patients in Buenos Aires, injecting drug use, irregular condom use, and heterosexual anal intercourse were associated with HIV108. Very high rates of HIV infection in IDUs have been reported, with 46% estimated to be HIV positive as of 2000106. Three-quarters of IDUs in Buenos Aires reported sharing injection paraphernalia, and efforts to address this problem by improving access to clean needles at pharmacies were reported at the International AIDS Conference in 2000109. IDUs living with AIDS are younger, less educated, and more concentrated in Buenos Aires, Rosario, and Cordoba than those who acquired AIDS through other routes106. Up to one-third have traded sex for drugs145. Among 111 detainees in Rosario Police Stations, 9% were HIV-positive, and 84% did not use condoms, although they knew condoms prevented AIDS. Twenty-six percent were IDUs. Similarly, among teens in correctional facilities in Buenos Aires in 1992-95, 4.6% were HIV-positive, and HIV infection was highly associated with injecting drug use110. Data on HIV prevalence in Argentine MSM were not available for this study. Three to 8% of CSWs tested in the early 1990s were infected111. Fifteen percent of 200 CSWs in Buenos Aires were HIV-positive in one sample, with higher rates among those in saunas or massage houses as opposed to those in hotels or on the streets. 23 Intertwined Epidemics: Injecting Drug Use and HIV In a sample of 33 CSWs in Rosario, 82% did not Injecting drug use is especially high in Brazil, Argentina, Uruguay, and Mexico, and is a growing problem in cocaine producing countries like Bolivia, Peru, and Colombia. Drug know how HIV was injection increases the risk of infection with HIV through several routes: (i) using a needle transmitted, and 73% previously used by someone with HIV; (ii) exchanging sex, often unprotected, for drugs or for money to buy drugs; and (iii) engaging in high-risk behavior while under the influence never use a condom with of drugs. their regular boyfriends. The drug of choice for injecting drug users (IDUs) in Latin America is cocaine; heroin use Nearly 100% of students is less frequent, especially in South America112,113. People often start by snorting or smoking cocaine and then switch to injecting. In 1996-97, a study of nearly 300 Brazilian in public secondary cocaine users found that 87% started by snorting cocaine; 68% later switched to smoking schools in Venado cocaine, and 20% to injecting. Both smoking and injecting were associated with higher dependence than snorting. Younger users and those who started after 1990 were less Tuerto were sexually likely to inject114. active, yet only 20% Cocaine use poses a greater risk for HIV infection than heroin, because cocaine is often reported regular condom injected many times a day. The high frequency of injection may lead cocaine injectors to neglect safer injection techniques; cocaine can also be a sexual stimulant and therefore use123. users may be more likely to engage in risky sexual behavior. As early as 1986-87, 47%of 99 IDUs in Buenos Aires who had hepatitis were also infected with HIV115, and by 1991, more than one-quarter of all reported AIDS cases in Brazil and Argentina were due to A 2000 estimate put the injecting drug use. The greatest risks for HIV infection among cocaine injectors include percentage of STI clinic injecting more than five times per day, failing to adopt AIDS-prevention behaviors, and sex between men116. patients infected with The major trafficking routes from the coca-growing countries are through Brazil, and cities HIV at 4.2. Rates along those routes have twice as many AIDS cases as other Brazilian cities and 4 times as among blood donors are many AIDS cases among IDUs. In Santos, Brazil, the largest port in Latin America, approximately 2% of the population are IDUs116. lower than the national Crack cocaine was introduced to Brazil in 1989, and studies in the Santos average, at 0.13%. metropolitan area showed that crack smoking increased from 11% in 1991-92 to 67% in 1999117, while the prevalence of injecting cocaine more than five times Tuberculosis is a serious per day decreased from 42% to 15% over the same period88 ,118. HIV prevalence also decreased from 63% to 42% during this period, in the absence of any major problem in Argentina, public health intervention117. which saw high rates of However, the injection-associated HIV epidemic shows no sign of abating in Brazil. HIV TB among HIV-infected is moving into younger age groups, more impoverished, and more rural areas of the prisoners from 1985- country,119. Interestingly, HIV is not the only bloodborne infection transmitted by injecting drugs; malaria is being spread to urban areas, at the same time that HIV/AIDS is 1991124. At a hospital in spreading into rural malarial areas along drug trafficking routes. Despite the huge Buenos Aires, 10% of injecting drug use problem, there is little access to treatment. Drug treatment in Brazil is available only through private or religious centers, and is too expensive for most drug HIV-positive patients users. had TB between 1987- Without effective treatment options, IDUs are frequently relegated to the criminal justice 1999125. Over half of system. The prison environment has been described as "selectively enriched" with IDUs, as many IDUs have criminal records related to their illegal drug use or drug-related these were IDUs. Only crimes. Indeed, injecting drug use and imprisonment are closely related: in 1993-94,22% 7% had received of prisoners in a Brazilian prison reported injecting drugs; overall, 16% were HIV- positive, and 18% had syphilis120,121. Similar data exist for Argentina: in Buenos Aires preventive treatment between 1992 and 1995, nearly 5% of imprisoned teens were HIV+, and in Rosario, 26% with INH, although the of youth detained by police injected drugs122. HIV risk increases with duration of incarceration, since injecting drug use continues in prison120,121. mean time between There is an urgent need for injecting drug use to be addressed in Latin America from a diagnosis of their HIV medical, rather than a law enforcement, standpoint. Drug users come from all segments of infection and society and may provide a bridge by which HIV can cross to the general population. The lack of data from countries outside Brazil and, to a lesser extent, Argentina and Mexico, hospitalization with TB does not imply that other countries are free of injecting drug use. Rather, the clandestine was 30 months. nature of illegal drug use, the marginalization of drug users, and the unwillingness to confront this problem has impeded the collection of basic data on this population at high- Survival in this group risk for HIV infection. increased after the introduction of highly active antiretroviral therapy (HAART). 24 Paraguay Few sources provide information about the HIV/AIDS epidemic in Paraguay. 1992 prenatal testing of pregnant women in Asunción identified no HIV positive pregnant women16. As of 2001, the prevalence in pregnant women was below 1%. Studies of CSWs in Asunción between 1987-90 found 0.1% infected with HIV16, and 0.17% of blood donors were reported to be infected in an unpublished 2001 survey (World Bank survey). This same survey indicated that 1% of voluntarily tested military recruits and 15% of voluntarily tested IDUs were HIV-positive. These numbers suggest that the epidemic is more serious than has been acknowledged, and that it is concentrated in IDUs, rather than in the general heterosexual population and MSM, as official statistics indicate. Paradoxically, while only 15% of 15-49-year-olds correctly stated two or more ways to prevent HIV infection, nearly 80% of females in this age group were reported to have used a condom during their most recent risky intercourse16. Uruguay Injecting drug use is increasingly significant in the Uruguayan HIV/AIDS epidemic. Forty percent of babies born with HIV were born to mothers who injected drugs23,145. Between 1994-97, 15-24% of IDUs in Montevideo tested positive for HIV18. Similar rates have been reported in transvestite and male CSWs in Montevideo in 200023; 3.3% of the 200 transvestite CSWs surveyed admitted to injecting drug use, and irregular or no condom use was reported with 22% of clients126. The government reported that 2% of female CSWs and 9% of male CSWs aged 15-34 were HIV-positive. Two studies of 12,000 laborers in 1997 and 2000 found 0.23% and 0.26%, respectively infected23, and among pregnant women in 2000, 0.23% were HIV-positive23. Among blood donors, the reported rate was more than twice as high, with 0.6% infected (World Bank survey). Luckily, 100% of blood donated in Uruguay is screened for HIV (World Bank survey). In 1993, 6% of military recruits were reportedly infected (World Bank survey), and 6% of tuberculosis patients in Uruguay have AIDS23. Regarding the prison population, a local NGO reported that prisoners with AIDS were subjected to numerous human rights violations, including the suspension of access to ARV therapy upon incarceration127. Chile Unlike other countries of the Southern Cone, injecting drug use does not appear to play a large role in HIV transmission in Chile. Heterosexual transmission is increasing in both men and women, and is especially associated with poverty in women128. The male:female ratio of AIDS cases as of 1997 was 8.4:1, but this ratio is expected to decrease as the prevalence of cases among MSM decreases. The highest numbers of AIDS cases by far have been reported from Santiago, followed distantly by Valparaiso and Viña del Mar. Seroprevalence in gay-identified males in Santiago is estimated to be 25 between 20-25%129. Data on HIV prevalence in IDUs and CSWs are lacking. STI clinic patients tested in 1999 had rates up to 3%, with the highest rates in Santiago. HIV prevalence in both pregnant women and blood donors is less than 0.1%6. Knowledge about HIV prevention is reported to be close to universal among urban 15- 49-year-olds, and according to one source condom use during high-risk sex is around 33% in this group6. PAHO reports that approximately 38% of 15-19-year-old males, 43% of 20-29-year-olds, 35% of 30-39-year-olds, and 33% of 40-49-year-olds used condoms with casual partners23. THE ECONOMIC IMPACT OF HIV/AIDS IN LATIN AMERICA The economic impact of HIV/AIDS in Latin America manifests itself in several different impacts, including: Ø Direct costs to government health care system, including the costs of treating PLWHA. These costs can be high on a per-case basis, due to the intensity of treatment required for some opportunistic infections and other ailments associated with the HIV/AIDS, as well as the relatively high cost of ARV agents prescribed to HIV patients. However, because HIV/AIDS prevalence is not very high in most countries, the overall HIV/AIDS-related resource demands on the public budget have been relatively low to date (only about 0.5%-2.6% of total health spending in several countries studied). Ø Opportunity costs of activities not undertaken by government health care systems in favor of spending on HIV/AIDS. The additional resource demands associated with HIV and other emerging health problems in general have not induced more overall health care spending, but rather have led to increased competition among priorities within the health sector. A full economic assessment requires consideration of unmet needs related to spending on HIV/AIDS. Ø Direct health care costs to PLWHA, including out-of-pocket spending on private (and sometimes public) health services, and costs paid by insurers. Ø Wages lost by PLWHA who face reduced labor market opportunities because they are unable to work, or due to discrimination. Tax revenues are also lost as a result of reduced productivity. Given that HIV/AIDS typically affects people in their most economically active years, lost wages are likely to constitute a large share of the total economic impact of the disease. Ø Wages lost by caregivers (often family members) of PLWHA due to additional demands on their time, which detracts from employment. 26 Ø Indirect costs to society, including higher insurance premiums in large populations and lost national income from tourism in areas where high HIV/AIDS prevalence makes locales less desirable to visitors. Few efforts have been made to estimate the full economic impact of HIV/AIDS in Latin America§; this remains on the future policy research agenda. However, several extensive analyses have examined the direct impact of HIV/AIDS on health systems, the results of which are summarized in the following section. Preliminary estimates of financing and expenditures in eight Latin American countries in 2000, show that the current expenditure in Argentina, Bolivia, Brazil, Chile, Costa Rica, Mexico, Peru and Uruguay on HIV/AIDS is US$1.13 billion; ranging from US$408,000 in Bolivia to US$579 million in Brazil. The estimated average per capita expenditure devoted to care in Bolivia is 18%, but in the other countries it was higher than 64% (the average is 78%). None of the countries, except Bolivia, depend heavily on external international cooperation; 25% of Bolivia's health expenditure is out-of-pocket expenditures, 64% is from external sources, and only a small fraction is covered by direct government funding. In the seven countries where ARV therapy is provided, most financing is provided by government resources through universal health systems (i.e. Brazil) or social security institutions. Latin America spends large proportions on treatment - between 60% and 80% of total HIV/AIDS expenditures. The majority of countries, such as Brazil, Argentina, Chile Uruguay and Mexico allocate substantial resources to ARV drugs, while spending only 10% to 30% of the total expenditure on prevention (Table 4). Table 4. Basic indicators of context and expenditure in selected countries, 1999 Costa Context Indicators Argentina Bolivia Brazil Chile Rica Mexico Peru Uruguay GDP US$ billion 283.2 8.3 751.5 67.5 15.1 483.7 51.9 20.8 GDP US$ billion 449.1 19.2 1,182.0 129.9 31.8 801.3 116.6 29.4 (PPP*) GDP per capita US$ 12,277 2,355 7,037 8,652 8,860 8,297 4,622 8,879 (PPP*) Population (millions) 36.6 8.1 168.2 15 3.9 97.4 25.2 3.3 Total Expenditure on 219,885 408 579,331 52,407 10,190 207,217 42,869 19,825 HIV/ AIDS (US$ million) § Studies have examined the macroeconomic impact of AIDS in Africa. However, the epidemiological, demographic and socioeconomic differences between Africa and Latin America preclude any extrapolation of these findings 27 Structure Indicators and Expenditure Weight (%) National Health 9.1 4.65 7.6 5.8 6.7 5.6 3.1 10.70 Expenditure/GDP (%) Public Health 21.7 81.3 42.1 46.6 77.6 45.0 40.0 46.3 Expenditure/ National Health Expenditure (%) Total Expenditure on 0.8 0.92 1.4 1.27 no data 0.5 2.6 0.87 AIDS/National Health Expenditure (%) Public Expenditure on 2.2 0.02 2.5 0.7 no data 0.96 1.5 0.64 AIDS/Health Public Expenditure (%) Public Expenditure on 57.5 2.09 79.3 28.4 67.7 86.01 22.2 34.03 AIDS/Total AIDS Expenditure (%) Family Expenditure on ND 22.64 15.0 66.9 0.6 11.52 74.9 45.13 AIDS/Total AIDS Expenditure (%) Condom Expenditure 1.91 0.03 0.05 0.08 1.23 0.13 0.16 2.69 per capita (US$ PPP) Anti-retrovirals 4.12 0.0 2.73 4.93 2.36 2.22 0.13 3.32 Expenditure (US$ PPP) Expenditure Composition (%) Personnel Health 77.9 18.0 72.0 88.5 67.6 83.0 91.9 64.4 Public Health and 22.1 53.3 28.0 11.5 32.4 17.0 8.1 35.6 Prevention PPP= (adjustments made for) Parity of Purchasing Power Source: SIDALAC. Estudio de cuentas nacionales VIH/SIDA. 2001 The vast majority of HIV/AIDS expenditures are financed by public sources. This includes direct government (i.e. ministries of health), or social security contributions, as in Argentina, Brazil and Costa Rica. In Mexico, Chile, Peru and Uruguay, the private sector contributes more to HIV/AIDS expenditures, primarily through out-of-pocket- expenditures (Table 5). Table 5. Financing by source (US$, adjusted for PPP*) in selected countries Financing by Costa Source Argentina Bolivia Brazil Chile Rica Mexico Peru Uruguay A. Public Sources 200,524 8 706,205 28,655 14,520 22,347 20,088 9,442 Government Funds 200,524 8 706,205 15,857 211 35,755 10,193 9,268 Social Security Funds na na na 12,798 14,309 186,612 9,895 174 B. Private Sources 148,121 282 197,523 71,993 6,941 28,928 74,960 18,580 Private Social Security 58,368 na na na na na na 5,633 Private Insurance 19,328 0 no data 5,962 na 0 na na *PPP=Parity of Purchasing Power na=not applicable Source: SIDALAC. Estudio de cuentas nacionales VIH/SIDA. 2001 28 Regarding prevention, the fact that a large portion of expenditures on condoms are financed out-of-pocket (i.e. Uruguay), means that prevention interventions led by governments might be successful since it is proven that people are willing to invest in priority prevention methods. Conversely, out-of-pocket expenditures for personal health care services demonstrates the lack of governments' ability or willingness to finance services for people suffering a potentially devastating (catastrophic) disease from the economic perspective, not to mention a lack of attention to one of the major causes of morbidity and premature mortality. 29 30 CHAPTER 2 EPIDEMIOLOGICAL SURVEILLANCE Summary This chapter assesses the performance of epidemiological surveillance systems in 17 Latin American countries surveys. Information on procedures and methodology was provided by technicians in charge of epidemiological surveillance at the national level. In Latin America, cases of HIV and AIDS are reported extensively, although case definition varies between even within countries. Generally, physicians are responsible for reporting HIV/AIDS cases to health authorities, although in some countries other professionals or entities are involved. The most common form of case identification is name-based, followed by various types of codes. Each country confirmed that they have laws protecting access to such information, but the existing legislation shows a lack of laws or regulation regarding ownership of surveillance data, information security and/or citizens' rights. Both under-reporting and delays in notification compromise the quality and validity of information available. The epidemic in Latin America probably includes about 30% more cases of AIDS and 40% more cases of HIV than is currently estimated. Generally, active surveillance is not being implemented in most countries. Sentinel surveillance is an indispensable tool for designing, implementing and evaluating prevention interventions targeted to all populations. Despite the fact that sentinel surveillance systems are widespread in Latin America, consistent and comparable data are not generated region-wide. Policies for promoting free and anonymous HIV testing, and ensuring availability and access to the test are basic conditions for expanding and improving prevention strategies and surveillance plans. Regarding the information systems currently in place, there is a need to improve the systems for reporting cases, particularly in terms of validity and comprehensiveness. Under-reporting is one of the most common problems in Latin America. Most of the sentinel surveillance problems are related to the need for systematizing information systems and incorporating new sub-populations. "Second generation surveillance" is a challenge to those responsible for surveillance systems, given the current lack of implementation and development. Increased resources, technically trained personnel and political, policy- related support are the primary objectives for improving HIV/AIDS surveillance in Latin America. 31 32 INTRODUCTION In Latin America, epidemiological surveillance of HIV/AIDS at the national level began at the same time as the appearance of the first AIDS cases - in the first half of the 1980s. As in the rest of the world, the first surveillance systems recorded cases of AIDS and were later expanded to include HIV. To various degrees, sentinel surveillance of high- risk behavior was incorporated during the 1990s. Epidemiological surveillance of HIV/AIDS is crucial to the control of the epidemic. Through surveillance, it is possible to measure the frequency and distribution of HIV/AIDS within and among populations, analyze its evolution and evaluate the effectiveness of prevention efforts. HIV/AIDS surveillance systems are imperative since HIV/AIDS is an infectious disease with serious public health implications; it is distributed heterogeneously throughout populations, but is also preventable and linked to behavior patterns. As in other regions of the world, the HIV/AIDS epidemic in Latin America has a different history, profile and pattern within and among various countries130. Therefore, high quality information and understanding the trends and the populations most affected are needed for the preparation and focus of prevention and treatment activities. This chapter assesses HIV/AIDS epidemiological surveillance systems in Latin America, including their capacity to collect, analyze, interpret and disseminate the information necessary to control the epidemic. Information was obtained through self-administered, semi-structured questionnaires aimed at the resources, characteristics and activities of national surveillance systems, as well as HIV/AIDS-specific surveillance. The questionnaires were given to those managing national HIV/AIDS surveillance systems in seventeen Latin American countries to the National AIDS Program or to the departments of epidemiology, depending on the countries. The response rate was 100 percent, but the level of completion of the questionnaires was variable, making it impossible to carry out a homogenous analysis of Latin America or establish parameters for country-to-region or country-to-country comparisons. However, wherever possible, this chapter presents some potential sub-regional (Central America, Andean Region, Southern Cone) areas of joint analysis. The information collected is presented in sections addressing resources, activities, policies and perception of needs and new directions. 33 RESOURCES FOR HIV/AIDS Table 1. HIV/AIDS surveillance personnel SURVEILLANCE in Latin America, 2000 Number of Surveillance Allocation of resources and personnel for Country fulltime personnel with surveillance has steadily increased since Sub-region HIV/AIDS HIV/AIDS surveillance training by the 1980s. According to the respondents of personnel sub-region (%) the World Bank survey, in 2000, the average Mexico 5 100 number of fulltime HIV/AIDS surveillance personnel per country was 2.5 in each Central America 2 83.3 Guatemala 0 country except Paraguay, Panama, El Salvador 0 Guatemala and El Salvador (see Table 1). Honduras no data Overall, one out of every four countries has Nicaragua 20* fulltime HIV/AIDS surveillance personnel. Costa Rica 2 Panama 0 With the exception of Guatemala, Paraguay, Colombia, Ecuador, Peru and Bolivia, all Brazil 15 no data countries require that surveillance Andean Region 9 20 professionals receive specific training in Venezuela no data HIV/AIDS surveillance. Colombia 1 Ecuador 3 Peru 2 HIV/AIDS INFORMATION SYSTEMS Bolivia 3 AND REPORTING Southern Cone 4 75 Argentina 1 Chile 1 In Latin America, cases of HIV and AIDS Uruguay 2 are reported extensively. In every country, Paraguay 0 it is mandatory to report AIDS cases, and in 94% of countries HIV cases must also be Latin America 35 62.5 reported. Source: World Bank survey, 2001 *The data supplied by Nicaragua were not used in calculating the overall values. Case Definition The definition of a case of AIDS varies throughout the Region, both between and within countries. The most frequently used definitions (in 47% of countries) are the 1993 definition from the Centers for Disease Control (CDC)131, the European version of this definition (also 1993)132,133, or a combination of these definitions (CDC 1987134, Caracas135, etc.). About 33% of countries use highly sensitive definitions based on complex clinical criteria (i.e. Caracas and WHO136). Use of the 1993 CDC definition requires a developed health infrastructure and sophisticated methods for suitable and appropriate diagnosis. Possibly for this reason, many countries use this definition in combination with others found to be more adaptable and appropriate for local health resources. The coexistence of different case definitions can generate problems in terms of sensitivity (proportion of cases diagnosed and captured in the system) and predictive value (proportion of cases reported that actually meet the criteria to be counted as a case)137. HIV case definitions are often based on serologic 34 detection of HIV antibodies, yet the definitions used in many cases are imprecise, non- specific and barely conclusive from a clinical point of view (see Annex 1). Table 2. AIDS case definitions in Latin America, 2000 CDC93 (includes Country European CDC93 + CDC87 Caracas Other Sub-Region version) + Caracas Mexico 0 0 0 1 Central America 1 2 1 1 Guatemala no data no data no data no data El Salvador ü Honduras WHO Nicaragua ü Costa Rica ü Panama ü Brazil CDC87 + Caracas + CDC87 modified Andean Region 1 1 4 0 Venezuela ü Colombia ü ü Ecuador ü Peru ü Bolivia ü Southern Cone 1 1 0 1 Argentina CDC87 + WHO Chile ü Uruguay ü Paraguay no data no data no data no data Latin America 3 4 5 4 Source: World Bank survey, 2001 Case reporting According to the World Bank survey data, physicians are most often responsible for reporting HIV/AIDS cases to health authorities although in some countries other professionals or entities are involved. For example, non-governmental organizations (NGOs) in El Salvador also report cases, and in Honduras, nurses, social workers and psychologists also report cases. In Bolivia, diagnostic labs report HIV/AIDS cases, which limits the clinical and socio-demographic information documented about patients. In Panama, the responsibility for notification is delegated to individuals such as physicians, managers of commercial sex workers (CSWs), personnel responsible for 35 medical patients, laboratory workers or any citizen with knowledge or "suspicion" of HIV/AIDS infection or illness. In every country cases are reported to the National Ministry of Health (MoH), either directly or through regional or state offices. Chart 1. Professionals responsible for reporting HIV and AIDS cases, 2000 AIDS HIV 100% 100% 40% 33% 20% 40% 80% 80% 100% 60% 60% 100% 50% 60% labs 100% 67% 100% 100% + 60% 20% 40% 17% 40% 40% 20% 33% 20% Physicians Physicians Phys. Physicians Physicians Physicians Physicians Phys. 20% Physicians Physicians 0% 0% Mexico Central Brazil Andean Southern Mexico Central Brazil Andean Southern America Region Cone America Region Cone Source: World Bank survey, 2001 Active vs. Passive Surveillance Active surveillance implies that surveillance services search for cases in relevant settings, whereas in passive surveillance these services receive and process data reported from elsewhere. Active surveillance has the potential for more comprehensive recording of HIV/AIDS cases, yet it is very costly since teams of professionals must travel to sites for data collection. In areas of high incidence of HIV/AIDS, active surveillance generates more sensitive surveillance data138. As shown in Table 3, active surveillance is used in only seven countries, and the level of use varies. Table 3. Countries with active HIV/AIDS surveillance systems, 2000 According to the data collected, Costa Rica and Peru are the countries with the most - Mexico extensive active surveillance of HIV/AIDS - El Salvador cases. The number of countries with active - Costa Rica - Peru surveillance may actually be less than is - Brazil presented here, since in some instances there - Venezuela was confusion between sentinel surveillance - Uruguay and active surveillance. Source: World Bank survey 2001 36 Reporting forms Standardized case reports help health professionals keep track of socio-demographic, epidemiological and clinical information needed to characterize cases. In most countries, there are standardized forms for HIV/AIDS case notification, although standard forms are used more for AIDS case reporting than for HIV (see Annex 2). Case Identification Table 4. Case identifiers for HIV and AIDS, 2000 The purpose of case identification is to Country eliminate or reduce duplication of Sub-Region HIV/AIDS case identifiers HIV/AIDS cases reported. A common Mexico Name method for identifying cases is through very detailed personal indicators (i.e. Central Name=50% Code=50% name, date of birth, personal America identification numbers/codes, etc.), as Guatemala Code well as other identifiers that have less El Salvador Name discriminatory power139,140,141. Honduras Name Nicaragua Code In the majority of countries (9 out of Costa Rica Code 17) duplication is controlled through Panama Name case identification by first and last name. In six countries, the most Brazil Name widely used code for identification consists of the person's initials (first Andean Region Name=60% Code=40% and last name) and date of birth. In Venezuela Name Colombia, personal identification Colombia Personal identification number Ecuador Name numbers are used as case identifiers, Peru Code and initials are most frequently used in Bolivia Name the Southern Cone and Central America (Table 4). Southern Cone Name=25% Code=75% Argentina Code Like all surveillance systems, those Chile Code designed for HIV/AIDS require a case Uruguay Name identification mechanism to prevent Paraguay Code reporting duplication, however, the Latin America Name=53% Code=47% question of patient confidentiality may be raised. Information systems Source: World Bank survey, 2001 containing personal data (names, codes, or others) may ultimately be sensitive enough to identify specific people, yet in order to carry out public health and assistance activities, health administrators often require access to this personal information. This issue clearly points to the need for secure, well-protected information systems that guarantee patients' rights to confidentiality and privacy. Each country interviewed confirmed that they have laws protecting access to such information. In some countries, these laws directly relate to HIV/AIDS cases, while in 37 others they are incorporated in rules for public health activities and standards for professional conduct. In a few countries these laws loosely exist in the Constitution or legislation, which are not specifically health-related (see Annex 3). In reviewing the existing legislation, it is interesting to note the scarcity of laws regarding ownership of surveillance data, information security or citizens' rights. Under-reporting and delays in notification Both under-reporting (i.e. cases diagnosed but not reported to the national or local registries) and delays in notification compromise the quality and validity of information available. It is possible to make mathematical predictions to compensate for delays in notification, yet under-reporting is still a serious limiting factor that results in under- estimation of the true magnitude of the HIV/AIDS epidemic. The time period between diagnosis of a case and reporting to national or local registries varies. According to respondents, in most countries, the turnaround time is about three to six months, except in Chile and Panama where over six months is the norm and Mexico and Colombia, where the longest delays were found, a period of over a year lapses between diagnosis and appearance of the case in the surveillance system. (Annex 4). Under-reporting in Latin America is high, with an average of 54.8% of HIV cases and 43.5% of AIDS cases not reported according to results from this survey. The lowest levels of under-reporting are found in Brazil, Uruguay, Chile and Argentina, and the highest levels are in Colombia, Guatemala and Honduras. Regionally, Central America and the Andean Region have the Box 1. Professionals/organizations receiving epidemiological information highest levels of on HIV/AIDS,2000 under-reporting. Not AIDS HIV/AIDS information Info. not Information distributed every country Adminis- Guatemala, El Salvador, Honduras, Nicaragua, estimates the number trators Panama, Mexico, Peru, Argentina, Brazil, Venezuela Chile, Colombia, Ecuador, Uruguay of cases Physicians Guatemala, El Salvador, Honduras, Mexico, Peru, Paraguay underreported (i.e. Panama, Argentina, Brazil, Chile, Colombia, Venezuela Ecuador, Uruguay Ecuador, Peru, Nurses Guatemala, El Salvador, Honduras, Mexico, Paraguay Venezuela and Panama Brazil, Chile, Colombia Universities Guatemala, Honduras, Nicaragua, Peru, El Salvador, Paraguay), and HIV Panama Argentina, Brazil, Chile, Colombia Paraguay under-reporting NGOs Guatemala, El Salvador, Honduras, Nicaragua, receives less attention Panama, Mexico, Peru, Argentina, Brazil, Venezuela Chile, Colombia, Ecuador, Uruguay than that of AIDS. Researchers Guatemala, Honduras, Nicaragua, Mexico, El Salvador, Based on the data Panama Argentina, Brazil, Chile, Colombia, Paraguay Bolivia, Ecuador collected for this Press/media Guatemala, El Salvador, Honduras, Nicaragua, study, the epidemic Panama, Mexico, Argentina, Brazil, Chile, Venezuela, Bolivia, Ecuador, Uruguay, Colombia in Latin America Paraguay Source: World Bank survey, 2001 38 probably includes about 30% more cases of AIDS and 40% more cases of HIV than is currently estimated. All countries in Latin America distribute periodic bulletins about the distribution and evolution of the HIV/AIDS epidemic. Information about AIDS is more systematized than that of HIV. Bulletins are usually disseminated quarterly or biannually, although Colombia issues more frequent bulletins on the spread of HIV/AIDS and Brazil does the same for HIV. Most countries distribute information about both HIV and AIDS, but there are some that only provide information on AIDS (Guatemala, Paraguay and Panama), and in Costa Rica based on the questionnaire response, it seems that this epidemiological information is not disseminated at all. In most countries, HIV/ AIDS data are distributed to the appropriate health administrations, health care professionals, universities, NGOs, researchers and the general media (Box 1). Only the respondents from Paraguay and El Salvador said that no information regarding HIV/AIDS is provided to professionals and/or researchers. In general, countries feel that wide distribution is useful since health care workers are better informed of the profile of the epidemic, there is greater collaboration among health care authorities and more interventions are planned as a result of the information contained in the bulletins and reports. The majority of countries maintain HIV- and AIDS-related data at the national level (Ministries of Health), while less information on HIV and AIDS is available at the local/regional level. This gap is especially notable in the Southern Cone (see Annex 5). Most countries feel that distribution of HIV/AIDS epidemiological information to the national government is very valuable for decision-making, most notably regarding the design, implementation and expansion of prevention programs, and to increase the resources allocated to fighting the epidemic. Evaluation of surveillance systems According to those surveyed, sixty-five percent of the countries had carried out evaluations of their epidemiological surveillance systems, as well as the registries of AIDS and HIV cases. Responses indicated that in some countries these evaluations are carried out periodically (Honduras, Nicaragua, Mexico, Peru, Bolivia and Brazil), while in other countries these evaluations have not been carried out at all (El Salvador, Costa Rica, Panama, Venezuela, Colombia and Paraguay). In the process of administering the surveys and collecting data, there appears to have been some confusion between actual evaluations of the surveillance systems and reports on the balance and trends of the HIV epidemic. The respondents indicated that the results of the evaluations carried out systematically in some countries were not always well-supported, and in some cases the evaluations did not correspond to true evaluation studies, but rather to reports on the status and evolution of the epidemic in the country. 39 SENTINELSURVEILLANCE OF HIV/AIDS Sentinel surveillance systems for HIV/AIDS provide more detailed information on the scope of the epidemic and its evolution in various sub-populations. For this reason, sentinel surveillance is an indispensable tool in design, implementation and evaluation of prevention interventions targeted to high-risk or variable-risk populations142,143,144. Most of the countries surveyed (14 out of 17) have structured systems for sentinel surveillance of HIV/AIDS integrated into the overall HIV/AIDS information system; Venezuela, Costa Rica and Panama are the exceptions. The populations prioritized and targeted by sentinel surveillance (by order of frequency) are CSWs, pregnant women, MSM, and patients with STIs. Although structured systems exist in most countries, only Argentina, Ecuador, Mexico, Brazil and Uruguay currently have information on the priority, high- risk populations. The most logical explanation for this gap is that many of the other countries only recently implemented sentinel surveillance, so information should be expected in the near future. In most countries, HIV/AIDS prevalence is estimated by collecting the results of voluntary tests in various testing/diagnosis centers. Unlinked anonymous testing is commonly used for blood collected for diagnostic purposes. This study found that despite the fact that sentinel surveillance systems are widespread in Latin America, consistent data are lacking. However, most of the estimates of HIV/AIDS prevalence are based on results of studies carried out at various points in time, in different areas, and by different institutions. These often disparate estimates generated by sentinel surveillance of HIV prevalence are shown in detail in Annex 6. High quality information on HIV/AIDS prevalence in Latin America is hard to come by and misleading or contradictory. This study found that there are wide differences between estimates available for the countries, which could be an effect of the various methods or procedures used by the country and international organizations (UNAIDS, PAHO, WHO)145,146, to produce them. Overall, it can be said that there is a high prevalence of HIV in most high-risk Latin American populations. The highest rates among CSWs are in Honduras (10% of CSWs) while much lower rates are found in Peru (1.6%), Argentina (1.9%) and Paraguay (less than 2%). The prevalence among transvestites in Uruguay (21%) is alarming. There is very little information on STI patients in Latin America. This is a major concern, considering their high prevalence in all countries and the fact that STI infections are a key risk factor for contracting HIV. High prevalence rates are found in Peru (7%) and Argentina (4.16%), while lower rates are found in Colombia (<2 percent) and Bolivia (0.03%). There are no data available from Central America although a multicenter study is currently projected by different organizations and information will be available soon. Prisoners show high prevalence rates in Central America (Honduras and Panama) and the Southern Cone (Argentina and Uruguay), possibly due to high numbers of IDUs in prison. Although they are considered one of the highest risk groups for transmission, there are very few sentinel studies on IDUs in prisons. Estimates of prevalence within 40 IDU populations in Argentina (45.87%) and Paraguay (15%) demonstrate the high-risk nature of injecting drug use and the urgent need for monitoring. Men who have sex with men (MSM) are one of the least-studied populations in Latin America, despite the fact that in most countries they represent the majority of AIDS cases and are considered a priority group for HIV sentinel surveillance. Honduras has data available on this population, yet even in this country the data are questionable (i.e. the estimate of a 8% prevalence rate among MSM in Honduras could be too low). In Colombia, HIV prevalence among MSM is estimated at 18% (1999-2000 data). These high-risk populations act as a reservoir for the epidemic and are key players in the spread of infection, but have not yet been the focus of systematic, periodic studies.147 Due to the scarcity of data the analysis of the current situation of the epidemic and its geographical and overtime trends becomes difficult. Subsequently, development of proper interventions for the country or from a regional perspective becomes a difficult task. Sentinel studies of groups with variable risk (truck drivers, hospital populations, etc.) and others with about the same risk as the general population (employees, pregnant women, etc.) are surprisingly common in Latin America. In some countries, studies of variable risk populations are more numerous and extensive than those of high-risk populations, in which monitoring infection patterns could have a greater impact on prevention and control. Since variable risk populations have relatively low prevalence rates, the studies designed for them are often larger in scope and more costly. The highest prevalence rates among variable risk groups are found in Honduras (1.1% in truck drivers, 8.4% in garifunas and 1.4% in pregnant women). Prevalence rates among pregnant women range from 0.05% in Ecuador to <1 percent in Colombia and Paraguay. The prevalence of 3.23% among army volunteers in Argentina is notable, and is possibly the result of a high level injecting drug use in this population. In some countries, blood donors have greater prevalence rates than the general population. For instance, in Uruguay, prevalence is 0.23% in the employed population and 0.6% among blood donors. According to the survey results, most countries (11 out of 17) have estimates of the number of people living with HIV, although many do not report the sources or publish the methods used. Some countries use UNAIDS/WHO/PAHO estimates, while others obtain estimates through sentinel studies that are not necessarily representative of the general population, or calculations with unclear scientific validity. None of the estimates are derived from the most common methods for estimating prevalence148,149. In turn, estimates of people living with HIV range from 0.22/1,000 in Venezuela to 0.02/1,000 in Bolivia. According to the data presented, prevalence in Honduras is 0.38/1,000 while in Panama it is 8.2/1,000 ­ these estimates are not coherent with the expected dimensions of the epidemic in each country, or with estimates from international organizations150 (see Annex 7). These estimates and those from sentinel surveillance systems are not comparable with epidemiological data supplied by regional authorities and studies. 41 Therefore, we are confronted with a case in which Venezuela would be the most affected country, surpassing Brazil and Honduras. Behavior Surveillance The study survey saw that seven of the seventeen countries have conducted KAP (Knowledge Attitude and Practice) surveys in last years. The populations studied most were the general population and young people (in Peru, Brazil, Paraguay, Uruguay and Chile), while high-risk populations were only studied in Uruguay (transvestites and IDUs), Brazil (CSWs, IDUs and people of low socio-economic status), Peru (MSM) and Chile (STI patients). Currently, Mexico is the only country collecting information on adolescent high-risk behaviors through sentinel sites. The most recent high-risk behavior studies are found in Peru (Endes 2000 and CER 1999), Brazil (various populations in 2000-2001) and Uruguay (transvestites). Respondents from eleven countries stated that they have surveillance system plans for high-risk, HIV-related behaviors; the most common target populations are MSM and female CSWs. In Mexico, Argentina, Brazil and Colombia IDUs and male CSWs are also targeted**. In Honduras, there is no plan for behavior surveillance although some studies of MSM and female CSWs have been carried out. El Salvador, Panama and Costa Rica have no information on prevalence of high-risk behaviors, or a plan for behavior surveillance. Instead, many have plans for future studies, or are focusing efforts on ensuring continuity among studies carried out in past years. Among these countries, only three (Brazil, Argentina and Paraguay) have concrete plans to identify behavior patterns in high-risk groups (i.e. MSM, CSWs, prisoners and IDUs). Participation of other institutions or researchers in these studies is rare. Universities are sometimes involved, but often these studies are carried out exclusively by ministries of health. HIV TESTING ANDDIAGNOSISPOLICIES Policies for promoting HIV testing, as well as facilitating availability and access to the test are basic conditions for any prevention, diagnosis or surveillance plans. Epidemiologists in twelve out of the seventeen countries reported that HIV testing is free, yet this information is not consistent with reports from NGOs and physicians in these countries also included in this study. For instance, in Peru, Colombia, Ecuador, Panama and Guatemala the test is supposed to be free, but people must pay for the diagnosis (often carried out in a separate laboratory) according to the same source. **Nicaragua's system also covers male CSWs. 42 Availability of services for HIV diagnosis According to the data collected from this study, with the exception of Bolivia and Guatemala, local laboratories are used to diagnose HIV, although all tests confirmed with Western Blot (WB), Immuno-Florescence Assay (IFA), etc. are analyzed centrally. Seven countries confirm positive tests in national laboratories (El Salvador, Honduras, Nicaragua, Peru, Chile, Paraguay and Mexico). Information on availability and coverage of national laboratories is scarce and occasionally found to be inconsistent. Estimates show variations in the number of laboratories per 100,000 inhabitants, from 0.001 in Panama to 7.5 in Argentina, averaging 1.13 per 100,000 inhabitants (Table 5). Availability of Table 5. Availability of laboratories and centers for anonymous anonymous diagnosis diagnosis, 2000 centers for high-risk Number of populations is crucial for Country Number of HIV diagnostic anonymous prevention, diagnosis and Sub-Region laboratories/100,000 diagnostic for counseling of HIV.151 inhabitants centers for HIV According to the study Mexico 0.31 22 findings, eight countries (Brazil, Mexico, Costa Central America Rica, Nicaragua, Guatemala no data no data Guatemala, Argentina, El Salvador 0.49 no data Chile and Bolivia) have Honduras 0.55 no data such centers. Nicaragua 0.49 17 Costa Rica no data 1 Surprisingly, Honduras, Panama 0.01 no data the country most affected by the epidemic, does not Brazil 0.30 208 have anonymous HIV diagnosis centers. Andean Region Venezuela 0.11 no data Colombia no data no data Cost of HIV testing and Ecuador 0.47 no data diagnosis Peru no data no data Bolivia 0.03 3 The information obtained from the participants in Southern Cone the study on cost of HIV Argentina 7.51 14 testing made not possible Chile no data 3 to estimate an average Uruguay 2.0 no data overall cost for the HIV Paraguay 0.40 no data test since data available Source: World Bank survey, 2001 from public and private centers are inconsistent and vary greatly. A significant difference was observed between the costs of testing in the public sector versus those in the private sector. The cost for HIV testing in Latin America range from 0 to 7 US$ in public centers and from 4 to 43 22.85 US$ in private centers (Annex 8). Median cost were 8 for public and 12,5 US$ for private centers. Frequency of HIV Testing Data collected through this study regarding the frequency of HIV testing are scarce and disparate, ranging from 77 tests per 1,000 inhabitants in Uruguay to 2.32 per 1,000 in Mexico. Frequency of HIV testing has risen since 1996 in almost all countries, and based on the information available it seems that it continues to rise. For example, the number of HIV tests carried out per 1,000 people in Venezuela has doubled from 1996 to 2000, from 4.13 to 8.26, and has increased dramatically in Argentina and Chile from 0.81/1,000 and 0.12/1,000, to 12.08/1,000 and 15.98/1,000, respectively (between 1996 and 2000). Uruguay is the country with the most frequent HIV testing, with an average of 77/1,000 people tested. BLOOD SUPPLY SAFETY Policies for preventing Chart 2. Percentage of Blood Screened for HIV, 2000 HIV transmission through medical 100% procedures requiring 90% 80% blood or blood 70% --100%-- --100%-- -100%- 100% 100% products are the 60% responsibility of each 50% 95% 95% 95% 98% country's national 40% 30% 40% health system. To this 20% end, universal screening of donated Brazil Peru Bolivia Chile blood as well as MexicoSalvadorHondurasNicaraguaPanama El VenezuelaColombiaEcuador Argentina Paraguay Uruguay voluntary, altruistic donation must be Source: World Bank survey, 2001 universally accepted norms152. According to Chart 3. HIV Prevalence Among Blood Donors* the World Bank survey and published data, ten 0.60% 0.60% out of the seventeen 0.50% 0.41% countries reported 0.40% screening 100% of the 0.30% 0.27%0.26% blood supply (there were 0.20% 0.13% 0.17% 0.13% no data from 2 0.10% 0.05%0.09% 0.01% 0.03% countries). The Andean 0.00% Region shows the lowest screening of donated Brazil Peru Chile blood, primarily due to ElSalvadorNicaragua Panama ColombiaEcuador Argentina UruguayParaguay the very low rates of *Data from 2000 for El Salvador, Nicaragua, Colombia, Ecuador and Argentina; from 1999 for Panama, Uruguay and Paraguay; from 1998 for Chile Source: World Bank survey, 2001 44 screening in Bolivia. According to the data collected, coverage of blood screening is comparable between Central America and the Southern Cone (Chart 3). HIV prevalence among blood donors in Latin America is very high (0.19%), according to this survey, with the highest prevalence found in Uruguay. In some countries, these high rates among blood donors could be related to policies for blood donation that provide compensation, HIV testing or any other kind of bad auto-exclusion system. Study findings indicate that in some cases, HIV prevalence rates among blood donors are higher than estimates for the Table 6. Blood donation policies, 2000 general population. Only Honduras, Argentina and Brazil Voluntary, Replacement Voluntary, altruistic have policies allowing only altruistic donors + other voluntary, altruistic blood donations. In Chile and Bolivia, Honduras Bolivia Mexico blood donation is based on Brazil Chile Guatemala Argentina El Salvador replacement donors (family Nicaragua members' donations for Costa Rica hospitalized patients) and in the Panama other countries surveyed, altruistic Venezuela donation coincides with other Colombia policies. Ecuador Peru Uruguay Paraguay Source: World Bank survey, 2001 WHAT DO THE COUNTRIES IDENTIFY AS BASIC NEEDS FOR IMPROVING EPIDEMIOLOGICAL SURVEILLANCE OF HIV/AIDS? All the respondents made reference to the need for increased resources for planning and consolidating the existing systems. For many participants, the need for training and new technicians was a common theme. Regarding the information systems currently in place, there is a need to improve the systems for reporting HIV/AIDS cases especially in terms of ensuring their validity and comprehensiveness. Under-reporting is one of the most common problems. Regarding sentinel surveillance, most of the problems relate to the need for systematizing information systems and incorporating new sub-populations. According to some of the interviewed, the "second generation surveillance" is troublesome to those responsible for the surveillance systems, given the current lack of implementation and development in the Region. In summary, the study concluded that increased resources, technically trained personnel and political policy-related support are the primary objectives for improving HIV/AIDS surveillance in Latin America. 45 CONCLUSIONS: STRENGTHS AND CHALLENGES Strengths v All countries developed epidemiological surveillance systems at the start of the epidemic. v Allocationofresourcesandpersonnelhassteadilyincreasedsincethe1980s. v Surveillancesystemswithnationalcoverage. v Information collection coordinated with different actors (i.e. epidemiology offices, NGOs, universities, the military) v Surveillance systems based on AIDS case notification are found to be well- established through years of implementation. v Humanresourcesallocatedtoepidemiologicalsurveillancehavebeenextensive at the national level. v ReportingofAIDScasesismandatory. v NationalstandardizedformsforHIV/AIDScasenotification. v Systemforidentificationofduplicates.. v Most of the countries surveyed have structured schemes for sentinel surveillance of HIV integrated into the overall HIV information system. v SomeinformationonbehaviorisavailablethroughKAPstudies. v Therearebaselinestudiesonpopulationswithhigh-riskbehaviors. v Surveillance plans developed for high-risk populations and behavior (ongoing or programmed). v Almostalldonatedbloodisscreened, close to 100% in most countries. v HIVtestingavailableandfreeofchargeoratlowcostinmanycountries. v Extensiveandwidedistributionofepidemiologicaldata. v Evaluationofthesurveillancesystemcarriedoutinmostcountries. Challenges v Persistent high levels of under-reporting and delays in reporting. There is an urgent need to revise the procedures and circuits through which cases are reported. v Gapsinhumanresources(i.e.techniciansandtraining)atthelocallevel. v Case definition of HIV and AIDS varies greatly and probably warrants evaluation of the practicality and usefulness of some definitions in terms of availability of diagnostic tools and certain health centers' capacity. On the other hand, it is possible that health centers with various levels of infrastructure development would assign different sensitivity and predictive values to the same definition. This, in turn, would affect the validity and comprehensiveness of the records. 46 v HIV information systems are fed by a limited infrastructure of public laboratories, and a diagnostic testing system that requires most populations to pay for their test and diagnosis. v In some countries the confidentiality standards for HIV/AIDS reporting should be revised, given the human rights and discrimination implications. Restricting access to case identifying information to health care professionals who carry out the diagnosis and care of patients falls within the norms for professional conduct and should be considered a common goal. v Methods for active surveillance are scarcely developed, especially in the countries most affected by the epidemic. Active surveillance could help reduce under-reporting. v Sentinel surveillance of HIV is neither systematized nor sufficiently developed. Most data are generated by periodic random studies that are not projected over time and lack evaluations of interventions or analysis of the epidemic, leaving authorities without the information necessary to make decisions. v There are very few sentinel surveillance studies of the highest risk groups (MSM, CSWs, IDUs) and more attention directed to the general population which is more expensive to survey (due to the size of the population) and ultimately generates less prevention activities for the populations needing them most. v Results of studies are poorly disseminated in scientific circles and are notably scarce at the international level. v Little behavior surveillance takes place. Information is usually produced by periodic random studies, which are not always shared with HIV/AIDS programs. In some countries there are already plans for behavior surveillance and results may be expected in the next few years. v In-depth evaluation of surveillance systems is needed. Oftentimes the supporting documents include descriptions of the process, or reports on the status of the epidemic rather than a focus on the surveillance system. v Study protocols vary widely, which makes it difficult to analyze the scope and trends of the epidemic. Furthermore, it leads to discrepancies in the results of different national or international studies. v HIV information systems are fed by a limited infrastructure of public laboratories, and a diagnostic testing system that requires most populations to pay for the test and diagnosis. v Lack of policies promoting HIV testing. This is a crucial element for increasing testing and diagnosis among high-risk populations, increasing counseling and prevention, and monitoring the epidemic. Testing is not always free or available in public centers, and sometimes there is limited access to anonymous diagnosis centers. Although these factors help regulate demand for the test, they have the negative consequence of reducing accessibility for those who need it. v Blood safety policies are not as widespread as needed, although most countries screen at least 95% of blood. HIV prevalence among blood donors is still very 47 high while policies for exclusive voluntary and altruistic blood donation exist in only a few countries. Review and revision of blood safety policies would do much to improve these systems. v Lack of resources needed for expanding epidemiological surveillance systems, training technicians, providing the necessary infrastructure for greater accessibility to testing and diagnosis, better development of sentinel surveillance plans and registries and systematic, secure treatment of epidemiological information. v Political commitment is needed to strengthen and improve epidemiological surveillance. 48 ANNEX 2.1 HIV/AIDS CASE DEFINITIONS HIV Case Definitions by Country, 2000 Country Definition of HIV case Mexico Person infected with HIV or diagnosis of AIDS who can infect others Guatemala no data El Salvador Double + test w/ different types of HIV reactive tests and + Western Blot (WB) Honduras All patients serologically positive for HIV with at least one major symptom characteristic of, or associated with AIDS Nicaragua Reactive ELISA, confirmed w/ WB, not necessarily w/ any symptoms of AIDS Costa Rica ELISA and WB Panama Positive, confirmed HIV test Brazil 2 reactive ELISA from different sources and 1 confirming test (WB, IFA) Venezuela no data Ecuador Adolescents and adults: 2 reactive ELISA confirmed w/ IFA or WB, or any test detecting HIV antibodies, HIV antigen or genetic evidence. Children <18 month: HIV + results in 2 tests (HIV culture, PCR antigen 24) Peru no data Colombia 2 reactive ELISA tests, 1 WB or IFA Bolivia no data Argentina CDC 1993 Chile CDC 1987, Diagnostic algorithm established in Chile Paraguay Persons older than 15 years w/ positive serologic test (ELISA, confirmed by WB) w/out signs or symptoms of AIDS. For children 18 months-15 years is same as for adult. Younger children: Polimerase Chain Reaction (PCR) (currently not in use) Uruguay no data Source: World Bank survey, 2001 For CDC case definition, see: http://www.cdc.gov/epo/dphsi/casedef/acquired_immunodeficiency_syndrome_current.htm For WHO case definition, see: http://www.who.int/emc-documents/surveillance/docs/whocdscsrisr992.html/01Aids.htm For European case definition, see: http://ceses.org For Brazil/Caracas AIDS case definition, see: http://lac-hiv-epinet.org 49 50 ANNEX 2.2 COUNTRIES/SUB-REGIONS WITH REPORTING FORMS FOR CASE NOTIFICATION*, 2000 Country AIDS case reporting Sub-Region form HIV case reporting form Mexico ü ü Central America 6 4 Guatemala ü El Salvador ü ü Honduras ü ü Nicaragua ü ü Costa Rica ü Panama ü ü Brazil ü ü Andean Region 5 1 Venezuela ü Colombia ü Ecuador ü Peru ü ü Bolivia ü Southern Cone 4 1 Argentina ü Chile ü Uruguay ü Paraguay ü ü Latin America 17 (100.0%) 8 (41.1%) Source: World Bank survey, 2001 * Most countries have the same reporting form to collect data from HIV and AIDS cases 51 52 ANNEX 2.3 LEGISLATION REGARDING CONFIDENTIALITY ISSUES* Guatemala: Decree 27-2000 El Salvador: Professional ethics law Honduras: Special Law for HIV/AIDS, articles 58, 60 and 61 Nicaragua: Non-specific legislation Costa Rica: General AIDS Law Panama: Law 3 of 5 of January 2000 Mexico: NOM 10 and NOM 17 Peru: Information protection law: Anti-AIDS Law 26626 Venezuela: Resolution for respecting rights to confidentiality Colombia: Decree 1543 of June 1997 Argentina: Law 23.798/90 ­ Article 2(a) Paraguay: Law #102/91 (in revision) Ecuador: Statistics Law Uruguay: No specific law; rights recognized in the Constitution. Personal information protected by the law of the Ministry of Public Health. Chile: Decree for obligatory reporting of infectious diseases (#712, article 4 of Nov. 1999) Brazil: Law for information protection; non-specific Chile: Law for information protection; non-specific Bolivia: No law for information protection * Data has been reproduced like was written on the questionnaire Source: World Bank survey, 2001 53 54 ANNEX 2.4 UNDER-REPORTING AND DELAYS IN NOTIFICATION, 2000 Country HIV under- AIDS under- Sub-Region Delay in HIV reporting Delay in AIDS reporting reporting reporting <6 mo. 6 mo.- >1 yr. N/A <6 mo. 6 mo.- >1 yr. 1yr. 1yr. Mexico ü ü 91.2%* 18.5%* Central America 50.0% 17.0% 0.0% 33.0% 83.0% 17.0% 0.0% 43.3% 33.2% Guatemala ü ü n/a 50.0% El Salvador ü ü 40.0% 40.0% Honduras ü ü n/a 47.0% Nicaragua ü ü 60.0% n/a Costa Rica ü ü 30.0% 30.0% Panama ü ü n/a 32.0% Brazil ü ü n/a 7.0% Andean Region 80.0% 20.0% 80.0% 20.0% 70.0% 55.0% Venezuela ü ü n/a n/a Colombia ü ü 80.0% 80.0% Ecuador ü ü n/a n/a Peru ü ü n/a n/a Bolivia ü ü 60.0% 30.0% Southern Cone 50.0% 50.0% 75.0% 25.0% 15.0% 14.0% Argentina ü ü n/a 20.0% Chile ü ü n/a 14.0% Uruguay ü ü 15.0% 10.0% Paraguay ü ü n/a n/a Latin America 59.0% 6.0% 12.0% 23.0% 76.0% 12.0% 12.0% 54.8% 43.6% n/a= no answer * Last estimates from CENSIDA (Mexico) Source: World Bank survey, 2001 55 56 ANNEX 2.5 SYSTEMATIZATION OF RECORDS OF HIV AND AIDS, 2000 Country Systematization of HIV Systematization of AIDS Data Sub-Region Data National MoH Local National MoH Local Mexico ü ü ü ü Central America 5 (83%) 4 (67%) 6 (100%) 4 (67%) Guatemala no data ü El Salvador ü ü ü ü Honduras ü ü ü ü Nicaragua ü ü Costa Rica ü ü ü ü Panama ü ü ü ü Brazil ü ü ü ü Andean Region 5 (100%) 3 (60%) 5 (100%) 3 (60%) Venezuela ü ü ü ü Colombia ü ü ü ü Ecuador ü ü Peru ü ü Bolivia ü ü ü ü Southern Cone 4 (100%) 1 (25%) 4 (100%) 1 (25%) Argentina ü ü ü ü Chile ü ü Uruguay ü ü Paraguay ü ü Latin America 16 (94%) 10 (59%) 17 (100%) 10 (59%) Source: World Bank survey, 2001 57 58 ANNEX 2.6 RESULTS OF HIV SENTINEL SURVEILLANCE STUDIES Epidemiological surveillance system data are in Italics for comparison with other different surveys Country Sub-Region Population Method Population size Estimated prevalence Date of start Mexico Hospital Population VT 19,286 0.35 1992 Prisoners (men) VT 5,751 1.4 1985 VT 798 3.1 1991 Pregnant women VT 12,068 0.09 1990 IV Drug Users (IDU) VT 1,816 4.13 1987 CSWs (female) VT 38,347 0.59 1987 CSWs (male) VT 15,784 4.41 1987 Blood donors OT 992,586 0.007 1986 Guatemala no data no data no data no data no data El Salvador no data no data no data no data no data Honduras Pregnant women ANL/VT 3.248 1.4 1998 Prisoners ANL/VT 2.095 6.8 1997 CSWs ANL/VT 699 9.9 1998 Night watchmen ANL/VT 200 0.5 1998 Population Garífuna ANL/VT 310 8.4 1998 MSM ANL/VT 422 8 1998 Truck drivers ANL/VT 458 1.1 1998 Nicaragua CSWs ANL 400 0.02 1998 Blood donors VT 1500 0.07 - TB patients ANL 760 0.52 - STI patients ANL - - 1999 Pregnant women VT 2001 CSWs ANL 2001 Blood donors VT Costa Rica no data no data no data no data no data Panama Pregnant women ANL Newborn´s mothers ANL Prisoners VT 879 5.8 1991 Blood donors OT CSWs OT Brazil STI patients ANL 2.748 4,7 1999 Pregnant women ANL 15.226 0,6 2000 Prisoners ANL CSWs ANL Blood donors OT Venezuela Pregnant women VT 1999 Blood donors Colombia MSM - - 18% 1999 STI patients ANL 4375 < 2 1999 Pregnant women ANL 8690 < 1 1999 General medicine patients ANL 9004 < 1 1999 Ecuador CSWs VT 100 per year 1999 MSM VT 100 per year 1999 Pregnant women VT 5000 0.05 2001 Perú STI patients ANL 7 1997 Pregnant women ANL 0.3 2000 Blood donors OT 0.01 2000 CSWs AL 1.6 1999 Prisoners ANL Pregnant women ANL Bolivia Hospital Population ANL 784 0.02 2000 STI patients ANL 784 0.03 2000 Pregnant women ANL 784 2000 CSWs ANL 784 0.03 2000 Argentina STI patients VT 320 4.16 2000 Pregnant women VT 96011 0.66 2000 Prisoners VT 2017 17.55 2000 IDUs VT 157 45.8 2000 Army volunteers VT 27011 3.23 2000 CSWs 1.9 Chile STI pat ients ANL no data no data no data Pregnant women ANL CSWs VT TB patients VT 59 Country Sub-Region Population Method Population size Estimated prevalence Date of start Pregnant women ANL Uruguay Pregnant women VT 2000 0.23 2000 Prisoners VT 6 1993 CSWs VT 500 0.45 1995 VT 300 0.35 2000 Transvestites VT 200 21 2000 Employed Population ANL 12000 0.23 1996 Pregnant women VT 2000 per year 0.23 1991 Blood donors OT 120000 0.6 1988 Paraguay Pregnant women ANL no data < 1 no data Prisoners VT 1 CSWs VT < 2 Blood donors OT 0.17 IDUs VT 15 Health care workers VT 0 ANL=Unlinked Anonymous testing OT=Obligatory Testing VT=voluntary testing 60 ANNEX 2.7 PEOPLE LIVING WITH HIV as of December 2000 Number of Persons living Number of persons Persons living with Country persons living with living with HIV HIV/100,000 Sub-Region with HIV* HIV/100,000** (UNAIDS***) (UNAIDS***) Mexico 116,000 117.29 150,000 151.67 Central America 29,971 307.21 196,900 525.11 Guatemala 73,000 640.35 El Salvador 3,444 54.66 20,000 317.46 Honduras 2,500 38.46 63,000 969.23 Nicaragua 4,900 96.08 Costa Rica 12,000 300.00 Panama 24,027 828.51 24,000 827.59 Brazil 597,000 350.97 540,000 317.46 Andean Region 634,627 631.46 204,200 74.25 Venezuela 540,000 2,231.40 62,000 256.20 Colombia 18,429 44.36 71,000 167.85 Ecuador 19,000 150.79 Peru 76,000 295.71 48,000 186.77 Bolivia 198 2.38 4,200 50.60 Southern Cone 143,517 208.49 154,000 130.93 Argentina 122,000 329.72 130,000 351.35 Chile 15,017 98.79 15,000 98.68 Uruguay 6,500 196.96 6,000 181.82 Paraguay 3,000 54.55 Latin America 1,514,825 381.13 1,245,100 301.08 Source: *Data given by national respondents **Calculated from data given by national respondents *** Epidemiological Fact Sheets (UNAIDS/WHO/PAHO 2000) 61 62 ANNEX 2.8 COST OF HIV TESTING IN PUBLIC AND PRIVATE HEALTH CENTERS, 2000 Country Cost of HIV test in private centers Cost of HIV test in public centers Sub-Region (US$) (US$) Mexico no data no data Central America Guatemala no data no data El Salvador 22.85 5.71 Honduras 13.00 no data Nicaragua 10.00 no data Costa Rica no data no data Panama 20.00 7.00 Brazil no data free Andean Region Venezuela no data no data Colombia 20.00 0.43 Ecuador 12.00 5.00 Peru 12.00 6.00 Bolivia 4.00 1.00 Southern Cone Argentina 15.00 3.00 Chile 6.50 no data Uruguay 10.00 no data Paraguay 15.00 no data Latin America 13.36 4.02 (average) Source: World Bank survey, 2001 63 64 CHAPTER 3 NATIONAL RESPONSES TO THE EPIDEMIC Summary The main objective of this chapter is to analyze and evaluate the health sector capacity for fighting the HIV/AIDS epidemic in Latin American countries. To this end, selected key respondents have been consulted (governments, physicians and non-governmental organizations). National HIV/AIDS programs have different levels of development within Ministries of Health (MoHs). However, they all have official identity and autonomy. Inter-institutional coordination and agreement is part of the national strategies. HIV/AIDS prevention interventions have been numerous. Almost all the countries surveyed carried out at least one mass media information campaign in 2000 and 57% confirmed that they have school-based HIV/AIDS prevention programs. Most recently, countries have carried out interventions focused on men who have sex with men (MSM), injecting drug users (IDUs) and prisoners. Coverage varies greatly. Programs targeted to commercial sex workers (CSWs) have the longest history. Government responses to the injecting drug use epidemic have been insufficient. Few countries surveyed are implementing harm reduction programs, and coverage is sub-par. Programs implemented by the non-governmental organizations (NGOs) surveyed provide general information and prevention activities, and some provide services and support to people living with HIV/AIDS (PLWHA). The target populations of the NGOs surveyed are prima rily low-risk groups, while prisoners, MSM, CSWs and IDUs receive less attention. Ninety-four percent of NGOs indicated that homosexuality is discouraged in Latin America, highlighting the inherent challenge in providing services for MSM. There is limited availability of HIV testing in public centers, and the high cost imposes barriers to both testing and counseling. Physicians confirm that 67% of HIV+ people did not seek health care until they were in advanced stages of infection, or showed signs and symptoms of AIDS. The rate at which HIV testing is offered to pregnant women is very low, although this varies between countries. Antiretroviral (ARV) therapy is provided to only half the patients who need it, and there is a significant percentage of PLWHA who lack resources to access such treatment. The main problems faced by national HIV/AIDS programs are political indecision on the part of government policymakers and lack of prioritization of the HIV/AIDS epidemic, which results in insufficient resource allocation. Physicians most often associated problems and barriers with insufficient government responses. NGOs attributed problems in controlling the epidemic to government policies, unmet needs in national program activities and cultural and social values. 65 66 INTRODUCTION The challenge of confronting HIV/AIDS in Latin America is a formidable one, requiring nothing less than mobilization of many actors for the response. Over the past few years there have been continuous efforts to mobilize political leadership at the highest levels of national, regional and global governance. A series of high level events, including the United Nations General Assembly Special Session on AIDS (UNGASS) in June 2001, have resulted in HIV/AIDS now being recognized as a fundamental issue directly related to world development and security, and requiring a truly global response. The World Bank has been one of the key advocates for expanding the response to HIV/AIDS and linking it more directly to development. Although this report focuses more on health- sector related issues, it is important to know and recognize the broader context in which the response to the HIV/AIDS in Latin America is taking place. At the country level, much has been achieved over the last few years. Efforts have focused on building political support for an effective national response to the epidemic. There have been important advocacy efforts to encourage national leaders to make a commitment to HIV/AIDS and build stronger multisectoral responses to the epidemic. Countries are developing their national strategic plans (or strategic frameworks) that spell out the national priorities toward HIV/AIDS, and there has been a clear shift in the perception of the epidemic, from a health-only to a broader social and developmental approach. The national strategic plan process also contributed toward stronger and more inclusive national coordination and partnership mechanisms with broad stakeholder representation. Latin America and the Caribbean made access to care, more than anywhere in the world. Access to universal treatment with antiretroviral drugs has changed the response to HIV/AIDS in many countries. Finally, achievements in coordination and regional responses (e.g. the creation of the Horizontal Technical Cooperation Group) as key pillars of inter-country collaboration should be acknowledged. A comprehensive analysis of national responses to the epidemic would require a multisectoral analysis that goes beyond the intent of this study. This document focuses on health sectors' national responses to the epidemic. Subsequently, this chapter covers the analysis and evaluation of the health sector capacity to fight the epidemic in Latin American countries through the eyes of key respondents in the prevention and control of the epidemic. These respondents include governments (through those responsible for national HIV/AIDS prevention and control programs), physicians (professionals working with HIV/AIDS), and non-governmental organizations (NGOs) working in the Region. The different actors were consulted through self-reported semi-structured questionnaires, sent to the countries in advance, and completed face-to-face by trained interviewers for the purpose of collecting more detailed information mainly from NGOs and physicians. 67 HIV/AIDS is an infectious disease transmitted from person to person through risk behaviors related to sexual practice (unprotected sex), individual habits (sharing needles, syringes or drug works), mother-to-child, or unsafe practices/protocols (blood safety policies, clinical protocols, etc.). High-risk sexual behavior is the cause of most HIV cases in Latin America, followed by unsafe practices among IDUs153. This epidemic is a serious public development and health problem with significant repercussions in terms of morbidity and mortality, socio-economic well-being and the community in general. Therefore, its control and prevention requires the participation and coordination of governments, civil society and many other actors joining in a common multisectoral effort154,155,156. NATIONAL AGREEMENTS AND MULTISECTORALCOORDINATION Most national HIV/AIDS prevention and control programs were created in the second half of the 1980s. Through the years, national programs have been shaped and reshaped sometimes for the better, sometimes for the worse. Subsequently, some of the programs have grown, strengthened and had a continuous response, while others have weakened due to political changes, decreased budgets, health sector reform, and others factors. National programs were primarily established under National Ministries of Health (MoH), specifically through the public health or epidemiology offices. Compared to other targeted health programs, National HIV/AIDS programs have a different level of development and influence within MoHs. Specifically, they have more official identity and autonomy and involve more multidisciplinary professionals. Governments have now declared AIDS a problem of the State, solely with the exception of the Andean region. 68 National budgets for HIV/AIDS control and prevention Table 1. Government budgets for HIV/AIDS, 2000 From the information reported in the study survey, Country Total budget Budget per 100 Central American countries Sub-region (US$) inhabitants have the lowest budgets. (US$) There are marked differences Mexico 100,100,000 101.2 in budget per 100 inhabitants, notably Argentina and Central America Mexico spend more than Guatemala 641,025 5.6 US$1.00 per inhabitant, El Salvador no data no data which is significantly more Honduras 451,612 6.9 than other countries (Table Nicaragua 100,000 1.9 1). Costa Rica no data no data Panama no data no data Multisectoral Coordination Brazil no data no data Andean Region Coordination and agreement Venezuela 43,170 0.2 among different Ecuador no data no data governmental institutions and Colombia 250,000 0.6 the civil society is essential Peru 5,150,000 20.0 for effective and efficient Bolivia no data no data control of the epidemic,157 responding to national- and Southern Cone community-level needs. In Argentina 65,904,071 178.1 Latin America, inter- Paraguay no data no data institutional and civil Uruguay 80,000 2.4 coordination and agreement Chile no data no data are part of national strategies. Source: World Bank survey, 2001 Regarding intersectoral coordination, all countries have collaboration agreements between the national program or ministries of health and other government administrations, regions or states. In most countries, agreements have been signed with ministries of education, regions and municipalities, prisons, and national defense. The survey revealed that there are few activities coordinated with social service ministries, despite the fact that HIV/AIDS is a serious social issue (see Table A in Annex 1). All countries except Panama, and Paraguay have national committees for HIV/AIDS prevention and control interventions. These committees consist of governmental and non-governmental participants involved in the fight against HIV/AIDS and provide a forum for consultation and evaluation (see Table B in Annex 1). Peru and Bolivia are not included, no data was collected 69 Table 2. Government funding for Community responses: NGOs in Latin NGOs, 2000 America Amount Country* (US$) Findings from this study indicated that in Latin Nicaragua 30,000 America the number of NGOs per sub-region Honduras 104,000 vary substantially from an average of 8.5 Mexico 164,386 HIV/AIDS-related NGOs in Central America, to Argentina 880,506 34 in the Andean Region and 60 in the Southern Brazil 24,622,204 Cone. Brazil and Mexico have the most Colombia Budget given, HIV/AIDS-related NGOs. amount unknown Chile Budget given ­ amount unknown According to the national officials collaborating in this survey, only half the governments Source: World Bank survey, 2001 *No current data from other countries (Honduras, Nicaragua, Mexico, Brazil, Colombia, Argentina and Chile) finance HIV/AIDS-related NGOs. This was corroborated by the NGOs surveyed; all did, indeed, confirm funding, with the exception of Honduras and Nicaragua (Table 2). Among the NGOs surveyed, 34.5% had received government funding within the last five years. Sub-regional differences are significant - in Brazil and Mexico all NGOs have received funds from the government, while in Central America, only 6.4% of financing comes from the government. The NGOs surveyed reported that when national programs allocate funds to NGOs, they are often targeted to the following populations: MSM, CSWs, PLWHA and adolescents. NGOs in Guatemala, Mexico and Uruguay stated that they receive funding from other organizations, as well. Relationship between NGOs and governments Besides financing, another way of estimating the level of coordination or collaboration between national or regional HIV/AIDS programs and NGOs is to calculate the frequency of institutional collaboration. This study revealed that in Latin America overall, 67.5% of NGOs participate in evaluation committees, or groups that assess the activities of national programs. The number of meetings or contacts between NGOs and national programs in the last five years varies, but in almost every sub-region, the NGOs surveyed had met more than twice with the national program (see Table C in Annex 1). Despite scarce institutional incentives, a culture of providing dedicated, voluntary professional services for HIV/AIDS has arisen which has the voice and capacity to support its goals and beliefs through consultations with national programs and others. 70 HIV/AIDS Legislation As a consequence of scientific and technical advances, and in order to protect human rights, countries have passed a significant amount of HIV/AIDS legislation. In some countries, there are extensive laws, rules and norms; in most countries legislation has mostly been passed for blood/blood products safety and control through systematic testing. INTERVENTIONS FOR THE GENERAL POPULATION AND SPECIFIC GROUPS The government officials surveyed reported that in Table 3. Number of mass media campaigns and budgets, 2000 all the countries 2000. surveyed (except for Bolivia, Budget for Ecuador, and El Salvador Country Number of campaigns which did not provide data) Sub-region campaigns (US$) carried out at least one mass Mexico 1 109,375 media information campaign. The budgets allocated to these Central America activities varied among Guatemala 1 no data countries. Some countries El Salvador no data no data coordinated activities with Honduras 3 18,900 World AIDS Day (Uruguay), Nicaragua no data 28,000 Costa Rica 1 no data Carnaval celebrations (Panama), Panama 1 no data youth meetings (Honduras) or in association with specific Brazil 2 4,153,186 geographic areas (Peru). The budget for these campaigns is Andean Region highly variable among countries Venezuela 1 2,000 (Table 3). Ecuador no data no data Colombia 1 no data According to data collected, in Peru 1 11,400 the past 10 years, there have Bolivia no data no data been few information campaigns for the general Southern Cone population. Brazil, Mexico and Argentina 6 90,000 some of the Central American Paraguay 4 15,285 countries run these general Uruguay 1 10,000 campaigns most often (Table 4). Chile 1 no data Latin America 24 Source: World Bank survey, 2001 71 Although sexual transmission is the most prevalent method of contracting HIV in all the countries, condom promotion as a central theme was only reported by a few of the campaigns carried out in the Region. Table 4. Mass media campaigns in the last Toll free HIV/AIDS hotlines are 10 years (1991-2000) for the general widespread in the Region and are most population and youth often run by NGOs; only Nicaragua and Ecuador do not provide this service Countries Number of mass according to our data. media campaigns Ecuador None Guatemala 1-3 Costa Rica 1-3 Youth and Adolescents Peru 1-3 Argentina 1-3 According to demographic distribution, a Colombia 3-5 large proportion of the population consists Chile 3-5 of youths and adolescents, and reaching El Salvador More than 5 these groups through school-based programs Honduras More than 5 is one of the most effective Nicaragua More than 5 interventions158,159,160,161. According to the Mexico More than 5 respondents, in Latin America, school Brazil More than 5 attendance of those 14 years and under is Venezuela More than 5 76%, with the lowest percentages found in Paraguay More than 5 Central America and the Andean Region Uruguay More than 5 (see Table D in Annex 1). Bolivia no data Panama no data Source: World Bank survey, 2001 In many countries, there is a significant proportion of children who do not attend school and who have an increased risk of contracting HIV through risky behavior possibly due to low educational level: lack of access to information through school-based education program, and/or they are hard to reach since they are not institutionalized. This important group should be taken into account when planning youth-related activities. According to the data collected through the survey, 62% of the countries have school- based HIV/AIDS prevention programs§§, and 31 % of the countries occasionally plan and provide such activities. Most school-based programs (64.3%) were designed and implemented in collaboration with the Ministry of Education. Most respondents said that they could not identify budgets specifically allocated to these activities, or the level of coverage of the school population. The information available shows that development of such activities is still lacking in schools for young people under 15 years of age. §§Here, "program" refers to an organized, systematized, and coherent group with integrated activities and services which are carried out with allocated resources and a goal of reaching previously determined objectives related to preventing new HIV infections in a defined population. This term does not refer to occasional activities, one-time activities or those which respond to an immediate, urgent demand. 72 Table 5. School-based programs, 2000 With school-based Without school-based Occasional activities Country program program Number (%) by sub- Sub-Region Number (%) by sub-region Number (%) by sub-region region Mexico b Central America 3 (50.0%) 1 (16.7%) 2 (33.3%) Guatemala b El Salvador b Honduras b Nicaragua b Costa Rica b Panama b Brazil b Andean Region 2 (50.0%) 2 (50.0%) Venezuela b Ecuador b Colombia b Peru b Bolivia no data no data no data Southern Cone 3 (66.7%) 1 (33.3%) Argentina b Paraguay b Uruguay b Chile b Latin America 10 (62.5%) 1 (6.2%) 5 (31.2%) Source: World Bank survey, 2001 High-risk adolescents have been the target of prevention interventions in half the countries according to the study, although the exact groups and level of coverage vary. The amount invested in programs per adolescent varies (US$126/adolescent in Honduras, US$27 in Brazil, US$25 in Uruguay, US$0.4 to US$3.0 in Paraguay and an average of US$589 in Argentina). The majority of these programs were carried out by NGOs. Men who have sex with men (MSM) All the countries surveyed, except Panama, have carried out interventions focused on MSM. Results from the survey indicate that in seven countries, these interventions are concrete programs and in three countries such interventions are occasional, but steady. Most frequent interventions are information/education activities, workshops on safe sex, counseling and condom distribution, many of which are planned and implemented through NGOs. The respondents indicated that these programs are very recent 73 (beginning in 1999-2000) and coverage varies greatly. This study could not identify the cost/beneficiary ratio in the Region as a whole because records of beneficiaries and costs either did not exist, or respondents were not aware of such information. However, during the study, it was found that in Honduras the cost/beneficiary ratio of these programs was US$16 per beneficiary, while in Mexico and Brazil it was US$1 per beneficiary. Male and Female Commercial Sex Workers (CSWs) Data from this study show that Table 6. Countries with CSW-focused programs, 2000 fourteen (82.3%) countries have programs targeting female CSWs, 12 Country Women Men Travestites (70%) target male CSWs and Sub-region 11 (65%) target transvestites Mexico yes yes no data (Table 6). These programs have the most historical Central America background, dating to the Guatemala yes yes yes El Salvador yes yes yes 1990s, however, systematized Honduras yes yes yes organization and data Nicaragua yes yes yes collection did not begin until Costa Rica no no no recently (1999-2000). Panama no no no Respondents indicated that most interventions involve Brazil yes yes yes distribution of educational materials, counseling and Andean Region promoting peer training, Venezuela yes yes yes among other areas. Ecuador yes no no Colombia yes yes yes Peru yes yes yes Bolivia no data no data no data Southern Cone Argentina yes yes yes Paraguay yes yes no Uruguay yes yes yes Chile yes no yes Source: World Bank survey, 2001 Access to health care services is a basic need for controlling the disease from the clinical point of view in terms of early diagnosis and treatment of HIV, as well as for preventive measures in high-risk populations such as CSWs162,163. The survey data revealed that in 59% of the countries, health care services are free for CSWs. In Mexico, Peru and Uruguay, for example, there are services specifically designed and reserved for CSWs, while in Ecuador such health care is provided through NGOs. 74 Injecting Drug Users (IDUs) Injecting drug use is most prevalent in Mexico, Brazil and the Southern Cone; Table 7. Estimated number of IDUs, 2000 other countries report that other methods Country Number of drug use (inhalants, pills, etc.) are Chile 29,046 more common. There are few estimates Mexico 48,000 published on the size of the IDU Argentina 64,558 population in the countries. Data collected from questionnaires in this Source: World Bank survey, 2001 survey is shown in Table 7. The most commonly-injected drug is cocaine164 (reported in 71.4% of countries), only Mexico and Colombia report higher rates of IV heroin use. Table 8. Needle exchange programs and needle According to the respondents, exchange units, 2000 government responses to the IV drug Number of needle - Number of use epidemic have been insufficient, exchange needle and very few countries are Country* programs exchange units implementing harm reduction Uruguay 0 no data programs, which often that offer sub- Mexico 1 1 par coverage. There are seven Argentina 5 no data countries that either have no program, Brazil 125 125 or only have sporadic "drug free" Source: World Bank survey, 2001 *no current data available from other countries programs that are barely effective for harm reduction and HIV control purposes165,166 (see Table F in Annex 1). Most interventions for IDUs consist of needle exchange programs (in which used needles can be exchanged for sterile ones), and training for IDUs on how to better clean their instruments Table 9. Availability of centers (Table 8). The data provided for the study were specialized in IDUs treatment, 2000 not precise, and little data were available on the beneficiaries or budgets in all countries. In the Country/Sub-Region Number of centers case of Brazil, it can be estimated that needle Mexico 1 exchange programs cost US$24,000 each, and the cost per IDU is as high as US$18. Overall, the Central America study concluded that needle exchange programs El Salvador 1 and other harm reduction methods in Latin Nicaragua 8 America are scarce and, with the exception of Costa Rica 1 Brazil, are insufficient when considering the scope Panama 1 of the HIV/AIDS epidemic and its relation to injecting drug use. Brazil 26 The survey data revealed that clinical attention to Southern Cone drug users is scarce in Latin America (Table 9). Peru 1 Even countries like Mexico, Argentina and Chile Paraguay 7 have insufficient infrastructures and resources for Uruguay 1 Source: World Bank survey, 2001 75 effectively and efficiently treating this population. Aside from national drug prevention, control and/or treatment programs, the groups most involved in fighting drug use are the few independent centers caring for drug addicts, and drug-related NGOs. According to the respondents, health professionals and pharmacists are rarely involved in treating this population. Prisoners The rate of HIV infection among prisoners varies from country-to-country. Often, countries with the highest prevalence rates among prisoners also have the highest rates among IDUs. There are some countries in which the rates reported among prisoners are alarmingly high (i.e. El Salvador), although it can be presumed that the highest prevalence rates among prisoners (based on rates among IDUs) would be found in the Southern Cone and Brazil (Chart 1). Chart 1. Prevalence among prisoners, 2000 50.00% 56% 40.00% 30.00% 20.00% 17.6% 10% 11.1% 10.00% 6.8% 6% 1.1% 1% 0.00% 0.01%1.5% Peru ElSalvador Honduras NicaraguaMexicoBrazil ArgentinaParaguayUruguayAmerica Latin Source: World Bank survey, 2001 Survey respondents from 13 countries (76.5%) stated that they have HIV prevention programs for prisoners; Honduras and several countries of the Andean Region do not have such programs (see Table E in Annex 1). According to the information collected, in Central America, these programs began recently (1999-2000) and consist primarily of health education and educational material distribution. Coverage is scarce and interventions are sporadic. In Mexico, these programs began earlier in the 1990s and provide a wide range of services, although coverage is still low. Programs offered in Mexico include HIV testing, condom distribution and sterile supplies for injecting drug use. Brazil also offers many services to a large number of prisoners. Recently, Southern Cone countries (i.e. Argentina in 1999) began implementing a wide variety of prevention services which are more prevalent in prisons in the larger cities. Overall, prisoners lack sterile supplies and permanent access to condoms since distribution is sporadic. There are no data available on health care for prisoners with HIV, and there is also a gap in 76 information on the coordination of services within and outside prisons for preventing, controlling and treating HIV within prisons. Outreach programs for hard-to-reach populations The goal of outreach programs is to establish contacts with people with high or moderate risk for contracting HIV. Specifically, these programs should be managed to drive people to health care and prevention services, compile information needed to protect these populations from HIV and provide social or emotional support167,168,169. Many of these high-risk, hard-to-reach populations are only accessible through such programs (CSWs, IDUs, marginalized groups). The data collected show that with the exception of Brazil and Mexico, outreach programs are scarce in the Region (Table 10). Table 10. Outreach programs, 2000 Country* Sub-region Outreach Programs IDUs MSM CSWs High-risk adolescents México ü ü ü ü Central America 0 1 1 1 Guatemala no ü ü ü Brazil ü ü ü ü Andean Region 1 1 1 0 Colombia ü ü ü no Southern Cone 2 3 1 2 Argentina ü ü Paraguay ü ü Uruguay ü ü ü ü Latin America 5 7 5 5 Source: World Bank survey, 2001 *Countries not listed do not have these programs 77 NGOS'CONTRIBUTIONS TO HIV/AIDS CONTROL IN LATIN AMERICA NGOs in the Region have different goals and cover a wide range of needs, including information and prevention, and psychological, social and family support for those affected. Over 50% of NGO respondents confirmed that they provide these services. There are few NGOs with one single purpose, rather, it is more common for NGOs to provide a number of different HIV/AIDS-related services. Chart 2. Distribution of Latin American NGO A review of the programs programs (n=366), 2000 implemented by the NGOs Reference surveyed (366 programs* in a Centers total of 84 NGOs surveyed) shows (7%) Homeless shelters Health centers that a little over half are involved Self-help (2%) (7%) in general information and (8%) Prevention prevention activities, including Legal services (14%) printing educational materials, and (9%) the rest provide services and Psychological Telephone support to PLWHA (Chart 2). assistance services (9%) (8%) Among these 366 programs, 215 Social Educational are focused on targeted assistance Classes Material populations. As shown in Chart 3, (11%) (12%) (13%) half of these programs are for women and adolescents, and the Source: World Bank survey, 2001 rest are for groups with high-risk for contracting HIV. The populations targeted by the NGOs CHART 3. Distribution of programs for targeted surveyed include youth populations, (n=215), 2000 (70.2%), women (54.7%), IDUs MSM (48.8%) and CSWs Prisoners 5.6% 8.4% (46.4%). Although Young people 27.4% prisoners and IDUs are at high-risk of contracting HIV, they do not receive CSWs 18.1% much attention fromNGOs. This is particularly alarming in the Southern Cone where HIV prevalence among these Women MSM 21.4% populations is very high. 19.1% Source: World Bank survey, 2001 * "Program" refers to an organized, systematized, and coherent group with integrated activities and services which are carried out with allocated resources and a goal of reaching previously determined objectives. This term does not refer to occasional activities, one-time activities or those that respond to an immediate, urgent demand. 78 Beneficiary Population and Costs of the Programs Underway There were many difficulties in collecting information regarding NGOs' population coverage and budgets since, in most cases, the people completing the questionnaires for the World Bank study are more involved in the design and implementation of programs than collecting and maintaining such data. Few NGO respondents could identify the number of beneficiaries for each program, and information on budgets for each activity was limited since NGOs do not always maintain this information. Consequently, the data presented in Charts 4 and 5 reflect only the responses of NGOs that had this information. It can be assumed that the actual number of beneficiaries and costs are higher than what is presented. Chart 4. Costs/beneficiary: Programs for PLWHA, 2000 Overall, programs for PLWHA, particularly 606 600 hospices (US$606 per beneficiary), are most costly, 500 followed by social support 400 (US$108 per beneficiary). Costs vary between sub- 300 regions, depending on the 200 level of volunteer 108.6 100 contributions, and systems 28.9 47.9 73.5 45.4 for contracting or payment of 0 services for employees. Self help Legal supoprt Psychological Social support Legal Health Hospices From an economic point of support support services view, programs providing support for those living with HIV/AIDS and self- Source: World Bank survey, 2001 supported programs are the most efficient. Costs per Chart 5. Costs/beneficiary in US$: Programs for targeted populations, 2000 beneficiary for such programs are relatively similar between sub-regions, except for Brazil Women Youth MSM CSWs Prisoners where the cost is higher (US$66.3 per beneficiary). US$ 80 77.6 Data showed that except for prisoners, programs targeting 60 specific populations have an 40 average cost of US$10 to 21.9 US$20 per person. CSW 20 18.5 20.06 13.1 programs are the least expensive, averaging US$10 0 per beneficiary, except in the case of Brazil where the cost is higher. Programs for Source: World Bank survey, 2001 79 MSM cost about US$20 per person; this high average is largely due to the high costs found in Brazil and the Southern Cone. Youth and women-based programs are the most expensive, yet it is important to keep in mind the large number of at-risk beneficiaries found in these population sub-groups. The highest costs per beneficiary are found in Brazil and Central America (for women-targeted programs) and Mexico (for youth programs). In Latin America, according to the study, the most economical interventions are information dissemination and prevention programs, such as the toll free HIV/AIDS information and support hotlines that offer wide coverage at a very low cost (US$2 per person). With the exception of the Southern Cone, information and prevention programs, including the printing of instructional materials are very low-cost activities. Cost-Effectiveness: The Big Question Measuring the costs of existing HIV/AIDS prevention programs, per person reached, is an essential part of developing the appropriate strategy for scaling-up and program planning, but much of the essential information for priority setting remains elusive. To obtain the greatest benefit from a fixed budget, policy makers and program managers require information about the cost per infection averted, or per life-years saved. This information typically is expressed in terms of cost-effectiveness ratio, in which the numerator represents the net cost (for example, the cost of condom distribution plus dissemination of appropriate educational messages minus the treatment and other costs not incurred because of the beneficial effects of the intervention) over the desired health outcome, such as the reduction of illness or death from HIV/AIDS. In concept, if this ratio is calculated for all interventions competing for common resources, decision makers can assign resources on the basis of cost-effectiveness, maximizing the "good" (lives saved) obtained from a given budget. Estimating cost-effectiveness is difficult in all health care disciplines, but HIV/AIDS interventions represent a particularly daunting challenge. Decomposing the elements of the cost-effectiveness ratio ­ costs of the interventions, costs not incurred because of the intervention, and effectiveness of the intervention ­ demonstrates the complexity of this analysis: Ø Costs of HIV/AIDS prevention strategies are difficult to calculate, largely because they tend to depend on hard-to-quantify outreach strategies, peer counselors and/or expansion of existing NGO activities. Often, there are no clear protocols for prevention activities, they evolve in an idiosyncratic manner and service statistics are often exaggerated. In addition, we face a question about the perspective from which the costs are calculated ­ do we care about all social costs implied by an intervention, or just the costs to the provider? Although these issues complicate the cost estimates, it is possible to arrive at credible per-person estimates of costs. 80 Ø Estimatingthesavingsintreatmentavertedasaresultoftheinterventionscarriedout, is a huge undertaking, typically requiring assumptions. Analysts must make "best guess" estimates about the effectiveness of the interventions being assessed ­ for example, out of 1,000 people reached with condoms and education, one infection per year is averted--and then must estimate the potential per-case costs associated with the treatment of opportunistic infections and other ailments affecting PLWHA. These treatment costs depend largely on the characteristics and underlying cost structure of the health care system, as well as accepted treatment protocols, which have changed rapidly over time, and are likely to continue to evolve with scientific discovery and technological innovation. Ø Estimating the infections averted or the disability-adjusted live years (DALYs) saved by the intervention, which comprises the denominator of the cost-effectiveness ratio, requires strong assumptions, as noted above. To further complicate matters, we are faced with the question of whether to include in the "effectiveness" estimate only the effect on the population directly benefiting from the intervention, or whether to consider the infections averted because of the reduced prevalence of HIV in the population: that is, the secondary, tertiary and other future infections prevented because of the reduction in the number of infections in the population directly targeted. With HIV/AIDS, as with any infectious disease, the multiplier effect of preventive activities can be many times larger than the direct effects, depending on the rate of spread of the disease in the population, which itself depends on a number of underlying epidemiological, demographic and social characteristics. In short, viewing the effects of preventive activities in a dynamic fashion is critical to arriving at a true picture of the benefits of prevention, but is a complex empirical task. With all these methodological complications, is there any point in attempting estimates of cost-effectiveness? The question can be answered only by considering the alternative: allocating scarce health care resources on the basis of allocation rules or practices that do not consider the quantity of the benefits per dollar spent. For example, a budget could be allocated on the basis of beliefs about the worthiness or "innocence" of the beneficiary populations (e.g., more for babies affected by mother-to-child transmission than for MSM who are assumed by some to have brought the disease upon themselves), or on the basis of the political influence of the organizations receiving funding, or even across beneficiary populations in a way that is proportional to the estimated prevalence of the disease across those populations (a common strategy intended to achieve "fairness"). While each of these approaches to resource allocation has its advocates, none of them is likely to lead to the greatest number of HIV infections averted per dollar spent ­ arguably the essential objective underlying all HIV/AIDS prevention programs. Only the application of cost-effectiveness analysis ­ with all its difficulties and imperfections ­ will lead to this outcome. A number of studies have been conducted to develop "best guess" estimates of the cost- effectiveness of specific interventions, but most of the evidence comes from industrialized countries. Jha P. and others compared the efficiency ratio, effect size and cost effectiveness of different evidenced-based interventions for HIV prevention for 81 developing countries. The Jha P. findings show that interventions for CSWs have the lowest cost per infection averted ($8-$12) followed by STI management interventions ($218), voluntary counseling and testing ($249-346) and antiretroviral therapy for HIV+ pregnant women ($276). Prevention resources should be Toward more rational allocation decisions allocated to prevent as many Over the next few months, the World Bank proposes to pilot-test, in infections as possible. Such an one Central American country, a methodology to determine the allocation must consider the cost allocation of resources among prevention interventions that and effectiveness of programs, maximizes the number of new infections averted. The exercise will as well as estimates of HIV draw on the techniques elaborated in No Time to Lose242 and relies upon subjective and systematic construction of two sets of estimates: incidence242, in order to allocate one related to the epidemiology of HIV (i.e. new infections in the the right amount of money to target populations), and one related to program effectiveness by programs for each specific risk subgroup (i.e. new infections prevented at different levels of program funding). The elaboration of these variables relies heavily on group. A follow-up World Bank consensus among local and international experts. study attempts to undertake exactly this approach, and It is expected that this exercise will inform policy decisions by explicitly illustrating the opportunity cost of alternative allocation determine appropriate ways of mechanisms (e.g., based on prevalence or on number of AIDS cases, allocating limited HIV/AIDS etc.). The exercise may also generate renewed policy interest in prevention resources among tracking incidence and program effectiveness, because doing so would dramatically improve allocation decisions and revert the programs for different epidemic faster. populations groups. THE POPULATION'S LEVEL OF KNOWLEDGE OF METHODS OF TRANSMISSION AND PREVENTION OF HIV/AIDS Most of the answers to the survey confirmed that countries had carried out knowledge, attitude and practice (KAP) surveys regarding HIV/AIDS, either through ministries of health or other institutions or agencies, in order to determine the population's level of knowledge regarding HIV/AIDS. Unfortunately, the results and lessons from these studies have not been shared with a wide audience and have barely been used to guide decision-making in national programs. Based on responses from the physicians participating in the survey, 20% of people would have a good level of knowledge, 65.6% would have some knowledge, and 14% would have little or no knowledge of modes of transmission and prevention of HIV/AIDS. Social attitudes toward sexual orientation The proven increased risk of contracting HIV through unprotected anal intercourse has resulted in categorizing MSM, and others with this practice, as high-risk since the beginning of the epidemic170,171,172. This leads to the need for prevention interventions, 82 and health and social services specifically targeted to this population. Intolerant social attitudes, or homophobia, are not only human rights infringements, but such attitudes impede effective prevention, early diagnosis and appropriate treatment for this group. Participating NGOs were asked about the socio-cultural attitudes regarding homosexuality and if there were any laws or regulations that restrict or prohibit homosexual orientation. Ninety-four percent of the NGOs surveyed indicated that homosexuality is discouraged in Latin America, either through socio-cultural attitudes (57.8%) or socio-cultural attitudes combined with legal penalties (36,1%). In Mexico and Brazil, most NGOs indicated that the restrictions are both socio-cultural (80%) and legal (60%), although specific laws mandating penalization were not identified. Thirty- eight percent of NGOs in Central America claimed that combined socio-cultural and legal restrictions are the main prohibitive factors; in Nicaragua five NGOs mentioned penalizations for homosexuality (see Annex 2), and in Guatemala punitive legislation was cited, although a specific law was not identified. 83 HIV infection rate in high- risk populations Table 11. Percentage of NGOs surveyed that identifie d homosexuality restrictions, 2000 (n=83) Data obtained from national Restrictions to homosexuality Country programs on the number of Socio- Socio-cultural Sub-region HIV tests carried out in 2000 cultural None + legal are not consistent with data Mexico 40.0% -- 60.0% obtained from the epidemiological surveillance Central America 51.6% 9.7% 38.7% offices (except in Venezuela Guatemala 50.0% 16.7% 33.3% and Nicaragua). The same El Salvador 83.3% -- 16.7% inconsistency was found in Honduras 75.0% -- 25.0% data regarding the prevalence Nicaragua -- 16.7% 83.3% rates in high-risk populations; Costa Rica 60.0% 20.0% 20.0% only Mexico and Honduras Panama 50.0% -- 50.0% provided data that were consistent among various Brazil 20.0% -- 80.0% sources (see Table G in Annex 1). These inconsistencies point Andean Region 68.0% 4.0% 28.0% to a lack of communication Venezuela 60.0% -- 40.0% between national programs and Ecuador 80.0% -- 20.0% epidemiological surveillance Colombia 50.0% 25.0% 25.0% offices. Peru 66.7% --- 33.3% Bolivia 80.0% --- 20.0% Condom distribution Southern Cone 70.6% 5.9% 23.5% According to the National Argentina 60.0% -- 40.0% HIV/AIDS programs surveyed, Chile 50.0% -- 50.0% 59% of the countries financed Paraguay 75.0% 25.0% -- condom distribution in 2000. Uruguay 83.3% --- 16.7% Regionally, US$20.2 million financed the distribution of Latin America 57.8% 6.1% 36.1% 219.5 million condoms. The unit cost per condom was Source: World Bank survey, 2001 about US$0.09 (Table 12). Most often, condoms were distributed to zones where CSWs work, areas frequented by MSM, pharmacies and NGOs. Colleges and universities did not receive government-provided condoms. Quality control is important not only for disease prevention, but also to maintain consumer satisfaction and confidence, which is crucial for encouraging safe sex behavior. Only half the countries have norms regulating condom quality; in the Andean Region condom quality control is largely inexistent, according to the data collected. 84 Table 12. Ministries of Health condom distribution and budget, 2000 Number of Budget for Country condoms financed condoms (US$) Mexico no data 2,500,000 Honduras 300,000 10,000 Nicaragua 5,000,000 no data Brazil 200,000,000 6,000,000 Venezuela 2,000,000 no data Colombia no data 18,000 Peru 11,000,000 11,600,000 Argentina 200,000 20,000 Uruguay no data 20,000 Chile 1,000,000 59,000 Source: World Bank survey, 2001 PREVENTION OF MOTHER-TO-CHILDTRANSMISSION The availability of highly active antiretrovirals, prophylaxis with AZT and new recommendations for labor and delivery for HIV+ pregnant women has resulted in a significant decrease in mother-to-child transmission of HIV173,174,175,176. However, these achievements are only possible through early and Chart 6. Percentage of pregnant women offered HIV efficient diagnosis of pregnant testing, 2000 women. For this reason, it is 100% important to offer HIV testing 100% 100% 75% to pregnant women, and to 80% 70% ensure easy access to 60% 50% 52% diagnosis and treatment 40% services. 20% 9% 10% 5% Seven countries (Brazil, 0% Honduras, Costa Rica, Peru, Venezuela, Argentina and Brazil Peru Uruguay) confirmed that they HondurasNicaraguaMexico VenezuelaArgentinaUruguayAmerica Latin have protocols for offering the HIV test to all pregnant Source: World Bank survey, 2001 women, although the actual coverage in terms of numbers of tests offered varies between countries. For instance, Honduras has one of the highest prevalence rates in Central America, and yet according to the respondents, it only offers HIV testing to 8.7% of pregnant women (Chart 6). Access to antiretroviral prophylaxis is also very low (only 20% in Honduras, and 40% in Brazil, with substantial differences between sub-regions, (see Chart 7), which is unfortunate since such prophylactic measures are one of the simplest and effective ways to prevent HIV transmission. 85 Chart 7. Percentage of HIV+ pregnant women with ARV prophylaxis, 2000 100% 90% 90% 100% 90% 100% 85% 80% 60% 57% 40% 40% 20% 20% 9% 0% 0% Peru Chile HondurasNicaraguaMexicoBrazil VenezuelaArgentina Uruguay Guatemala America Latin Source: World Bank survey, 2001 HEALTH ANDSOCIAL SERVICES Access to health services and prevention interventions for high-risk populations Information provided for this study about health centers, STI diagnosis and treatment centers, and hospitals with programs specifically for HIV/AIDS (testing, counseling, condom distribution, health education) differed greatly between countries and sub- regions, and there was a tendency to overestimate services provided. In general, national programs interviewed confirmed that almost all health centers (STIs centers, primary care centers and hospitals) have prevention programs planned specifically for HIV/AIDS, including voluntary testing and counseling, health education and condom distribution. Information provided by physicians and NGOs regarding coverage and access to health services differ greatly from that provided by governments. Availability of clinical practice guidelines According to respondents, clinical practice guidelines for HIV/AIDS patients (measured by current knowledge and availability of resources) are scarce. In areas where access to antiretrovirals is limited, national guidelines for prophylaxis against opportunistic infections are also lacking or are scarcely used (only 15.6% of countries). Forty-three percent of physicians surveyed stated that they have formal guidelines for managing antiretrovirals, but such guidelines are scarcely distributed or not well known in sub- regions such as the Andean Region and the Southern Cone (28.5% and 35.7%, 86 respectively). Several physicians announced that new guidelines would soon be available, and many others usually consult guidelines from international organizations. Table 13. Percentage of physicians surveyed (n=64) confirming availability of guidelines for clinical management and treatment of PLWHA, 2000 Country Full ARV Prevention of mother- Prevention of Sub-region management therapy to-child transmission opportunistic infections Mexico 20.0% 80.0% no 40.0% Central 15.8% 47.3% 15.7% 21.1% America Guatemala no 33.3% no 33.3% El Salvador 40.0% 40.0% no 20.0% Honduras 33.3% 33.3% no 33.3% Nicaragua no no no no Costa Rica no 100.0% 75.0% 25.0% Panama no 50.0% no no Brazil no 80.0% no no Andean 9.5% 28.5% no 19.0% Region Venezuela no 66.6% no 25.0% Ecuador 25.0% 25.0% no no Peru no 60.0% no 60.0% Colombia no no no no Bolivia 33.0% no no no Southern 7.1% 35.7% 14.3% no Cone Argentina 20.0% 60.0% 40.0% no Chile no 66.7% no no Paraguay no no no no Uruguay no no no no Latin America 10.9% 43.7% 7.8% 15.6% Source: World Bank survey, 2001 no=no guidelines According to responses from national program directors, health services, other than ARV therapy, are free and universally offered in 6 countries (Costa Rica, Brazil, Venezuela, Argentina, Chile and Paraguay). In six other countries (Honduras, Nicaragua, Panama, Peru, Colombia and Mexico) health services are provided to people with insurance, and in the rest of Latin America such services are paid by the patient, out-of-pocket. Often, MoHs provide "welfare" services, but coverage is scarce and infrastructure and resources 87 are very limited. With few exceptions, a very small part of the population is covered by social security, especially in Central American countries. Access to HIV testing Physicians and NGOs groups that were surveyed had similar estimates regarding conditions related to access to HIV testing. Fifty-one percent of physicians and 54% of NGOs feel that HIV testing is available to the population. According to physicians, the average cost of the test in public health centers is US$21, and US$56 in private centers. There are few differences between sub-regions in terms of cost in public centers, however, there is a wide range of prices for testing in private centers ­ from US$49 in Central America to more than US$100 in Mexico (see Table H in Annex 1). Chart 8. Main barriers to HIV testing (%) according to NGO surveyed (N=84), 2000. According to the Central America Mexico Brazil participating NGOs, Andean Region Southern Cone Latin America the main barrier to testing in all sub- 26.2 regions and 22.2 28 countries is social Availability of testing 60 discrimination, 20 22.5 followed by low 76.1 demand for the test 83.3 76 in high-risk Discrimination 60 populations, and the 80 77.4 infrequency of 66.6 offering voluntary 50 80 testing Low demand in health 60 60 centers. In the 65.6 Andean Region, the 53.6 cost of the HIV test 55.5 Professional 36 is considered an recommendations 60 80 important barrier 61.3 (see Chart 8). 47.6 16.6 Cost 80 Limited availability 40 of HIV testing in 48.3 public centers, and 35.7 38.8 the high cost in Lack of testing centers 32 countries where 60 60 coverage is not 29 universal impose barriers to testing Source: World Bank survey, 2001 88 and counseling for people infected with HIV/AIDS, or people with high-risk behaviors. Overall, these barriers lead to many negative consequences for patients such as decreased benefits from counseling, early diagnosis and treatment. Promotion of HIV testing and increased accessibility to the test should be a priority for all Latin American countries. Laboratory Infrastructure According to the national programs, infrastructure for laboratories working with HIV is under-developed. The number of laboratories per country capable of providing CD4 counts is low in Central America, the Andean Region, and Mexico. The number of laboratories that count viral load is even lower (see Table I in Annex 1). Chart 9. Percentage (%) of patients who have had According to the physicians at least one CD4 measure or CD4+ viral load count surveyed, in most sub-regions, (n = 62 physicians surveyed), 2000 access to the diagnostic testing needed to evaluate patients and make treatment decisions is limited. 48 Almost half of patients are required 81 to pay for CD4 counts. In general, Viral load + 50 prices are higher when viral load or CD4 8 resistances are also requested; the 65.2 Latin America 29.4 Southern Cone highest costs are found in Mexico Andean Region and Central America (see Table J in Brazil Annex 1). 63 Mexico 79.3 Central America According to those physicians, 69 CD4 access to basic serologic tests used 27 75.6 for clinical evaluation and to plan 51.4 antiretroviral treatment varies among sub-regions. Overall, physicians 0 10 20 30 40 50 60 70 80 90 confirm that about half of HIV+ patients (48%) have had at least one Source: World Bank survey, 2001 measure of viral load and CD4. Very low coverage is estimated by physicians in Central America, and especially in Brazil (8% and 29% respectively; Chart 9). Stage of HIV infection at time of diagnosis Sixty percent of the physicians surveyed stated that patients often do not seek medical attention for the first time until they are already in clinically advanced stages of infection177. In Latin America, 67% of HIV+ people did not seek health care until they were in advanced stages of infection, or showed signs and symptoms of AIDS. The longest delays in seeking health services are found in Central America, where 8 out of every 10 patients present with advanced infection or AIDS. CD4 count refers to a measure of "helper" T cells which help B cells produce antibodies. The number of CD4 cells is an important measure of an individual's immune system capacities. Viral load test is a measure of the amount of HIV in the blood to determine how far infection has progressed. 89 Treatment Coverage According the information provided by Table 14. Coverage (%) of antiretroviral physicians surveyed. ARV therapy is treatment for patients who need it, provided unequally throughout the Region, according to national programs (2000) and there is a significant percentage of PLWHA who lack the resources to access Country Percentage of patients such treatment. In Latin America, 1/3 of receiving ARV therapy HIV+ patients who should be taking ARVs Nicaragua 0% lack the resources to do so, while 44% of Peru 0% HIV+ people use highly active antiretroviral Honduras <25% Ecuador <25% treatment (HAART) or multiple Panama 25%-50% combination therapies. Brazil, Mexico and Guatemala 25%-50% the Southern Cone provide the greatest Chile 50%-75% coverage of HAART treatment, while low Uruguay 50%-75% coverage due to lack of resources is more Costa Rica >75% common in Central America where almost Mexico >75% half of HIV+ patients who should receive Venezuela >75% ARV therapy (46.5%) do not (Chart 10). Paraguay >75% Argentina >75% According to the national programs, the Brazil >90% proportion of patients who need, and Bolivia no data receive, antiretroviral treatment varies. El Salvador no data Overall, antiretroviral treatment is provided Colombia no data to half of the patients in Latin America who Source: World Bank survey, 2001 need it. Central America and the Andean Region offer the least coverage of Chart 10. Level of ARV coverage (%), 2000 antiretroviral treatment (Table 14). 44 Prevention of opportunistic infections is on 53.7 another basic component of good clinical 45 practice for treatment of HIV/AIDS. This patients 60 HAART 51 treatment is inexpensive, and is accessible % 30 even in areas with few resources. According to the physicians, 72% of 18.7 Latin America patients in the Region are treated to no 23 Southern Cone w/ 12.06 Andean Region prevent opportunistic infections. HIV+ 27 Brazil According to those, the countries offering % treatment patients recommended 7.6 Mexico this treatment least are Brazil (13.7%), 23.06 Central America Panama (45%), Argentina (55%) and Mexico (57%). 31.2 due of 18 34 w/out lack 0 % to resources treatment 28 46.5 0 10 20 30 40 50 60 70 Source: World Bank survey, 2001 90 Spending on antiretrovirals There is relatively little spending on antiretrovirals in Latin America, which reflects the lack of coverage. According to the national programs, the total spending on ARV therapy in 2000 was US$427 million, including public (US$420.2 million) and private spending (US$6.7 million). The average cost per patient is estimated at US$7,000- US$8,000 per patient, per year. Considering that there are about 500,000 patients in Latin America who should be treated with ARVs, the spending on this treatment could be a high as US$3.0 billion per year. Patient Care Table 15 presents estimates as of 2000 from national programs regarding the proportion of HIV+ patients who have received health care, psychological or social services during the course of their infection. This includes measures such as prophylaxis against opportunistic infections, vaccinations and/or antiretroviral treatment. Few people interviewed could provide this information, yet the data available point to some trends that may be indicative of the overall picture. From the information collected, it appears that Central America and the Andean Region are the areas most deficient in terms of services and treatment provided. Table 15. Percentage of HIV+ patients who have received services/treatments, 2000 Oppor. Health PPD TB PPC CMV Tetanus Pneumo- HBV ARV Infect. Psycho Social Country* -care prophy prophy prophy vaccine coco vaccine treat- Treat- ser- support -laxis -laxis -laxis vaccine ment ment vices Nicaragua 50% -- -- 10% 10% 20% -- -- -- 70% 25% 30% Mexico 95% 30% 50% 85% 2% -- 2% 10% 85% 95% 40% 10% Venezuela 10% -- -- -- -- -- -- -- 10% 5% -- -- Chile 100% -- 100% 100% 95% -- 100% -- 50% 60% -- -- Paraguay -- -- -- -- -- -- -- -- 100% -- 100% -- Uruguay 100% 70% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Latin America 71% 50% 83.3% 73.8% 51.8% 60% 67.3% 55% 69% 66% 66.3 46.7% % Source: World Bank survey, 2001 *no data from other countries CMV=cytomegalovirus; HBV= hepatitis B virus; PPC=Pneumocystis carinii; PPD=Purified protein derivative, used to test for tuberculosis exposure; TB=tuberculosis To estimate needs for health care, psychological and social services for PLWHA, NGOs were asked to estimate the level of concern with certain issues, or the problems faced by PLWHA, such as: health care, psychological care, employment, social integration, and family and social services. In Latin America, the problems most frequently mentioned were social discrimination and access to employment (at a level of 4.47 and 4.33, respectively, out of 5). NGOs in Brazil emphasized the problem of discrimination, while in Central America the primary concern was access to employment. Social services for PLWHA are another priority concern in Latin America, particularly in the Southern Cone, Andean Region and Central America. Concerns regarding psychological and 91 health care services were most frequently cited by NGOs in Mexico and the Andean Region (Table 16). Table 16. NGOs estimations ratings of main problems faced by PLWHA (scale of 1-5), 2000 Country Access to Health Social Psychological Family Sub-region Discrimination employment services services services rejection Mexico 3.50 3.00 4.00 3.75 4.00 2.33 Central America 4.53 4.45 3.81 3.97 3.61 3.47 (average) Guatemala 4.50 4.17 4.67 4.17 3.67 3.50 El Salvador 4.83 4.83 4.67 4.83 4.50 3.33 Honduras 3.75 4.50 2.75 2.50 2.75 2.75 Nicaragua 4.50 4.33 4.67 5.00 3.83 3.67 Costa Rica 5.00 4.80 1.60 2.80 3.20 3.60 Panama 4.50 4.00 3.75 3.75 3.25 4.00 Brazil 4.80 3.80 2.80 2.60 2.60 3.00 Andean Region 4.30 4.18 4.04 4.14 3.48 3.43 (average) Venezuela 4.40 3.80 4.20 3.75 2.00 3.80 Ecuador 5.00 3.00 4.00 4.33 3.33 4.00 Colombia 3.75 5.00 3.25 4.50 4.00 3.50 Peru 3.67 4.00 4.33 4.00 3.33 2.83 Bolivia 5.00 5.00 4.20 4.20 4.20 3.60 Southern Cone 4.72 4.72 3.50 3.94 4.00 3.62 (average) Argentina 5.00 4.60 3.67 3.80 3.50 2.60 Chile 5.00 4.33 3.67 4.00 3.33 3.67 Paraguay 5.00 5.00 5.00 5.00 5.00 4.50 Uruguay 4.17 4.83 2.33 3.50 4.20 4.00 LATIN AMERICA 4.47 4.33 3.76 3.91 3.61 3.41 (average) Source: World Bank survey 2001 Gaps in health care services Regarding the gaps in health care services, there is a high level of agreement between estimates provided by physicians and national programs surveyed. According to national programs the primary cause of the most significant health care deficiencies is lack of 92 resources (71%), insufficient training for professionals (64%) and lack of coordination among the various levels of service providers (64%). Responses vary between sub- regions, for instance, in Central America these three issues were cited in 80% of the countries, while in the Andean Region all the countries stated that the main problem is lack of training for professionals. In the Southern Cone the main problems perceived are lack of coordination among various levels and insufficient resources. Among the physicians surveyed, lack of resources and training were cited as very important problems in the Region. Lack of training was considered particularly important in Mexico, Brazil and the Andean Region. The physicians surveyed attributed gaps in health care services to the following factors: lack of government support/policies (22%), low educational level of the population (14%), lack of access to antiretrovirals (7.8%) lack of social infrastructure for support (7.8%) and stigmatization of HIV in health care settings (6.3%). Overall, the main finding of this survey is that there are large gaps in health care services provided, and the services offered are very limited. 93 COLLABORATION WITH INTERNATIONAL AGENCIES There are many unilateral, Table 17. Funding allocated to national HIV/AIDS bilateral and multilateral programs from international agencies and percentage agencies working to control the of government HIV/AIDS budget, 2000 HIV/AIDS epidemic in Latin Funding as American countries. Eighty- Country Funding received a proportion five percent of national Sub-region* (US$) of programs estimate that the level government budget (%) of coordination, activities and Mexico 18,100,000 5.53 prioritization of objectives with these agencies is adequate. Central America With the exception of Guatemala 210,000 3.05 Colombia, all Latin American Honduras 1,231,677 0.36 countries received funding in Nicaragua 125,000 0.80 2000 from international Panama 50,000 no data agencies. This financing supplemented the funds Brazil 4,500,000 no data allocated by governments. The amount of funding received, as Andean Region a proportion of the national Venezuela 100,000 0.43 HIV/AIDS program budget, Colombia 0.00 0.00 varied between countries from Peru 810,000 6.35 as low as 1% to as much as 40% (Table 17). Southern Cone Argentina 1,350,000 48.81 Paraguay 37,500 no data Uruguay 110,000 0.72 International Agency support for NGOs Latin America (average) 2,420.37 8.26 In Latin America, governments Source: World Bank survey, 2001 *no data from other countries do not provide much funding for NGOs, rather, most of the Chart 11. Sources of NGO financing, 2000 funding comes from International Agencies international agencies (43.7%) and Government 4.7% and NGOs' own resources (42.2%). Government/Ministry of Health contributions were NGOs scarce, supporting less than 10% 42.2% of programs in the Region. International Agencies 43.7% Government 9.4% Source: World Bank survey, 2001 94 PRINCIPALBARRIERS ANDNEEDS FOR MORE EFFECTIVE CONTROL OF THE HIV/AIDS EPIDEMIC National HIV/AIDS Programs The main problems faced by national HIV/AIDS programs (cited by 45% of the respondents from the national programs surveyed) are (i) political indecision on the part of government policymakers; and (ii) lack of prioritization of the HIV/AIDS epidemic. This results in insufficient resource allocation to the fight against HIV/AIDS (as mentioned by 40% of national programs), which further exacerbates the problem. National programs also alluded to the difficulties encountered in reaching high- risk and marginalized populations, problems of under-reporting of HIV and/or AIDS cases, lack of sufficient training for health care professions and the lack of a response and social movement against sexual and social taboos, in order to respect the rights of PLWHA. Physicians The group of physicians surveyed mostly associated problems and obstacles with insufficient control and responses from the government, MoH and/or national program. The issues cited involve policy considerations, technical aspects and training for professionals. The main barriers mentioned are: v Inadequate and insufficient information and prevention strategies (62.5%) v Lack of political willingness on the part of governments and national programs (41.7%) v Insufficientepidemiologicalsurveillance (20.8%) v Lack of development of the national program and lack of technical training for national program employees (16.7%) v Religious barriers (16.7%) v Lack of social awareness of the work of NGOs (16.7%) v Discrimination of PLWHA in health care and socialsettings(12.5%) v Lack of access to antiretrovirals (12.5%) v Lack of sexual education in schools (12.5%) v Lack of access to diagnosis and counseling services (8.3%) v Scarcity of policies for safe blood supplies (4.2%) According to the physicians surveyed, the following interventions should be undertaken by national programs: v Adequate information/prevention campaigns for the general population as well as high-risk groups (79%) 95 v Access to antiretroviral treatment for all HIV+ patients, and for HIV+ pregnant women (45.2%) v Increased level of political commitment to the fight against HIV/AIDS, and increased leadership in national programs (25%) v Introduce and/or expand sexual education provided in schools (25%) v Improve the epidemiological surveillance system for HIV/AIDS (20.8%) v Train health care personnel and increase sensitivity to HIV/AIDS (12.5%) v Condompromotion(12.5%) v Define an adequate legal framework for ensuring the human rights of PLWHA (12.5%) v Increased resources for diagnostic services (8.3%) v Bloodsafety programs (8.3%) v Programs for IDUs(4.2%) v Gain consensus on guidelines for diagnosis and treatment of HIV/AIDS (4.2%) v Incorporate clinical perspectives in decisions made by national programs (4.2%) NGOs The group of Latin American NGOs included in the study attributed problems in controlling the epidemic to three primary factors: (i) government policies (or lack thereof); (ii) unmet needs in national programs' activities; and (iii) cultural and social values. Sixty-four percent of all the NGOs surveyed, and 70% of NGOs in the Southern Cone, felt that governments are to blame for political indecision, lack of resources for HIV/AIDS programs, limited access to health services, inadequate legislation and lack of policies for early sexual education. National HIV/AIDS plans, in particular, were strongly criticized from technical perspectives; 78% of NGOs*** made reference to the following aspects: v Limited capacity to obtain and disseminate high-quality information about the dimensions of the epidemic v Lack of a structured, multisectoral plan for responding to the epidemic v Lack of training for technicians responsible for controlling the epidemic at both the national and local levels v Lack of resources for prevention activities, and inadequate and/or ineffective interventions v Lack of sensitivity to the need for sexual education v High cost and lack of access to HIV testing According to 46% of the NGOs surveyed, the community is also responsible for certain problems in fighting HIV/AIDS, such as ***Central American NGOs were even more critical of national programs, with 85% citing these problems. 96 v Cultural and social barriers to sexual dialogue and education v "Macho" attitudes which foster discrimination against women and homophobia v Poverty and low socio-cultural/economicstanding v Stigmatization of PLWHA Sixteen percent of NGOs felt that the Catholic Church blocks many prevention activities, and 10% mentioned lack of health coverage and access to antiretrovirals as key problems. The group of NGOs surveyed proposed the following interventions to improve efforts to control the HIV/AIDS epidemic: v Governments: (i) stronger policy decisions, including prioritization of policies regarding HIV/AIDS and sexual education in schools; (ii) increased resources; (iii) stimulate citizens' movements; (iv) strict penalties for violations of human rights and discrimination against PLWHA. (mentioned by 43% of all NGOs, and 62% of Central American NGOs) v National programs: (i) training for employees/technicians of national programs; (ii) prevention campaigns for high-risk groups; (iii) incorporate sexual education in schools; (iv) develop multisectoral strategies with the capacity to articulate the work among different sectors; (v) improve and disseminate more accurate information about the epidemic; and (vi) introduce and expand policies for integrated, comprehensive management of patients with HIV/AIDS. (mentioned by 94% of NGOs) v Communities: Promote human rights and equality (especially sexual). (mentioned by 7% of NGOs; 12% of Central American NGOs) v Improve access to health services and antiretroviral treatments. (mentioned by 8.5% of NGOs; 17.6% of NGOs in Central America) The NGOs surveyed were also asked to identify barriers to implementing the above- mentioned interventions. Ninety-one percent of NGOs in Central America and Mexico, and 84.8% of NGO group in the Southern Cone mentioned lack of government policy support. National programs were considered to be responsible for lack of coordination and resources for NGOs, as well as attention and services for high-risk groups by 56% of Central American and Mexican NGOs and 61% of Southern Cone NGOs. Thirty-five percent of Central American NGOs surveyed felt that the Catholic Church would be a barrier due to the lack of separation of Church and State, while 30.4% of NGOs in the Andean Region, Brazil and the Southern Cone felt that the community itself would be a barrier in terms of the prevailing "macho" attitudes and other cultural stereotypes. 97 98 ANNEX 3.1 Additional Tables Table A. Collaboration between Ministries of Health and other government institutions in the fight against HIV/AIDS, 2000 Country Ministry of Ministry Ministry Ministry Prisons/ Drug Munici- Sub-region Education of of Labor of Social Ministry Preven- Regions palities Defense Affairs of Justice tion Mexico ü ü ü ü Central America 83.3% 66.7% 33.3% 16.7% 83.3% 66.7% 66.7% Guatemala ü ü ü ü ü El Salvador ü ü ü ü ü Honduras ü ü ü ü ü ü Nicaragua ü ü ü ü ü ü ü Costa Rica ü ü Panama no data no data no data no data no data no data no data no data Brazil ü ü ü ü ü ü ü ü Andean Region 60.0% 20.0% 20.0% 40.0% 40.0% 40.0% Venezuela ü ü ü ü ü Ecuador ü Colombia ü ü ü ü ü Peru no data no data no data no data no data no data no data no data Bolivia no data no data no data no data no data no data no data no data Southern Cone 50.0% 50.0% 75.0% 50.0% 75.0% 75.0% 75.0% 75.0% Argentina ü ü ü ü ü ü Paraguay no data no data no data no data no data no data no data no data Uruguay ü ü ü ü ü ü ü Chile ü ü ü ü ü ü ü ü LATIN 12 8 7 4 11 5 11 11 AMERICA (70.5%) 47.0%) (41.2%) (23.5%) (64.7%) (29.4%) (64.7%) (64.7%) Source: World Bank survey, 2001 99 Table C. Number and percentage of NGOs Table B. Countries with national receiving government funding and participating in commissions for evaluating national or regional HIV/AIDS program evaluation HIV/AIDS prevention and committees, 2000 control activities, 2000 Number and % of Number and NGOs participating Country % of NGOs in national Country National Sub-region receiving HIV/AIDS program Sub-region Evaluation government evaluation Commission funding committee Mexico ü Mexico 5 (100.0%) 3 (60.0%) Central Central America 2 (6.7%) 25 (83.3%) America 5 Guatemala 1 (20.0%) 2 (40.0%) Guatemala ü El Salvador 1 (16.7%) 5 (83.3%) El Salvador ü Honduras no data 4 (100.0%) Honduras ü Nicaragua no data 6 (100.0%) Nicaragua ü Costa Rica no data 5 (100.0%) Panama no data 3 (75.0%) Costa Rica ü Panama no Brazil 5 (100.0%) 5 (100.0%) Brazil ü Andean Region 7 (28.0%) 17 (68.0%) Venezuela 1 (20.0%) 4 (80.0%) Andean Region 3 Ecuador no data 4 (80.0%) Venezuela ü Colombia 2 (50.0%) 2 (50.0%) Ecuador ü Peru 4 (66.7%) 2 (33.3%) Colombia ü Bolivia no data 5 (100.0%) Peru no Bolivia no data Southern Cone 10 (55.5%) 6 (33.3%) Argentina 5 (100.0%) 3 (60.0%) Paraguay 0 2 (50.0%) Southern Cone 3 Uruguay 2 (33.3%) no data Argentina ü Chile 3 (100.0%) 1 (33.3%) Paraguay no Uruguay ü LATIN 29 (34.5%) 56 (67.5%) Chile ü AMERICA Source: World Bank survey, 2001 Latin America 13 Source: World Bank survey, 2001 100 Table E. HIV prevention programs in prisons, 2000 Table D. Percentage of children up to 14 years attending school, Country/Sub-region HIV prevention 2000 programs Mexico ü Countries % Central America 5 Ecuador 30.6 Guatemala ü Nicaragua 32.0 El Salvador ü Honduras 64.0 Honduras no Chile 87.0 Nicaragua ü Paraguay 91.0 Costa Rica ü Mexico 92.1 Panama ü Brazil 95.7 Argentina 96.5 Brazil ü Uruguay 98.0 Andean Region 2 Average 76.3 Venezuela no Source: National programs surveyed Ecuador no Colombia ü Peru ü Bolivia no Southern Cone 4 Argentina ü Paraguay ü Uruguay ü Chile ü LATIN AMERICA 13 Source: World Bank survey, 2001 101 Table F. Interventions for Intravenous Drug Users, 2000 Country Sub-region Drug free/Drug prevention programs Harm reduction programs Mexico ü ü Central America Guatemala ü no El Salvador ü no Honduras no data no data Nicaragua ü ü Costa Rica no data no data Panama no data no data Brazil ü ü Andean Region Venezuela no data no data Equador no data no data Colombia ü Peru no data no data Bolivia no no Southern Cone Argentina ü Paraguay no no Uruguay ü Chile ü Source: World Bank survey, 2001 102 Table G. HIV prevalence among high-risk populations, 2000 Number of Number HIV HIV HIV HIV Country HIV tests of IDUs prevalence prevalence prevalence prevalence Sub-region conducted treated in IDUs in MSM in CSWs in pregnant women Mexico 251,763 800 4.60 15.00 0.35 0.09 Central America Guatemala 4,000 ND ND ND ND ND El Salvador ND ND ND ND ND ND Honduras ND ND ND 8.0 9.9 1.4 Nicaragua 50,000 ND ND 35.0 2.0 0.7 Costa Rica ND ND ND ND ND ND Panama 93,500 ND ND ND ND 0.9 Brazil ND ND 37.0 8.9 7.0 0.5 Andean Region Venezuela 200,000 ND ND 70.0 ND 0.01 Ecuador ND ND ND 11.3 0.6 ND Colombia ND ND ND 18.9 0.1 <1 Peru ND ND ND 11.0 1.2 0.3 Bolivia ND ND ND 0.04 0.03 0.0 Southern Cone Argentina 800,000 1,000 45.9 14.9 1.7 0.7 Paraguay ND ND ND ND ND ND Uruguay ND ND 25.0 21.0 0.4 0.3 Chile ND ND ND ND ND 0.05 Source: National HIV/AIDS programs ND=No Data 103 Table H. Average cost of HIV testing in public and private health centers, according to physicians surveyed, 2000 Cost in public Cost in private Country health centers health centers Sub-region (US$) (US$) N=22 N=46 Mexico 19.0 106.0 Central America (average) 15.6 49.0 Guatemala 5.0 71.3 El Salvador 18.7 58.3 Honduras no data 35.0 Nicaragua 10.0 15.0 Costa Rica 35.0 no data Panama 14.0 32.5 Brazil free 32.5 Andean Region (average) 25.4 54.3 Venezuela 82.0 95.0 Ecuador 43.0 25.3 Colombia 10.0 40.0 Peru 23.4 74.2 Bolivia 8.5 23.7 Southern Cone (average) 50.2 Argentina no data 112.5 Paraguay no data 25.0 Uruguay no data 5.7 Chile no data 10.0 LATIN AMERICA 20.9 56.7 (average) Source: World Bank survey, 2001 104 Table I. Laboratory testing of CD4 and viral load counts, and cost of HIV/AIDS health services, 2000 Number of Number of Number of HIV/AIDS Country laboratories Number of laboratories viral load health Sub-region* performing CD4 counts testing viral tests services CD4 counts performed load performed costs (US$) Mexico 9 920 3 1,831 24,800,000 Central America Honduras 2 no data 1 no data 20,288,461 Nicaragua 1 no data 0 no data no data Panama 4 1,200 2 625 no data Brazil 73 207,500 65 203,100 no data Andean Region Venezuela 2 12,000 2 12,000 no data Ecuador 0 no data 1 no data no data Peru 5 no data 3 no data no data Southern Cone Argentina 125 no data 8 14,760 no data Uruguay 12 2,700 12 1,300 no data Chile 1 5,000 2 6,000 6,116,866 Source: World Bank survey, 2001 *No data from other countries 105 Table J. Percentage of patients who pay for testing, cost per test and number of tests per patient per year, 2000 % Cost CD4 % Cost Viral % Cost per Test of Country patients per tests patients per load patients test of resistance Sub-region paying CD4 per paying viral count paying for resistance per for count patient for viral load per tests of (US$) patient CD4 (US$) per load test patient resistance per year counts year counts (US$) per year Mexico 82.00 83.75 2.20 85.80 125.00 1.60 76.67 491.33 ND Central America 54.56 88.93 2.59 66.47 221.21 2.71 87.50 675.00 1.00 (average) Guatemala 83.33 38.67 1.67 100.00 146.67 1.67 100.00 850.00 ND El Salvador 60.00 113.00 2.40 75.00 265.50 2.20 100.00 ND ND Honduras 67.33 39.33 2.67 100.00 266.67 ND 100.00 ND ND Nicaragua 100.00 250.00 2.00 100.00 300.00 3.50 100.00 ND ND Costa Rica 0.00 67.50 3.67 0.00 102.50 3.67 0.00 ND 1.00 Panama 30.00 150.00 4.00 30.00 290.00 4.00 100.00 500.00 1.00 Brazil 0.00 ND 3.40 0.00 ND 3.20 80.00 425.00 ND Andean Region 61.59 35.20 2.38 68.00 185.23 2.08 81.82 551.29 0.57 (average) Venezuela 51.25 27.33 2.67 53.75 222.60 2.33 100.00 800.00 0.500 Ecuador 70.00 20.00 2.00 52.50 155.00 2.00 100.00 ND ND Colombia 26.25 53.25 3.00 50.00 139.50 3.00 50.00 539.75 0.200 Peru 100.00 30.00 1.33 100.00 246.00 0.67 100.00 450.00 1.00 Bolivia 55.67 20.00 2.50 ND 50.00 ND ND ND ND Southern Cone 22.27 52.88 3.00 19.82 134.38 2.90 100.00 338.00 2.17 (average) Argentina 11.67 64.33 4.00 5.67 200.00 4.00 100.00 445.00 3.00 Paraguay 10.00 100.00 2.50 10.00 150.00 2.00 ND ND ND Uruguay 23.33 0.00 2.00 23.33 0.00 2.00 ND ND ND Chile 40.00 43.33 3.33 37.00 108.33 3.00 100.00 266.67 0.500 LATIN AMERICA 47.93 63.74 2.67 52.77 181.63 2.52 84.84 485.42 1.275 (average) Source: World Bank Survey 2001 ND=no data 106 ANNEX 3.2 Legal Restrictions to Homosexuality Guatemala: There are some gaps in the legislation, but there are punitive repercussions (according to 1 NGO). Special legal restrictions exist against transvestites (according to 1 NGO). Nicaragua: Penalties according to Law 150, article 204 (cited by 4 NGOs). Costa Rica: Legal restrictions exist. The General Law for treatment of AIDS is not generally followed (according to 1 NGO). Mexico: Subject to "police repression as an illegal activity" (according to 1 NGO). Argentina: Subject to imprisonment, involvement of law enforcement officials. The law does not permit homosexual couples, and there are edicts and police norms against homosexual behavior. Brazil: Couples are not legally recognized, therefore benefits cannot be shared and couples may not adopt children (cited by 3 NGOs). Peru: Formal marriage is not allowed, inheritance of goods and money is prohibited, as is adoption. Uruguay: Legal restrictions exist. Same sex couples are not legally recognized and are not mentioned in Family Rights laws. Bolivia, Honduras, Panama, El Salvador, Colombia, Chile, Ecuador and Venezuela: No comments 107 108 CHAPTER 4 KEY AREAS FOR INTERVENTION AND CHALLENGES AHEAD Summary Despite relatively high rates of HIV infection in most countries, and the lack of effective interventions carried out thus far, Latin America has the necessary infrastructure to efficiently and effectively confront the HIV/AIDS epidemic, if provided with the necessary resources. This chapter highlights the main areas in need of improvement, strategies that might make national responses more effective, and the principal challenges to implementation. High-risk groups constitute the majority of HIV infection and are the groups most likely to spread HIV, yet interventions for these groups are still not widespread. The implementation of interventions for these groups, as well as school-based sexual education and HIV/AIDS information programs stand to contribute greatly to the fight against HIV/AIDS. Guidelines for prevention interventions are needed, concentrating on interventions that have been most effective. Review and revision of blood safety policies would begin the process of achieving universal testing of donated blood and acceptance of only voluntary, altruistic, non-remunerated blood donations. Multisectoral coordination is an indispensable condition for producing synergies, long-lasting social and political agreement and increasing the intensity and scope of interventions. Health care coverage, social and psychological support are also key challenges. Health care coverage is a necessary condition for improving impacts and guaranteeing the effectiveness of interventions, yet many people infected with HIV do not have access to health care. Lack of resources and medical training are the main deficiencies within the health care setting. Promotion of HIV testing, especially among high-risk populations, is a basic and essential strategy, and expansion of centers for anonymous diagnosis, counseling and treatment is urgently needed for early diagnosis, health care access, treatment and prevention. The coverage of current interventions for decreasing mother-to- child transmission of HIV requires more action, since coverage is still low. Universal availability of HIV testing to pregnant women, and incorporating HIV testing into the battery of prenatal diagnostic tests would help prevent mother-to-child transmission. At the same time, social and psychological support services are still poor and limited. Including a fight against ignorance and promotion of human rights in the messages delivered to the general population, health and social services personnel would help ensure the right to health care, "normalization" of HIV/AIDS, access to HIV testing and implementation of universal precautions. Indeed, these factors are the key elements for reducing rejection based on bias and social stigma, and increasing knowledge. There is a need for more information about the epidemic and its trends. One of the main priorities is the production of high quality epidemiological information for decision-making. To this end, technicians working for national programs need training in prevention, management and epidemiological surveillance. Based on the findings of this study, the main challenges to meeting the current needs are (i) availability of resources; (ii) institutional capacity to provide training in all areas; and (iii) cultural, social and religious factors. Coordinated and targeted interventions from various agencies, NGOs and governments may guide future region-wide interventions. 109 110 INTRODUCTION As in many countries, the multiplicity of health problems affecting Latin America inhibited recognition to the need for a dedicated, tailored response to the HIV/AIDS epidemic, and its serious consequences in terms of morbidity and mortality and its capacity for aggravating existing health problems (i.e. tuberculosis and other infectious diseases). As a result, HIV/AIDS was not given priority among health concerns until international organizations and social movements gained significant social and political importance and the epidemic demonstrated how lethal it can be, not only in terms of health care, but also in terms of social and economic consequences Since the late 1980's Latin American countries have confronted the HIV/AIDS epidemic through creating new structures and showing the social fabric necessary to promote community responses178,179,180,181,182,183,184,185. Latin American national HIV/AIDS programs have a tradition of carving out their own unique roles and responsibilities within ministries of health, and benefit from the involvement of multidisciplinary professionals and sectors. There has been tremendous progress in management capacity and articulating social responses. The Latin America Region has an excellent framework for effective interventions with multilateral and/or bilateral organizations; the resources infrastructure and professionals are in place to implement a variety of interventions, evaluate their impact and sustain them over time. However, the capacity to respond has been limited by political, technical and social problems. These limitations were confirmed by the national program directors, health professionals and NGOs interviewed. Despite the political commitment of governments to confront the epidemic, as evidenced by the prioritization of HIV/AIDS in health care agendas and the HIV/AIDS-related legislation throughout the Region, limited resources and high turnover of personnel have been serious obstacles to fully effective responses. The technical capacity of national entities to offer a stronger response has been constrained by the same problems. A significant proportion of physicians mentioned deficiencies in prevention strategies (62% of the physicians group), epidemiological surveillance (20% of physicians) or in the technical capacity of professionals working in national programs. NGOs were even more concerned with the technical training needs for national program professionals; 78% mentioned this. Finally, social, cultural and religious values have also been significant barriers to an adequate response to the epidemic in certain sub-regions. Overall, the study shows a high level of consensus among physicians and NGOs, shared in a lesser degree by national programs, regarding the problems faced in fighting HIV/AIDS. 111 This chapter synthesizes the areas in need of improvement and recommends strategies that may make national responses more effective, taking into account the principal challenges to implementation. As a whole, this document also aims to help countries tailor the Global Strategy Framework186 to their local context, depending on the key problems identified. Recommendations are intended to strengthen the health sector response, in terms of expanding its influence in neglected areas and by entering into multisectoral partnerships. Finally, although this chapter does not delve into the roles and responsibilities of other sectors, it takes into account the advances in strategic thinking and the elements of a successful multisectoral response to the epidemic. NATIONALRESPONSETO THE EPIDEMIC: PREVENTION Key problems Although there have been numerous programs and campaigns for the general population, fewer prevention activities for high-risk groups have been conducted in many countries. The reason for this could be a substantial lack of information on the level of infection and trends in these groups. With the exception of Mexico and Honduras, the respondents from national programs felt that they did not have opportune data on prevalence rates in different populations, or data were inconsistent when compared with different sources. Information collected from respondents showed that men who have sex with men (MSM) have been the target of prevention programs in most countries, although there are gaps in some Central American and Southern Cone countries. At the same time, according to those interviewed, 41% of countries developed CSW programs as late as 1999-2000 and they are not widespread in all sub-regions. In the most affected areas, interventions for injecting drug users (IDUs) are still insufficient. Harm reduction programs are relatively new in Argentina, Chile, Mexico and Brazil, and their scope depends on the level of political commitment, a favorable legal framework and the capacity for health, social and community responses to the problem of injecting drug use. Recent adoption of new policies has led to interventions that meet the needs in these countries, but at the same time, respondents from countries strongly affected, such as Colombia and Paraguay, did not claim to have programs, and data collected from Uruguay showed only drug-free programs, which are not as effective as harm reduction programs. Although 70% of countries stated that they have programs for prisoners, with the exception of Mexico, it was reported that these programs were only recently started (1999-2000) and coverage is low. Honduras and most countries from the Andean Region lack prisoners programs. Aside from the challenges of expanding health education programs, counseling and promoting diagnostic testing and condom use, there is the additional challenge of introducing harm reduction programs and 112 coordinating with external health services, especially in prisons with high rates of injecting drug use. Health and sexual education programs for adolescents and young people are the most widespread interventions in Latin America. According to the respondents, 47% of countries have school-based programs and 29% carry out occasional activities, yet the contents are not always appropriate due to religious or cultural censor, social conservativism and frequent political veto. Of those interviewed, 25% of physicians and 90% of NGOs mentioned the need to improve and expand these programs. In terms of high-risk groups, only respondents from half the countries surveyed indicated that they have programs for adolescents who do not go to school, or those considered "high-risk". The promotion of condom use for young people has met cultural and religious barriers, which are significant challenges to the control of the HIV/AIDS epidemic. Interventions for the general population, which were reported as more widespread and frequent in the Region, have not always obtained the anticipated results in terms of creating the climate of solidarity and confidence necessary for effective prevention, according to the perception of the respondents. Study data indicated that the frequency of campaigns in the last 10 years was low in the Southern Cone and Andean Region. Only 25% of countries have programs for promoting condom use, despite the fact that sexual transmission is the most prevalent way in which HIV is contracted in Latin America. Seventy-nine percent of physicians felt that it is necessary to develop better prevention strategies for the general population and high- risk groups. Indeed, there a significant difference between the more widespread interventions for the general population with greater visibility and political impact, and those for high-risk groups, which are much more cost-effective mechanisms for controlling the spread of the epidemic. In terms of multisectoriality, Latin American countries have developed strategic plans with participation from a broad range of stakeholders (i.e. various government ministries, civil society, associations of people living with HIV/AIDS, bilateral and multilateral partners), and they serve as the common reference for action. Now, plans are ready to become reality. Data from the study group showed that the levels of multisectoral coordination are unequal among countries in the Region. The study also showed that although there are structures in place to foster multisectoral coordination in almost all countries, the level of true collaboration is still low due to a lack of resources and coverage for coordinated execution of interventions. Community-based movements have a strong tradition in Latin America, primarily in countries with more economic potential and where there are government-financed programs (i.e. Southern Cone countries, Brazil and Mexico). However, most Latin American NGOs finance their own programs, or receive financing from international agencies; only 34% of NGOs surveyed had received government funding in the last 5 years. The level of NGO representation in national programs and commissions is high, and 67% of the NGOs surveyed belong to national committees. Still, NGO 113 respondents indicated that there is limited coordination between NGOs and governments in interventions for specific populations. NGOs are much more likely to have access to marginal populations, or those that lack health services, yet most NGOs and governments dedicate the majority of their efforts to groups with "variable risk" for infection (i.e. the general population, young people, women, etc.). Almost half of the targeted NGO programs (48%) are focused on young people and women, while CSWs or MSM are the focus of only 25% of such programs. Interventions addressing the problems identified Enhance approaches that focus on social mobilization and building community responses, which combine and reinforce strategies for risk, vulnerability and impact reduction. Stronger involvement and continued pressure from civil society may be the only way to expand the response to HIV/AIDS in the near future. It is essential to strengthen civil society organizations dealing with HIV/AIDS as well as those working on development, human rights, gender and other issues. Ultimately, communities and civil society, including associations of PLWHA are the basis of the response to HIV/AIDS in the Region. Intensify interventions for high-risk groups since this is where the highest levels of infection are found, and since they are the groups most likely to spread HIV to other groups and the general population187. The interventions could combine risk reduction with other strategies that focus on vulnerability and impact reduction, which implies decreased stigma, policy development, and care and support that work to create incentives for early detection, thereby reinforcing prevention efforts. Multisectoral coordination, in government and non-government institutions, is an indispensable condition for producing partnerships, long-lasting social and political agreement and increasing the intensity and scope of interventions. In all Latin American countries, sexual activity is the most prevalent way HIV is spread, which means that it is critical to have interventions focused on decreasing the risk of infection for MSM, CSWs and people with STIs and/or multiple partners. Strategies that have proven their effectiveness include counseling, health education, condom use promotion, promotion of HIV testing, management of STIs and promotion and preservation of human rights188,189,190,191,192,193,194,195,196,197. Collaboration with STI clinics, creation of a network of anonymous diagnosis centers and access to free services are key elements for successful programs. Collaboration with gay organizations in planning programs for MSM would do much for the development of services and prevention messages that respond to the needs and communication norms of this group198. The Network of MSM for Latin America and the Caribbean could strengthen effective approaches focusing on social mobilization and building community responses. 114 Due to their constant exposure to risk, male and females CSWs are a key group for prevention of HIV/AIDS199,200,201,202. Interventions to decrease vulnerability for CSWs are highly cost-effective in terms of reducing the possibility of transmitting HIV to clients (usually men) and their partners (often women of childbearing age and possibly their children)203. A variable percentage of CSWs are also injecting drug users, so their risk of becoming infected is even greater. Therefore, harm reduction programs (needle exchange or distribution of "kits" or sterile needles) might do well by targeting areas frequented by CSWs, especially in countries where IDU prevalence rates are high. Male CSWs are exposed to even greater risk, given the frequency of services they provide204 to other men. Finally, transvestite and transsexual CSWs require specially-tailored programs, due to their unique socio- cultural characteristics and sexual identity. Access to health centers and STI clinics for CSWs plays an important role in preventing transmission, promoting HIV testing and the diagnosis and treatment of STIs205,206. Ideally, these centers would offer free services and be accessible to all CSWs, men and women, regardless of where they work. IDUs are one of the groups most at-risk for contracting HIV and disseminating it to the general population. A substantial proportion of IDUs rarely use health services, so it is important to implement community-based outreach programs207,208. With the exception of Brazil and Mexico, such programs have been scarcely developed in Latin America. Harm reduction programs are most effective for preventing transmission of HIV and other blood borne diseases, as well as for achieving higher quality of life and health for IDUs209. In the most affected countries, there is a need for the initiation or expansion of harm reduction programs that address the specific substances injected (heroin, cocaine, etc.). Programs for needle-exchange, training on how to clean injecting drug equipment, outreach programs for drug addicts and diagnosis of HIV and other infections are crucial for treating this high- risk group210,211,212,213,214,215,216. Prevention of sexual transmission is another challenge for IDUs, since they place their partners at great risk of becoming infected. Mass condom distribution associated with harm reduction programs and health education for IDUs, their friends, family and partner(s) are much-needed interventions. Given the needs for prevention, health care and social resources, mobile units for dissemination of prevention materials and needle exchange are potentially key resources for guaranteeing the coverage and continuity of interventions. Intensifying programs for reducing vulnerability with a focus on adolescents and young people is an essential step. To this end, sexual education and HIV/AIDS information for adolescents and young people are key217. Integration of such programs into school curriculums, and involvement of ministries of education in these activities would guarantee continuity and expansion of school-based HIV/AIDS and sexual education and peer relations that model safer behaviors. These programs would reinforce condom use, making condoms accessible to young 115 people through distribution in areas frequented by young people in schools and universities218. There is also a significant percentage of children who do not go to school (especially in Central America). In such cases, it is necessary to implement health and sexual education activities outside of the school environment. Outreach programs can be very effective for reaching these children. Due to the high-risk environment in which they live, prisoners also require interventions218. Health education and human rights programs are fundamental for creating favorable conditions for behavior change for prisoners. Active participation of prison health authorities and responsible ministries is crucial for the expansion and continuity of these activities. Promotion of voluntary HIV testing, access to health care219, diagnosis and treatment of STIs, condom distribution and harm reduction programs for IDUs220 are important elements in the control of HIV in prisons221. These services could be coordinated with health and preventive services working with the general population222 since many prisoners will eventually be released and will require further treatment, particularly prisoners who are also IDUs. The HIV/AIDS impact on women and girls calls for strong efforts addressing the factors that place them in disadvantaged situations, increasing their risk (i.e., ability to negotiate sex, access to preventive services) and decreasing their sense of control over their own lives. Gender policies that strengthen and build women's empowerment and capacity for sexual negotiation are very effective223, especially for women at high-risk (i.e. sexual partners of IDUs, or PLWHA, women with STIs, residence in high prevalence areas, etc.), but are underdeveloped in Latin America. Analysis of this situation justifies the development of policies and interventions to reduce vulnerability at the individual and community level, and demonstrates a need for continuous coordination between governments and NGOs, including an increase in the participation of NGOs in planning national responses to the epidemic. Indeed, coordination among governments, NGOs and international financing agencies is an urgent need given the lack of strategies that could help reduce the risk of infection and its negative consequences in high-risk populations, especially those most marginalized (CSWs, IDUs and MSM in certain sectors of the population) and most reachable through NGO-led interventions. 116 ACCESS TO HEALTHAND SOCIAL SERVICES Key problems It is estimated that a substantial proportion of people infected with HIV do not have adequate health care. The reasons for this are diverse, including limited access to services, the cost of services including those provided in public hospitals, clinical care below quality standards, lack of infrastructure for prevention programs in health care environments and insufficient psychological and social services. Only six countries in Latin America offer universal health care coverage (Costa Rica, Brazil, Venezuela, Argentina, Chile and Paraguay); in the other countries, health care is guaranteed for clients with insurance, while the rest must pay out-of-pocket for services. In Central America, coverage under social security systems is scarce and payment for services is more common. The cost of HIV testing is high, even in public centers. The average cost of the test is US$20. In Latin America, there are few clinical management guidelines for HIV/AIDS that are reasonable in relation to countries' resources, particularly in the Southern Cone and the Andean Region, and guidelines for prophylaxis indications were reported in only 15.6% of countries in the Region. Physicians and national programs surveyed in this study agreed that medical training is one of the main deficiencies in health care. This was mentioned as an important problem by governments (especially in Central America) and physicians throughout the countries surveyed. Respondents from Mexico, Brazil and the Andean Region considered themselves most in need of improvement. All three groups surveyed (physicians, NGOs and national programs) provided inconsistent information regarding the availability of prevention programs in health centers; only national programs confirmed availability of such programs. Psychological and social services were considered insufficient by governments, physicians and NGOs. According to the physicians surveyed, 63% of patients receive adequate clinical management, according to current quality standards. Central American countries (primarily Honduras and Nicaragua) and the Andean Region are working to improve the quality of clinical care provided. In the physicians' opinion, coverage of prophylactic measures against opportunistic infections has been estimated at only 13% in Brazil, and from 45% and 57% in Panama, Argentina and Mexico; regional coverage is about 72%. New antiretroviral therapies have resulted in increased quality of life and survival for people living with HIV/AIDS (PLWHA)224,225. However, the situation is not so simple ­ treatment must be followed for a lifetime; insufficient prescriptions, misuse or missed doses can generate resistances and increase the possibility of transmitting 117 resistant strains of the virus226. In order for ARV therapy to be effective, broad health resources infrastructure is needed, including specialized laboratories and infectious disease services in hospitals, capable of complying with quality standards. By strengthening current infrastructure and training physicians, the Region could soon use new treatments more effectively. According to estimates from the surveyed physicians and governments, between 44% and 55% of PLWHA receive ARV therapy, yet there is wide disparity between countries; coverage is notably low in Central America. Health resources infrastructure varies in terms of levels of development and accessibility throughout Latin America. Many countries are immersed in reform processes, which can impact the level of attention given to patients and the quality of health care. At the same time, there are general deficiencies in areas such as resources infrastructure, especially the network of HIV diagnostic laboratories, labs for determining CD4 levels and viral load, as well as infrastructure for diagnosis and follow-up on coinciding infections and other disease processes associated with HIV/AIDS. According to the national programs, the network of laboratories is insufficient, especially in Central America and the Andean Region. Access to services is limited by the payment required; almost half of patients must pay out-of- pocket for CD4 level tests, and even more must pay for viral load testing. Consequently, only half of PLWHA (48%) have had at least one viral load and CD4 test, according to the physicians surveyed. Coverage in Brazil and Central America was particularly low, at 8% and 29% respectively. There is an unquantified, yet substantial, proportion of infected people who do not know that they are HIV positive, and who will probably only know when late, undeniable symptoms of infection are present. According to the physicians surveyed, 67% of people infected with HIV/AIDS access services for the first time at advanced stages of infection, or when they have already progressed to AIDS. The latest diagnoses are found in Central America, where eight out of every ten patients access health services with advanced infection or AIDS. This situation is even more serious for women planning to have children, or pregnant women, because in these cases early diagnosis is essential to ensure access to treatments that may prevent mother-to-child transmission. Overall, improvements are needed for early diagnosis, access to counseling and follow-up lab testing. Although more than 50% of physicians and NGOs participating in the study feel that HIV testing is accessible, there are still barriers to coverage that have implications for supply and demand. These barriers include discrimination, specificity/uniqueness of the test and consequently the unlikelihood of it being offered in most clinics, cost, and availability of health centers and the test itself. Finally, interventions for decreasing mother-to-child transmission of HIV in health centers require more action, since coverage is still low, according to the survey. Only 52% of pregnant women in Latin America are offered the HIV test; Central America and Mexico have the lowest rates of offering HIV testing to pregnant women. Even more worrisome is the fact that only 56% of HIV positive pregnant women receive ARV prophylaxis, which can prevent mother-to-child transmission. 118 Interventions for addressing the problems identified All interventions aimed at improving health and social services require multisectoral collaboration227. Coordination among those responsible for health and social services in governments, regions, states and municipalities is key. In many countries, it is necessary to expand coverage of health services for HIV/AIDS patients in order to provide maximum quality of care (clinical follow-up, prophylaxis against opportunistic infections, diagnosis and treatment of pathology associated with HIV/AIDS and palliative care for terminally ill patients). There are certain prerequisites that could make this possible, including (i) strengthening the network of health centers and hospitals; (ii) increased services for people without health care coverage; and (iii) training in clinical management and treatment of HIV and other STIs for physicians, pediatricians and nurses. In addition, expansion and wide coverage of quality health care for HIV/AIDS is one of the key elements for guaranteeing the effectiveness of ARV therapy228. Promotion of the HIV test, especially among high-risk populations, is a basic strategy at the regional level. Expansion of centers for anonymous diagnosis, counseling and treatment229,230 would help reach the goal of adequate coverage, early diagnosis and health care for PLWHA, as well as prevention for those who are at high-risk. When such services are well-publicized in different communities problems of discrimination and stigmatization are avoided and populations who would not access the test elsewhere are attracted. Health care professionals in these centers require training in prevention, education, counseling and management of emotionally difficult situations. Training in syndromic management of STIs is also highly recommended. Universal offering of HIV testing to pregnant women and its incorporation into the battery of prenatal diagnostic tests would go a long way toward preventing mother-to-child transmission231,232,233,234. The current guidelines for clinical management, treatment for pregnant women, and prophylaxis with ARV therapy may only be followed when services are adequately and appropriately planned, so collaboration with professional associations of gynecology, obstetrics, midwifery, community health workers, pediatrics, managers of prenatal services and citizens organizations is imperative. Taking this a step further, maternal and child postpartum care is also important, including counseling on continued care needed and feeding strategies. Laboratory networks are in need of strengthening and expansion in all of Latin America in order to ensure that services offered meet the needs of patients. Laboratories conducting CD4 and viral load tests may work toward carrying out at least two tests per year, per patient. Training for laboratory technicians is also necessary to ensure knowledge of current and new, upcoming techniques, as well as tests used for diagnosis and determining resistances. 119 Policies for multisectoral integration also have implications for physicians, whose representation and voice in national programs has been lacking. Partnerships and dialogue between physicians and national programs would help to: (i) develop guidelines and recommendations for clinical management and treatment, based on current quality standards and adapted to the patients' needs and resources available; and (ii) guarantee consideration of the physicians' perspective when decisions are made by national programs. HUMANRIGHTS Key problems Among the main barriers to improved effectiveness of programs and expanding access to prevention and clinical care are lack of information, stigmatization, homophobia and social prejudices regarding sexual orientation or behavior. These barriers affect the general population, as well as health care and social services professionals. Ninety-four percent of the NGOs surveyed confirmed social or legal restrictions to homosexuality. There are still significant barriers preventing PLWHA from accessing health centers, which impedes fair and equitable treatment and generates more stigmatization and rejection. Interventions to address these issues are scarce, and there are numerous obstacles that people at high-risk or HIV+ face when trying to access services for prevention, diagnosis and treatment. In terms of human rights for PLWHA, discrimination and employment difficulties (primarily regarding access) are the main challenges mentioned by Latin American NGOs. Interventions that address the problems identified A fight against ignorance and promotion of human rights235 should be part of the message delivered to the general population, as well as health and social services personnel. Communication and media messages about the right to health care236, "normalization" of HIV/AIDS, access to HIV testing and implementation of universal precautions would help to reduce rejection and stigmatization of PLWHA in the health care environment. In coordination with national education authorities and interdisciplinary teams, programs addressing the issue of schooling for HIV positive children would benefit many through guaranteeing the right to an education. The right to work and integration or re-integration in the workforce237,238,239 chould be reinforced through a collaborative effort with ministries of labor and social issues; this is crucial for reducing stigmatization of HIV/AIDS. In addition, equal work conditions for PLWHA are fair and just measures, as is voluntary access to health check-ups and transparency of health screening in order to avoid possible discrimination and other negative consequences faced by PLWHA. 120 Involving PLWHA in all strategies for prevention and control of the epidemic is a key to success. This involvement can work to reduce stigma and discrimination toward PLWHA and radically change their position in society. Finally, the right to access health, social and psychological services and to a dignified death must be ensured, and is particularly a challenge for NGOs, justice authorities and prison institutions. NATIONALCAPACITY: STRUCTURE ANDMANAGEMENT Key problems All countries have multisectoral plans to confront the epidemic, but the actual functionality and capacity for a collaborative response has been mediated by the technical and political capacity of national programs and by limited resources available for HIV/AIDS control. Forty-one percent of physicians surveyed identified the need to strengthen leadership in national programs and create greater political commitment, while 94% of NGOs mentioned the need to strengthen training and improve interventions in national programs. The level of integration and commitment of community-based movements and the creation of networks is still limited in most countries. Thus, most social and psychological services for PLWHA are provided by NGOs; government involvement is lacking. International agencies have an important role in responding to the epidemic, financing national programs and many Latin American NGOs. Although most national programs stated that the level of coordination with international agencies is high, the programs implemented through such collaborative efforts do not always meet the needs of the population. For instance, 48% of NGO programs target populations that are easy to access through multisectoral structures or programs, which neglects high-risk and hard-to-reach populations. Health sector reforms currently underway are another obstacle to plans for integrated HIV/AIDS services in Latin America, but eventually advancement of these reforms will result in greater coordination among different levels of specialization and complexity, and progressively incorporate prevention strategies in the services provided. In clinical management of HIV/AIDS patients, prevention is an essential component that may benefit the patient, friends, family, and partner(s)240,241. Epidemiological surveillance systems in Latin America vary in terms of level of development, but their overall capacity to provide the information needed is low. Availability of systematized information on the incidence of newly diagnosed HIV infections and sentinel surveillance coverage (especially among the most affected groups) is scarce throughout the Region. Registries of AIDS cases, which have existed the longest suffer high levels of under-reporting in certain sub-regions, 121 especially Central America. Consequently, services and programs are planned, interventions are evaluated, and decisions are made based on partial information that is not always adequate for decision-making. Surveillance infrastructure is limited and there is a critical need for technical training for surveillance professionals in order to attain greater quality and applicability of information generated, particularly in Central America. Higher levels of development and implementation are needed in the surveillance of HIV infection, behavioral risk factors and the information systems used, in order to better meet the current needs. The main challenge for epidemiological surveillance is to develop activities based on the characteristics and evolution of the epidemic, with an aim toward sustainability over time and capacity to produce data that is comparable and consistent at the national and international level. Safe blood supply programs are heterogeneous throughout the Region, so blood or blood products are not as safe as desired in certain countries. Indeed, in most countries less than 100% of donated blood is screened for HIV. The greatest deficiencies in blood testing are found in Central America and the Andean Region, particularly Bolivia where increased coverage is urgently needed. Blood donation policies have not been adapted to meet the necessary quality standards in which donation is exclusively voluntary, altruistic and non-remunerated. For instance, aside from Argentina, Brazil and Honduras, where blood donation is always voluntary and never remunerated, the rest of Latin American countries allow both voluntary and remunerated donations, which have been proven to be less safe. Interventions that address the problems identified Ministries of health and national programs require improved and increased infrastructure and resources to consolidate and lead multisectoral, national responses to the HIV/AIDS epidemic. Active participation of NGOs, states, regions, municipalities and international agencies is imperative for establishing prevention and control policies, especially for high-risk and vulnerable populations. To this end, NGO networks deserve much encouragement and support. Such networks would coordinate interventions and, with national programs, prioritize the main areas for activities. One of the main priorities is the production of adequate and appropriate epidemiological information for decision-making242,243,244,245. Training programs covering methodology, epidemiological surveillance and data for decision making are needed for all those working in surveillance. National plans for epidemiological surveillance, containing priorities and specific working protocols are urgently needed for homogenizing and increasing efficiency in the production of information. The involvement of physicians and public and private health centers is fundamental for reducing under-reporting. Guidelines for prevention interventions are needed, consolidating those interventions that have been most effective. These guidelines would have the 122 consensus of the different actors involved and would include protocols for programs targeting different groups. Interventions are needed at different levels in order to reach those at greatest risk. The elimination or minimization of legal barriers to prevention methods and health care for IDUs (legalized sale and distribution of sterile needles, etc.), MSM (elimination of discriminatory norms) and CSWs (ensure access to health care) would greatly improve efforts in these high-risk groups. Ideally, blood safety policies would be revised to achieve universal testing of donated blood, and acceptance of only voluntary, altruistic, non-remunerated donations. In order to cover all these needs and improvements, it is necessary to guarantee personnel with training in epidemiological surveillance, HIV/AIDS prevention, coordination with NGOs and other government or regional institutions, planning, blood and blood products control and safety, clinical management and management of health care services. In order to guarantee the efficacy and sustainability of the interventions needed, the continuity of professionals, in terms of roles and positions, must be ensured within the scope of HIV/AIDS services. Main challenges in implementing the recommended interventions The difficulties in carrying out a more effective response to the HIV/AIDS epidemic are multiple and, in many cases, similar to those facing other health problems in Latin America. An increase in available resources is a key element for confronting the epidemic. In the last five years, multilateral organizations such as UNAIDS have stimulated the creation of networks for linking national programs, in order to analyze and design responses throughout the Region. However, policy strength and international involvement has not always led to increased budgets, or greater political willingness to create solid, sustainable organizations and structures. Another substantial problem lies in the institutional capacity to provide a response that is effective, and the capacity of universities to ensure that the response is within the range of professional training (clinical, prevention, epidemiological surveillance, planning, etc.). The continuity of professionals with appropriate technical training is subject to political changes, availability of sufficient personnel and resources, which is a handicap for the consistency and quality of interventions implemented. Finally, cultural, social and religious factors constitute barriers that, in many countries, obstruct good technical proposals or government decisions that could protect public health and the overall well-being of citizens. In virtually all of Latin America, it is very difficult to separate religious and cultural beliefs from the role of the State. 123 CONCLUSIONS Strategies for addressing HIV/AIDS are tailored to different settings based on their own unique dynamics. HIV/AIDS in Latin America falls within the framework of a low endemic setting. For the most part, the epidemic is concentrated in populations with increased risk for contracting HIV. In the countries studied, the populations identified as key groups for interventions include MSM, STI patients, CSWs, IDUs and prisoners. Survey respondents also identified other populations with increased vulnerability in which interventions would be crucial (e.g. young people and women). People living with HIV/AIDS (PLWHA) are a priority group, since they are crucial for effective prevention interventions, as well as a source of infection when access to preventive services and health care are poor. Latin America has the necessary infrastructure and knowledge to efficiently and effectively confront the epidemic, if provided with the necessary resources. The needs vary, so it is important to adjust the interventions to respond to each country's profile and capacity. Country fact sheets follow this report, and identify the main areas for improvement and propose solutions for each individual country. Given the great value-added of appropriate allocation of national resources for an expanded response to the epidemic, international agencies and programs are in a position to increase regional or sub-regional interventions in concrete areas. Cooperation would lead to multiple returns from effective interventions, as well as a positive cost-benefit ratio. Results from this study show that the areas requiring the most attention for interventions in the Region are as follows: - Strengthening national HIV/AIDS programs, working collaboratively with civil societies. - Enhanced approaches focusing on social mobilization and building community responses. - Reducing the risk of infection by expanding programs for the populations at highest risk (i.e. harm reduction for IDUs, counseling, condom promotion and sexual education). - Fortifying risk and vulnerability reduction programs for populations at the highest risk for infection. - Reduced vulnerability through improving access to services for the populations at highest risk. - Establishing the health care setting as a key point for prevention strategies, ensuring that people living with HIV are included as target populations within prevention interventions. - Building human capacity in different areas of expertise. - Improved capacity for monitoring and evaluation of the magnitude of the epidemic and the response. - Definition of the costs of interventions, financial gaps and resource allocation strategies related to the response to HIV/AIDS. 124 - Supportive legal and social norms (i.e. regarding gender, equity, human rights, stigma). - Systematic inclusion and active engagement of PLWHA. 125 126 Appendix.1 COUNTRY FACT SHEETS (PLEASE NOTE THAT IN SOME COUNTRIES, THE PREVALENCE RATESIN CERTAIN HIGH RISK GROUPS WERE NOT AVAILABLE. THEREFORE, THEY ARE NOT INDICATED/INCLUDED ) 127 128 MEXICO HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group 0.29% of adult population estimated to be living with HIV/AIDS at the end of 1999 150,000 people estimated to be living with HIV/AIDS at the end of 1999 4,204 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Mexico à MexicohasthethirdlargestnumberofAIDScasesintheAmericas,behindtheUnitedStates and Brazil. à MigrantworkersreturningfromtheU.S.infecttheirpartners;agreaterproportion à More rural than urban cases are female à HighratesofSTIsandlowratesofcondomuse Approximate HIV Prevalence in High Risk Groups HIV Prevalence in Pregnant Women: >10% >10% 0.6% (1994); 0.09% (1996-1998) CSWs IDUs 5%-10% 5%-10% <5% <5% Re$ources: The national >10% program receives most of its financial support from the Federal MSM 5%-10% Government, and some from <5% international agencies. A portion is dedicated to NGOs. Modes of Transmission in Reported AIDS Cases (1983-1999) Other Heterosexual 1% Transmission Unknown 22% 31% Major Mode of Transmission: Sex between men Contaminated Blood Products 7% Injecting Drug Sex between Mother-to-Child Use Men Transmission 1% 37% 1% 129 ISSUESANDCHALLENGES: Prevention Adolescents Status: Therearenoadolescent-focused programs carried out in collaboration with the Ministry of Education. Challenge(s): Sexual education and HIV/AIDS education should be introduced in the school curriculum, and interventions for high-risk adolescents are needed. MSM Status: Some programs underway Challenge(s): - Programs underway should be expanded, in collaboration with gay-focused NGOs, states and municipalities. - Information and education programs should be strengthened, including education on correct condom use, targeting areas frequented by MSM (i.e. saunas). -Social, cultural and legal barriers to homosexuality must be reduced. IDUs Status: Current harm reduction programs offer little coverage. Challenge(s): - Programs are needed for needle exchange, promotion of HIV testing, health education and methadone substitution. Programs should be carried out by NGOs, in collaboration with the National Drug Program. - The infrastructure of centers for drug addicts should be strengthened. Prisoners Status: Prison programs are scarce and have limited scope. Challenge(s): - Programs are needed for promotion of condom use, HIV testing and health education. - Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. - Programs should target the prisons with the highest prevalence of IDUs. NGO Program Funding Challenge: Program funding should prioritize IDUs and CSWs. Vertical Transmission Status: Coverage of HIV testing for pregnant women is only 5% Challenge(s): Coverage of HIV testing for pregnant women should be expanded and all HIV+ pregnant women should be provided with ARV. ISSUESANDCHALLENGES: Care Diagnosis Status: 60% of patients are diagnosed at advanced stages of infection. Access to testing is limited by lack of demand, discrimination, scarcity of healthcare professionals who recommend it, high cost and scarcity of anonymous diagnosis centers. Challenge: Anonymous diagnosis centers should be established in high prevalence areas, and the HIV test should be promoted among MSM, CSWs and IDUs. Follow-up testing Status: 65% of HIV/AIDS patients have had CD4 and viral load counts. Challenge: The network of laboratories should be strengthened and expanded to increase coverage of diagnostic and monitoring tests. 130 Prophylaxis against opportunistic infections Status: Coverage is limited (only 57% of patients) Challenge: Continuoustraining in the care and treatment of HIV/AIDS patients and associated infections is needed in clinics. Psychological and social support and workplace integration activities Status: These activities offer limited coverage. Challenge: Programs should be organized that respond to these needs, in collaboration with self- supported NGOs and social and labor ministries. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 18.5%, with regional variations. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance should be facilitated, at least in large cities. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision- making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establishaltruistic,voluntaryandnon-remunerated donations as the only option for donation or transfusion. 131 BRAZIL HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group 0.60% of adult population estimated to be living with HIV/AIDS at the end of 1999 540,000 people estimated to be living with HIV/AIDS at the end of 1999 18,000 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Brazil à BrazilhasthesecondlargestnumberofAIDScasesintheAmericas. à InjectingdruguseisincreasinginimportanceasarouteofHIVtransmission. à Theepidemicisconcentratedinthesoutheast,butisspreadingtothenortheast. à Locally produced generic antiretroviral medications are provided by the Government to PLWHA. Approximate HIV Prevalence in High Risk Groups HIV Prevalence in Pregnant Women: 0.6%-1.5% STI clinic >10% IDUs >10% (2.6%-3.3% in Porto Alegre) Patients 5%-10% (36%) 5%-10% <5% <5% Re$ources: Receives financial support from international agencies >10% >10% and finances NGOs. CSWs Prisoners 5%-10% 5%-10% <5% <5% Modes of Transmission in Reported AIDS Cases (1980-1999) Unknown Heterosexual 19% Transmission Major Mode of Transmission: Sex between men Contaminated 19% Blood Products 3% Sex between Injecting Drug Men Use 29% Mother-to-Child 27% Transmission 3% 132 ISSUESANDCHALLENGES: Prevention MSM Status: Prevalence among MSM is high. Some programs are underway. Challenge: Programs already in place should be expanded, in collaboration with gay-focused NGOs, states and municipalities. Information and education programs should be strengthened, including education on correct condom use. Such programs should target areas frequented by MSM, including saunas. IDUs Status: Current harm reduction programs have recently started and offer limited coverage. Challenge: Needle exchange programs are needed, especially through outreach programs. Pharmacists and health centers should be involved in needle exchange programs in order to increase coverage. CSWs Status: Some programs in place, with limited coverage. Challenge: Coverage of programs needs to be expanded, including programs for male CSWs. NGO programs should prioritize CSWs working on streets and in clubs. Prisoners Status: Prison programs have recently begun, and rates of HIV infection are high. Challenge: Programs for prisoners need to include promotion of HIV testing, diagnosis and treatment of STIs and health education. Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. These programs should target the prisons with the highest prevalence of IDUs and should be coordinated with services provided outside prisons to ensure continuity. Vertical Transmission Status: Only 50% of pregnant women are offered HIV testing and only 40% of HIV+ pregnant women receive ARV prophylaxis. Challenge: HIV testing should be offered to all pregnant women and ARV prophylaxis should be increased for HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: 75% of patients are diagnosed at advanced stages of infection, or when they have already progressed to AIDS. Challenge: In order to promote early diagnosis, testing should be promoted through the creation and expansion of anonymous diagnosis centers and programs for high-risk groups, including people with STIs. Follow-up tests Status: Only 8% of patients have had CD4 and viral load counts. The laboratory network is limited in terms of coverage in states and municipalities. Challenge: The network of laboratories should be strengthened and new laboratories should be incorporated to increase availability of CD4 and viral load tests. Prophylaxis against opportunistic infections Status: Coverage is very low (13%). Challenge: Continuous training in the management and treatment of HIV/AIDS patients, in accordance with current norms and standards. Psychological and social support and workplace integration activities Status: These activities offer limited coverage. 133 Challenge: In collaboration with NGOs and social and labor ministries, programs should be organized to improve social and psychological care in some areas. ARVTreatment Status: A substantial proportion of HIV+ patients (85% by government estimate) who have indications for ARV, receive HAART. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimatedatabout5%-10%, which is probably under-estimating the true rate of under- reporting. Challenge: HIV/AIDS case notification systems should be more exhaustive, and already -existing systems for active surveillance should be facilitated. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision- making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information sy stems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. HIV/AIDS Registry Status: There has been increased access to ARV treatment and the reduction in AIDS cases and mortality Challenge: Create a universal registry of HIV infection. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establishaltruistic,voluntaryandnon-remunerated donations as the only option for donation or transfusion. 134 PANAMA HIV/AIDS EPIDEMIC STATUS: Low Level <5% in high-risk groups 1.5% of adult population estimated to be living with HIV/AIDS at the end o f 1999 24,000 people estimated to be living with HIV/AIDS at the end of 1999 1,200 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Panama à Panama has the second-highest HIV/AIDS rate in Central America, but surveillance data from high-risk groups is lacking à HIV and STIs are increasing à 5.8%ofprisonersreportedHIV-positivein1991 Approximate HIV Prevalence in HIV Prevalence in Pregnant Women: High Risk Groups up to 0.9% >10% CSWs 5%-10% <5% Re$ources: The national program receives financial support from international agencies, and does not finance national NGOs. Panama' national program is the newest HIV/AIDS national program in Latin America, and it has not yet articulated an integrated national response. Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Injecting Drug Use Unknown Major Mode of Transmission: Heterosexual Sex Mother-to-Child 2% 7% Transmission 5% Heterosexual Transmission Sex between 52% Men 34% 135 ISSUESANDCHALLENGES: Prevention General Population Status: Prevention and information campaigns have been insufficient. Challenge: Morecampaignspromotingcondomuseamongyouthsareneeded. Youths and Adolescents Status: There are no school-based prevention programs. Challenge: - Sexual education and HIV/AIDS education should be introduced in the school curriculum, in collaboration with national education authorities. - Health education programs specifically targeting high-risk adolescents should be developed. MSM Status: There are no programs for MSM. Challenge: - A national strategy for MSM interventions should be designed, in collaboration with the national and/or local gay movements. - NGO programs should prioritize MSM. CSWs Status: There are no programs for CSWs. Healthcare control is obligatory, but individuals must pay for services. Challenge: - A program is needed to provide information, promote HIV testing and distribute condoms to CSWs, as well as improve and expand access to health centers and STI centers where free services could be obtained. - NGOs working with street pr ostitutes should be supported. Prisoners Status: A program for prisoners is underway, but offers little coverage. Challenge: This program should be expanded to promote access to HIV testing, STI diagnosis and condom distribution. Vertical Transmission Status: It is unknown how many pregnant women are offered the HIV test, or how many received ARV prophylaxis. Challenge: Coverage of HIV testing for pregnant women should be evaluated, and access to prophylaxis for HIV+ pregnant women should be promoted. Access to condoms Status: Condoms are only available in pharmacies and supermarkets. Challenge: Condoms should be available in more locations, especially places where CSWs and MSM frequent, as well as in youth and education centers. Community movements and NGOs Status: Community and NGO involvement with HIV/AIDS is scarce. Challenge: Community responses need to be strengthened, and NGOs should be supported and new ones should be introduced. ISSUESANDCHALLENGES: Care Diagnosis Status: Barriers to HIV testing include scarcity of demand and discrimination. 136 Challenge: Anonymous diagnosis centers should be expanded, and the HIV test should be offered in STI diagnosis and treatment centers. Follow-up tests Status: Coverage of laboratory tests is limited. Only 24% of HIV/AIDS patients have had CD4 and viral load counts. Challenge: The network of laboratories providing these tests should be strengthened and expanded. Prophylaxis against opportunistic infections Status: Coverage of prophylaxisagainst opportunistic infections is low (45%). Challenge: Continuous training in the management of HIV/AIDS patients is needed in clinics. This training should include current recommendations for prophylactic measures and ARV therapies. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 32%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision- making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. Case reporting Status: Cases are reported by clinicians, as well as people outside the medical field. Challenge: Normsareneeded to exclusively delegate case notification responsibilities to healthcare personnel (clinicians or laboratory personnel). 137 ISSUESANDCHALLENGES: BLOODSAFETY Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 138 NICARAGUA HIV/AIDS EPIDEMIC STATUS: Low Level <5% in high-risk groups 0.2% of adult p opulation estimated to be living with HIV/AIDS at the end of 1999 4,900 people estimated to be living with HIV/AIDS at the end of 1999 360 people estimated to have died from HIV/AIDS in 1999 Some Important Points about HIV/AIDS in Nicaragua à >50%ofreportedAIDScasesarefromManagua à No surveillance data on HIV prevalence in pregnant women are available à Gonorrheaandsyphilisratesarehigh;reported condom use is low Approximate HIV Prevalence in High Risk Groups Blood Donors: >10% 0.05%-0.09% MSM >10% CSWs >10% 5%-10% 5%-10% <5% 5%-10% <5% <5% Re$ources: The national program receives support from international agencies, and finances NGOs. Distribution of Modes of Transmission in Reported AIDS Cases (1987-1999) Injecting Drug Contaminated Use Blood Products Major Mode of Transmission: Mother-to 7% 1% Heterosexual Sex -Child Heterosexual 1% Transmission Sex between 49% Men 42% 139 ISSUESANDCHALLENGES: Prevention Youths and adolescents Status: Formal education coverage is very low (32%). Challenge: Programs for adolescents attending school should be expanded, and programs should be started or expanded for high-risk adolescents and those who do not atten d school. MSM Status: Some programs underway. Challenge: It is necessary to expand programs for MSM in large cities. Toll free information hotlines may facilitate this. CSWs Status: Some programs underway. Challenge: It is necessary to expand programs for CSWs, especially in large cities. Prisoners Status: Programs for prisoners are fairly new and offer little coverage. Challenge: These programs should be expanded to cover more prisoners, and should include condom distribution and health education. ISSUESANDCHALLENGES: Care Diagnosis Status: Almost all HIV/AIDS patients are diagnosed at the point of advanced infection or full-blown AIDS. HIV testing is free in some health centers. Challenge: - Eliminate the main barriers to testing: (i) professionals often do not offer the test; and (ii) social discrimination issues. - To facilitate earlier detection, HIV testing should be promoted and should be made more available in health centers. Follow-up tests Status: The network of laboratories offering CD4 and viral load counts is insufficient. Less than 1% of HIV/AIDS patients have had a CD4 and/or viral load count. Challenge: It is necessary to broaden the services offered by laboratories. Treatment Status: 72% of patients do not take ARVs because they lack the financial resources, and only 3% of HIV/AIDS patients are on HAART. Challenge: Improve the percentage of patients receiving the treatment they need. Social and psychological help and workplace integration Status: Coverage of these activities is low. Challenge: Resources should be increased for health centers as well as NGOs so that they may provide more psychological and social services. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting 140 Status: Estimated at about 60%. Challenge: HIV/AIDS case notification systems should be more exhaustive, andsystems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntaryandnon-remunerated donations as the only option for donation or transfusion. 141 GUATEMALA HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group <1% in pregnant women, up to 1.7% in urban lowlands and about 0% in highlands. 1.4% of adult population estimated to be living with HIV/AIDS at the end of 1999 73,000 people estimated to be living with HIV/AIDS at the end of 1999 3,600 people estimated to have died from HIV/AIDS in 1999 Approximate HIV Prevalence in HIV infection is still low or absent in high-risk groups highland regions; AIDS knowledge is >10% very limited among indigenous CSWs 5%-10% highland groups and must be <5% improved to avoid rapid spread. Re$ources: The national program receives support from international agencies, and does not finance NGOs working with HIV/AIDS. Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Mother-to-Child Contaminated Transmission Blood Products 5% 2% Major Mode of Transmission: Sex between Men Heterosexual Sex 17% Heterosexual Transmission 76% 142 ISSUESANDCHALLENGES: Prevention General population Status: Therehave been few information/communication campaigns, and none of the campaigns thus far have promoted condom use. Challenge: Campaigns fighting discrimination and promoting condom use should be developed and implemented. Youths and Adolescents Status: There are no school-based prevention programs, but rather occasional school-based activities. Challenge: Sexual education and AIDS education should be introduced into the school curriculums, in collaboration with national education authorities MSM Status: Some programs underway. Challenge: Programs currently underway need to be expanded and coordinated with NGOs working in the large cities. Programs should focus on access to HIV testing, health education and promotion of condom use. CSWs Status: Someprograms are in place. Challenge: It is necessary to expand programs for CSWs, especially Guatemala City and other large cities. These programs should include information campaigns, promotion of HIV testing, condom distribution and improved access and r esults from health centers and STI treatment and diagnosis centers. Prisoners Status: There is only one program in place, and coverage is low. Challenge: More programs are needed to promote HIV testing, distribute condoms and provide health education. NGO priorities Challenge: NGOs should prioritize MSM and CSWs in their activities, and maintain the current level of involvement with young people. Vertical transmission Status: It is unknown how many pregnant women are offered the HIV test, and ARV prophylaxis against vertical transmission is low (9%). Challenge: The HIV test should be offered to all pregnant women in the most affected areas, and ARV prophylaxis should be given to all HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: It is not easy to access the HIV test. The majority of patients are diagnosed at advanced stages of infection. The main barriers to testing are the cost, and issues of social discrimination. Challenge: Anonymous HIV diagnosis centers are needed,and testing should be promoted in high-risk groups. Follow-up tests Status: Laboratory infrastructure is insufficient; only 1/3 of patients receive the necessary tests (only 34% have had CD4 and viral load counts). Challenge: The laboratory network should be strengthened and broadened to provide more diagnostic and monitoring tests. Social Assistance Status: Limited. Challenge: Programs should be developed to give support to PLWHA, in collaboration with ministries of social affairs, labor ministries and NGOs. 143 Treatment and Prophylaxis against opportunistic infections Status: There is good coverage of medications to fight opportunistic infection, but unfortunately coverage of ARV treatment is low (22%). 64% of patients do not take ARVs due t o lack of financial resources. Challenge: Increase coverage ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 50%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and thereis no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 144 EL SALVADOR HIV/AIDS EPIDEMIC STATUS: Concentrated 75% of reportedcases are from San Salvador >5% in at least one high-risk group <1% in pregnant women 0.6% of adult population estimated to be living with HIV/AIDS at the end of 1999 20,000 people estimated to be living with HIV/AIDS at the end of 1999 1,300 people estimated to have died from HIV/AIDS in 1999 Re$ources: The national program does not receive HIV Prevalence in Women of support from international agencies, and does not Childbearing Age: finance HIV/AIDS NGOs. 0.5% (0-1.1%) Approximate HIV Prevalence in high-risk groups >10% >10% >10% MSM I IDUs STI 5%-10% 5%-10% Patients 5%-10% 0.13% 1996-97 in <5% <5% <5% blood donors >10% >10% CSWs 5%-10% Prisoners 5%-10% <5% <5% Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Injecting Drug Use Unknown 1% Major Mode of Transmission: 19% Heterosexual Sex Mother-to-Child Transmission 3% Heterosexual Sex between Transmission Men 65% 12% 145 ISSUESANDCHALLENGES: Prevention General population Status: There have been few campaigns for the general population, and very few focused on condom promotion. Challenge: Campaignsfighting discrimination and promoting condom use should be developed. Adolescents Status: There is no plan in the Ministry of Health (MoH) for including sexual education or AIDS education in the school curriculums. Challenge: In collaboration with the MoH, sexual education, AIDS and drug education programs should be initiated in schools, beginning in the areas with highest HIV prevalence. MSM Status: There are no programs for MSM; only occasional activities. Challenge: A national strategy for interventions targeting MSM should be designed, in collaboration with the national and/or local gay movements. The majority of NGO programs should prioritize MSM. CSWs Status: Some programs are underway. Challenge: It is necessary to expand programs for CSWs, especially in the large cities. These programs should include information campaigns, promotion of HIV testing, condom distribution and improved access and results from health centers and STI treatment and diagnosis centers. Prisoners Status: There is only one program for prisoners, which offers little coverage. Challenge: This program should be expanded and more should be developed to promote access to HIV testing, STI diagnosis and provide health education. NGO priorities Challenge: NGO programsshould prioritize MSM and CSWs. Vertical Transmission Status: It is unknown how many pregnant women are offered the HIV test, or how many received ARV prophylaxis. Challenge: HIV testing should be offered to all pregnant women in the most affected regions, and ARV prophylaxis should be given to all HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: It is not easy to access the HIV test. 60% of patients diagnosed with HIV presented at advanced stages of infection. The main barrier s to testing are the cost and issues of social discrimination. Challenge: Anonymous diagnosis centers should be established, and HIV testing should be promoted in high-risk populations. Follow-up tests Status: Half of HIV/AIDS patients have had a CD4 count, and only 4% have had a viral load count. Challenge: The network of laboratories providing these tests should be strengthened and expanded to provide greater coverage of diagnostic and monitoring tests. Social support and workplace integration Status: These activities are still weak. Challenge: Community self-help initiatives should be promoted, as well as social programs for PLWHA, in collaboration with social and labor ministries. Treatment Status: Coverage of ARV treatment is low (14%). 52% of HIV/AIDS patients are not on ARV therapy because they lack financial resources. 146 Challenge: Increase coverage. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 40%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information planis needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. Case reporting Status: Cases are reported by clinicians, as well as people outside the medical field. Challenge: Norms are needed to exclusively delegate case notification responsibilities to healthcare personnel (clinicians or laboratory personnel). ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policiesareneededtoestablishaltruistic,voluntaryandnon-remunerated donations as the only option for donation or transfusion. 147 HONDURAS HIV/AIDS EPIDEMIC STATUS: Generalized 1.9% of adult population estimated to be living with HIV/AIDS at the end of 1999 63,000 people estimated to be living with HIV/AIDS at the end of 1999 4,200 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Honduras à HondurashasthehighestprevalenceofHIVinLatinAmerica à Nearlyasmanyfemalesasmalesareinfected,andAIDSistheleadingcauseofdeath among women of childbearing age à GarífunashaveHIVinfectionratessixtimesthenationalaverage Re$ources: The national program Approximate HIV Prevalence in High Risk receives support from international Groups agencies, and finances HIV/AIDS NGOs. >10% >10% MSM Prisoners HIV Prevalence in Pregnant Women: 5%-10% 5%-10% 1.4% overall; 2-5% San Pedro Sula <5% <5% >10% CSWs 5%-10% Blood donors: <5% Tegucigalpa 0.6% San Pedro Sula 1% Distribution of Modes of Transmission in Reported AIDS Cases (1985-1999) Other Unknown 17% Major Mode of Transmission: 11% Heterosexual Sex Heterosexual Mother-to Transmission -Child 59% 4% Sex between Men 9% 148 Issues and Challenges: Prevention General population Status: Somecampaignsunderway Challenge: More campaigns fighting discrimination and promoting condom use should be implemented. Youths and adolescents Status: Coverage of sexual education and AIDS education programs is about 50% in public schools. Challenge: - Coverage of school-based programs should be increased, especially in the most affected cities. - Efforts should be focused on high-risk adolescents, as well as those who do not attend school. MSM Status: Programs are in place, but coverage is low. Challenge: Current programs should be strengthened and expanded, in collaboration with MSM-focused NGOs. Information, health education and instruction on condom use should be emphasized, and these programs should reach out to MSM in their communities. CSWs Status: Some programs are underway. Challenge: Expand programs for CSWs in the large cities. These programs should include information campaigns, promotion of HIV testing, condom distribution and improved access and results from health centers and STI treatment and diagnosis centers. Prisoners Status: There arecurrently no programs for prisoners. Challenge: Interventions for prisoners should be designed and implemented, focusing on health education, condom distribution and access to health services, STI and HIV diagnosis. Vertical Transmission Status: Very few pregnant women are offered the HIV test (8%), and very few HIV+ pregnant women receive ARV prophylaxis (20%). Challenge: All pregnant women in the most affected areas should be offered HIV testing, and ARV prophylaxis should be provided to all HIV+ pregnant women. NGO Funding Challenge: Funding allocated to NGOs should prioritize those with interventions for MSM and CSWs. ISSUESANDCHALLENGES: Care Diagnosis Status: It is not easy to access the HIV test due to social discrimination, cost and the infrequency of healthcare professionals' recommendations for testing, or offering of the HIV test. 60% of patients diagnosed with HIV presented at advanced stages of infection. Challenge: - Anonymous diagnosis centers should be established, and HIV testing should be promoted in high- risk populations. - Symptomatic management of STIs should be expanded, and HIV testing should be more frequent in patients presenting with suspected STIs. Follow-up Tests Status: Very few HIV/AIDS patients have had CD4 and/or viral load counts (only 3%), and the laboratory network is not capable of providing the necessary coverage. Challenge: The network of laboratories providing these tests should be strengthened and expanded to provide greater coverage of diagnostic and monitoring tests. Social support and workplace integration Status: Activities are still weak. 149 Challenge: Community self-help initiatives should be promoted, as well as social programs for PLWHA, in collaboration with social and labor ministries. Treatment Status: 86% of HIV/AIDS patients are not on ARV therapy because they lack financial resources, and only 3% of HIV/AIDS patients are on HAART. Challenge: There is a great need for training healthcare professionals in clinical management and treatment of HIV/AIDS patients. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 47%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. Case reporting Status: Cases are reported by clinicians, as well as people outside themedical field. Challenge: Norms are needed to exclusively delegate case notification responsibilities to healthcare personnel (clinicians or laboratory personnel). 150 COSTA RICA HIV/AIDS EPIDEMIC STATUS: Concentrated <5% in high-risk groups 0.53% of adult population estimated to be living with HIV/AIDS at the end of 1999 12,000 people estimated to be living with HIV/AIDS at the end of 1999 750 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Costa Rica à UniversalsocialsecurityprovidesHIV/AIDScare,includingantiretroviraltherapy,toall. à HIV/AIDS infections areconcentrated in urban zones. à CostaRicaisuniqueinCentralAmericaforthepredominanceofmenwhohavesexwithmen among reported AIDS cases. Approximate HIV Prevalence in High Risk Groups Re$ources: The national program >10% >10% receives support from international agencies, and does not finance HIV/AIDS MSM 5%-10% CSWs 5%-10% <5% <5% NGOs. >10% 5%-10% HIV Prevalence in Pregnant Women: STI patients <5% <0.5% Distribution of Modes of Transmission in Reported AIDS Cases (1983-1999) Contaminated Blood Products Injecting Drug Use 8% Unknown 2% 3% Heterosexual Mother-to- Transmission Child 18% 2% Major Mode of Transmission: Sex between men Sex between Men 67% 151 ISSUESANDCHALLENGES: Prevention General population Status: Information and prevention campaigns have been scarce, and none have promoted condom use. Challenge: More campaigns should be carried out for the general population and youths, focusing on promoting condom use. Youths and adolescents Status: There are currently no school-based programs. Challenge: Sexual education and HIV/AIDS education should be incorporated into school curriculums, in collaboration with national education authorities. MSM Status: Thereare currently no programs for MSM, but rather, occasional activities. Challenge: - A national strategy for MSM initiatives should be designed, in collaboration with the national and/or local gay movements. - NGO programs should prioritize MSM. CSWs Status: Only occasional activities have been carried out, and there have been no interventions for male CSWs or transvestites. Challenge: It is necessary to develop a program including information campaigns, promotion of HIV testing, condom distribution and im proved access and results from health centers and STI treatment and diagnosis centers. Prisoners Status: Some programs are underway. Challenge: More interventions for prisoners should be designed and implemented, focusing on health education, condom distribution and access to health services, STI and HIV testing and diagnosis. Vertical Transmission Status: Universal testing is recommended for all pregnant women, but actual coverage is unknown. Challenge: Evaluations of the rate at which testingis offered and carried out should be conducted, and HIV testing should be offered more frequently. CondomAccess Status: Access is limited. Challenge: More condoms should be available at pharmacies and supermarkets, areas frequented by MSM, education centers and universities. ISSUESANDCHALLENGES: Care Treatment Status: Healthcare and treatment coverage is very high. Challenge: Programs are needed to train healthcare professionals in clinical management of HIV/AIDS patients and administration of ARV therapies. Social support and workplace integration activities Status: Still weak. Challenge: Self-supported community initiatives should be promoted, as well as social programs for PLWHA, in collaboration with social and labor ministries. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. 152 Challenge: National protocols forHIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimatedatabout 50%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especiallyhigh-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems fr om the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with otherforms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 153 BOLIVARIAN REPUBLIC OF VENEZUELA HIV/AIDS EPIDEMIC STATUS: Low Level <5% in high-risk groups 0.49% of adult population estimated to be living with HIV/AIDS at the end of 1999 62,000 people estimated to be living with HIV/AIDS at the end of 1999 2,000 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in the Bolivarian Republic of Venezuela à Little information about the HIV/AIDS epidemic in B.R. Venezuela is available; data suggest the epidemic may be more advanced than official statistics indicate. à HIVisbelievedtobeincreasingintourist,industrial,andminingareas. à B.R. Venezuela's highest HIV prevalence is reported from Caribbean islands (i.e. Margarita Island) Re$ources: The national program Approximate HIV Prevalence in High Risk Groups receives support from international agencies, and does not finance HIV/AIDS >10% >10% NGOs. Prisoners CSWs 5%-10% 5%-10% <5% <5% HIV Prevalence in pregnant women: 0.0% (1996) Distribution of Modes of Transmission in Reported AIDS Cases (1983-1999) Contaminated Other Unknown Heterosexual Blood Products 4% 10% Transmission 4% 19% Injecting Drug Major Mode of Transmission: Use Sex between men 2% Mother-to-Child Sex between Transmission Men 1% 60% 154 ISSUESANDCHALLENGES: Prevention Young people and Adolescents Status: Some programs underway. Challenge: Programs are needed for high-risk adolescents. Such programs should be extended in the main urban areas MSM Status: Some programs underway. Challenge: - Programs already underway should be expanded and coordinated with NGOs in large cities. - Programs should be based on increasing access to HIV testing, health education and promotion of condom use. IDUs Status: There are currently no programs for IDUs. Challenge: Outreach programs for IDUs are needed which could promote HIV testing, information dissemination and education. These programs should also promote condom use and needle-exchange. Prisoners Status: There are currently no programs for prisoners. Challenge: Programs should be implemented to promote HIV testing, distribute condoms and provide health education. NGO Priorities Challenge: NGO programs should prioritize MSM, CSWs and IDUs. Access to condoms Challenge: - Marketing strategies should be implemented to increase availability of condoms in key areas (areas frequented by MSM and CSWs and schools). - Condom quality control is also needed. ISSUESANDCHALLENGES: Care Diagnosis Status: 60% of patients diagnosed with HIV presented at advanced stages of infection. Challenge: - Anonymous diagnosis centers should be established. - Testing should be promoted in high-risk populations. Follow-up Tests Status: The laboratory network providing CD4 and viral load counts is small, yet over 80% of patients have had a CD4 and viral load count. Challenge: The current laboratory network should be evaluated and strengthened to increase the number of laboratories providing CD4 and viral load tests. Treatment Status: Less than 50% of patients receive ARV treatment; about 30% of patients do not receive ARVs due to lack of financial resources. Challenge: Increase the percentage of patients receiving the treatment they need. Social services Status: Limited. Challenge: Support programs should be implemented for PLWHA, in collaboration with social and labor ministries, through NGOs. 155 ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: No available data, but estimated to be high. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoringinterventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 156 COLOMBIA HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group <1% in pregnant women 0.45% of adult population estimated to be living with HIV/AIDS at the end of 1999 120,356 people estimated to be living with HIV/AIDS at the end of 1999 1,423 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Colombia à HIVprevalenceamongteenCSWshasbeenreportedatmorethan10% à Sex between men is thepredominant mode of transmission in the highlands, while heterosexual transmission is more important along the Atlantic Coast. Approximate HIV Prevalence in high-risk groups HIV Prevalence in pregnant >10% >10% women: 0.1%-0.7% MSM 5%-10% STI 5%-10% <5% Patients <5% <1% in blood donors >10% CSWs 5%-10% Re$ources: The national program does <5% not receive support from international agencies, but it does finance HIV/AIDS NGOs. Distribution of Modes of Transmission in Reported AIDS Cases (1983-1999) Heterosexual Unknown Transmission 28% 30% Mother-to-Child Major Mode of Transmission: Transmission Sex between men 2% Sex between Men 40% 157 ISSUESANDCHALLENGES: Prevention General population Status: Somecampaignsunderway. Challenge: Campaigns for the general population should be intensified, based on fighting discrimination and promoting condom use. Young people and Adolescents Status: There is no sexual education or HIV/AIDS education program in the current school curriculum, nor are there interventions for high-risk adolescents. Challenge: In collaboration with the Ministry of Health, programs should be designed to incorporate sexual education and HIV/AIDS education in schools. These programs should be carried out in collaboration with youth organizations and NGOs focused on high-risk adolescents. MSM Status: Programs have only recently started and require greater strengthening and expansion. Challenge: Programs should be developed, in collaboration with NGOs andmembers of the gay movement, focusing on promotion of HIV testing, health education and promotion of condom use. CSWs Status: Some programs underway. Challenge: Programs should be expanded in large cities to increase access to HIV testing, improve diagnosis and treatment of STIs and promote systematic condom use. IDUs Status: Substantial numbers of IV cocaine and heroin users have been found in Colombia. Challenge: Outreach programs are needed to access IDUs and promote HIV testing, needle exchangeand condom use. Prisoners Status: There are no programs for prisoners. Challenge: Extensive programs should be implemented that promote HIV testing, distribute condoms and provide health education. NGO priorities Challenge: The majority of NGO programs should prioritize MSM and IDUs. Vertical Transmission Challenge: HIV testing should be offered universally to all pregnant women, and vertical transmission should be reduced through prophylactic ARV treatment. ISSUESANDCHALLENGES: Care Diagnosis Status: 50% of patients diagnosed with HIV presented at advanced stages of HIV infection, or with full- blown AIDS. Challenge: Anonymous diagnosis centers should be promoted and HIV testing should be made more available in STI treatment centers. Treatment Status: The level of ARV treatment coverage is low. Psychological and social support and workplace integration Status: Activities are limited. Challenge: In collaboration with self-supported NGOs and social and labor ministries, programs should be organized that respond to these needs. 158 ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 80%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. HIV/AIDS Registry Status: There has been increased access to ARV treatment and the reduction in AIDS cases and mortality Challenge: Create a universal registry of HIV infection. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation, and less than 100% of the blood supply is tested. Challenge: - Policies are needed to establish altruistic, voluntary and non -remunerated donations as the only option for donation or transfusion. - Blood testing should be increased, and the blood bank network needs to be strengthened. 159 ECUADOR HIV/AIDS EPIDEMIC STATUS: Low level <5% in high-risk groups 0.3% of adults estimated to be living with HIV/AIDS at the end of 1999 19,000 people estimated to be living with HIV/AIDS at the end of 1999 1,400 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Ecuador à Data on HIV/AIDS are scarce à Sexually transmitted infections are veryprevalent among CSWs and adolescents. à Condom use and availability are low There is no multisectoral plan for fighting HIV/AIDS. HIV Prevalence in pregnant Consensus should be sought among all the relevant women: players (ministries, professionals and NGOs). 0.05% (0.3% in Guayaquil) Approximate HIV Prevalence in high-risk groups >10% 0.26% in blood donors STI Patients 5%-10% <5% Re$ources: The national program receives support from international agencies, but does not finance HIV/AIDS NGOs. Distribution of Modes of Transmission in Reported AIDS Cases (1986-1999) Injecting DrugUnknown Use 4% 1% Other Heterosexual Mother-to-Child 1% Transmission Transmission 34% 1% Major Mode of Transmission Sex between men Sex between Men 59% 160 ISSUESANDCHALLENGES: Prevention General population Status: Activities have been scarce. Challenge: Campaigns for thegeneral population (targeting adults and young people) should be planned, based on fighting discrimination and promoting condom use. Adolescents: Status: There is no sexual education or HIV/AIDS education in schools. The level of schooling up to 14 years of age is very low (only 36%). Challenge: - In collaboration with the Ministry of Education, a program should be designed to incorporate HIV/AIDS education in the school curriculum in areas with high prevalence. - Programs should also be anticipated for high-risk adolescents who do not attend school. These programs could be implemented through NGOs. MSM Status: There are no programs for MSM. Challenge: - Interventions should be implemented to promote education, prevention and HIV testing, as well as condom use, in collaboration with NGOs working with the gay movement. - STI diagnosis centers and centers offering anonymous HIV testing should be expanded and upgraded. CSWs Status: There are programs, but coverage is limited. There are no programs for male CSWs. Challenge: - Programs should be implemented to promote information, prevention and promotion of HIV testing and condom use, in collaboration with NGOs. - Male and female CSWs should be provided easy access to STI centers for diagnosis and treatment of STIs and HIV testing. Prisoners Status: There are no programs for prisoners. Challenge: Programs should be implemented that promote HIV testing, distribute condoms, and provide information. CondomAccess Status: Access is limited. Challenge: Programs are needed to market condoms and increase availability in areas frequented by MSM, young people and CSWs. Access should also be increased in commercial centers. Vertical Transmission Status: The HIV test is not systematically offered to all pregnant women, and the level of coverage with ARV prophylactic treatment is unknown. Challenge: In collaboration with gynecological associations and health services, HIV testing for pregnant women should be expanded in areas of high prevalence, and ARV prophylactic treatment should be guaranteed for all HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to HIV testing is limited by the cost, discrimination and lack of demand. Most patients diagnosed with HIV presented at advanced stages of HIV infection. Challenge: Anonymous diagnosis centers should be established in high prevalence areas, where diagnosis would be offered free-of-charge. Follow-up Tests Status: Only 33% of patients have had CD4 and viral loadcounts. 161 Challenge: The diagnostic laboratory network should be strengthened. Opportunistic Infections and Treatment Status: Coverage of diagnosis and treatment of opportunistic infections is low. Over 50% of patients receive HAART; 36% of patients do n ot receive treatment due to lack of financial resources. Challenge: Improve diagnosis and treatment of opportunistic infection, and increase the percentage of patients receiving the treatment they need. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: No available data, but estimated to be high. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all per sonnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 162 PERU HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group <1% in pregnant women 0.35% of adult population estimated to be living with HIV/AIDS at the end of 1999 48,000 people estimated to be living with HIV/AIDS at the end of 1999 4,100 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Peru: à HIV/AIDSisconcentratedamongthepoorincoastalcities,especiallyinLima à HIVisincreasinginIquitosasaresultofgaytourism. à Sexuallytransmittedinfections(STIs)arehigh,buttreatmentisrarelysought. Approximate HIV Prevalence in high-risk groups Re$ources: The national program receives support from international >10% >10% agencies, but does not finance HIV/AIDS MSM 5%-10% STI Patients 5%-10% NGOs. <5% <5% HIV Prevalence in pregnant >10% >10% CSWs IDUs women: 0.23%-0.58% in 15-24 5%-10% 5%-10% year-olds in Lima (0.3% in 1999) <5% <5% 0.24% in blood * Data from 1986-1990 donors Distribution of Modes of Transmission in Reported AIDS Cases (1983-1999) Contaminated Blood Products Unknown 2% 10% Other 3% Mother-to-Child Heterosexual Transmission Transmission 2% 41% Major Mode of Transmission: Sex between men and heterosexual Sex between transmission Men 42% 163 ISSUESANDCHALLENGES: Prevention General population Status: Campaigns for information and prevention have been scarce, as well as condom promotion campaigns. Challenge: Campaigns for the young people and adults should be increased, based on fighting discrimination and promoting condom use. Young people and Adolescents Status: There are no sexual education or HIV/AIDS education programs in schools. Challenge: - In collaboration with the Ministry of Education, programs should be incorporated into the school curriculum. - Interventions for high-risk adolescents should be increased. CSWs Status: Some programs underway. Challenge: Programs should be expanded in large cities to increase access to HIV testing, and increase testing available at STI treatment centers toensure control and promotion of HIV testing. Prisoners Status: Programs have recently been developed and offer limited coverage. Challenge: Programs should be implemented that provide health education, distribute condoms and provide HIV testing. Access to condoms Challenge: - Access to condoms should be increased, especially in areas frequented by MSM and young people. - - Programs for condom quality control should be developed. NGOs Status: There are few NGOs working in this country. Challenge:Collaborative community movements should be facilitated, prioritizing work with CSWs and MSM. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to testing is limited by cost and risk of discrimination. 80% of patients diagnosed with HIV presented at advanced stages of HIV infection, or with full-blown AIDS. Challenge: Anonymous diagnosis centers should be expanded and sites of free diagnosis should be increased. Follow-up Tests Status: Only 14% of patients have had at least one CD4 and viral load count. Challenge: The laboratory network providing diagnostic tests must be strengthened. Treatment Status: 72% of patients do not have access to ARV treatment due to lack of financial resources, and only 10% receive HAART. Challenge: Increase the percentage of patients receiving the treatment they need. Social support and workplace integration Status: Activities are limited. Challenge: In collaboration with NGOs and social and labor ministries, programs for social and employment support should be organized. 164 ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: No available data, but estimated to be moderate to high. Challenge: HIV/AIDS case notification systems should be more exhaustive, and already -existing systems for active surveillance should be expanded. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 165 BOLIVIA HIV/AIDS EPIDEMIC STATUS: Low level <5% in at least one high-risk group 0.1% of adult population estimated to be living with HIV/AIDS at the end of 1999 4,200 people estimated to be living with HIV/AIDS at the end of 1999 380 people estimated to have died from HIV/AIDS in 1999 Some important points about HIV/AIDS in Bolivia à HIV/AIDSisconcentratedinurbanareasofthecentralcorridor:LaPaz,Cochabamba,Santa Cruz à Sexuallytransmittedinfections(STIs),includingsyphilisandgonorrheaareincreasing à LessthanhalfofdonatedbloodisscreenedforHIV à Sexually transmitted infections (STIs) are high, but treatment is rarely sought. Approximate HIV Prevalence in high-risk groups HIV Prevalence in pregnant women: 0%-0.5% CSWs STI >10% Patients >10% 5%-10% 5%-10% Re$ources: The national program does <5% <5% not receive support from international agencies and does not finance HIV/AIDS NGOs. There is no multisectoral plan for fighting HIV/AIDS Distribution of Modes of Transmission in Reported AIDS Cases (1985-1999) Injecting Drug Use Unknown 4% 15% Mother-to-Child Heterosexual Transmission Transmission 4% 42% Sex between Major Mode of Transmission: Men Heterosexual sex 35% 166 ISSUESANDCHALLENGES: Prevention Status: There are no data available on prevention activities for the general population or specific groups. Challenge: It is necessary to design and implement a prevention strategy. This strategy should prioritize the following interventions - Campaigns for the general population and young people based on fighting discrimination and promoting condom use; - Programs for MSM, in collaboration with NGOs, in order to inform, provide services for STI diagnosis and promote HIV testing and condom use; - Programs for CSWs, based on facilitating access to STI diagnostic and treatment services, information and promotion of HIV testing andcondom use - Prison programs based on information, promotion of HIV testing and condom distribution. Vertical transmission Status: HIV testing is not offered to pregnant women. Challenge: In collaboration with gynecological societies and health services, programs should be implemented to facilitate offering HIV testing to all pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to testing is limited by cost, risk of discrimination and lack of demand. Most patients diagnosed with HIV presented at advanced stages of infection. Challenge: Anonymous diagnosis centers should be expanded in areas of high prevalence, and testing should be free-of-charge. Follow-up Tests Status: Only 10% of patients have had at least one CD4 and viral load count. Challenge: The laboratory network providing diagnostic tests must be strengthened. Diagnosis and treatment of opportunistic infections Status: Coverage is low and use of ARV treatment is inconsistent with current standards. Challenge: Programs for continuous training of clinicians in the management and treatment of HIV/AIDS patients and associated infections are needed. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at about 30% for HIV and 60% for AIDS. Challenge: HIV/AIDS case notification systems should be more exhaustive, and active surveillance systems should be facilitated. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. 167 Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Only 40% of blood donations are tested for HIV. Challenge: - Policies are needed to establish altruistic, voluntary and non -remunerated donations as the only option for donation or transfusion. - Increase the percentage of blood tested through strengthening infrastructure and training in blood banks. Overall Challenges Ø SinglecasedefinitionforAIDS Ø ImplementasystemforHIVcasenotification Ø EstablishanationalprotocolforregisteringHIVandAIDScases Ø Developbetternormsforprotectingconfidentialityofpersonalinformation Ø TrainpersonnelworkinginepidemiologicalsurveillanceanddevelopanationalHIVsurveillance plan, including behavioral risk factor surveillance. Such programs should prioritize high-risk and variable-risk groups. Ø IncreasetheexhaustivenessofHIVandAIDScasenotificationthroughimplementingmoreactive surveillance systems, at least in large cities. Ø Linkinformationtodecision-making Ø Planperiodicevaluationsofthesurveillancesystem. 168 ARGENTINA HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group <1% in pregnant women 0.66% of adult population estimated to be living with HIV/AIDS at the end of 1999 130,000 people estimated to be living with HIV/AIDS at the end of 1999 1,800 people estimated to have died from HIV/AIDS in 1999 Approximate HIV Prevalence in high-risk groups HIV Prevalence in pregnant women: 0.56%-0.66% (as high as 2% in urban areas) IDUs >10% STI >10% Patients 5%-10% 5%-10% 0.13% in blood <5% <5% donors >10% >10% CSWs 5%-10% Prisoners 5%-10% Re$ources: The national program <5% <5% receives support from international agencies and finances HIV/AIDS NGOs. The HIV/AIDS program budget is one of the highest in the Southern Cone. Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Contaminated Blood Products Unknown Heterosexual 2% 3% Transmission 21% Major Mode of Transmission: Injecting Drug Use Sex between Men 26% Injecting Drug Use Mother-to-Child 41% Transmission 7% 169 ISSUESANDCHALLENGES: Prevention General population Status: There have been few campaigns for the general population; none focused on condom promotion. Challenge: Campaigns fighting discrimination and promoting condom use should be developed. Adolescents Status: There is no plan in the ministry of health for including sexual education or AIDS education in the schoolcurriculums. Challenge: In collaboration with the Ministry of Health, sexual education, AIDS and drug education programs should be initiated in schools, beginning in the areas with highest HIV prevalence. IDUs Status: Harm reduction programs have only recently begun and their coverage is insufficient. Challenge: Urgently needed activities include needle exchange programs, condom use and HIV testing promotion (via NGOs) and establishment of centers for healthcare and services for drug addicts. Prisoners Status: Prison programs are scarce and need to be expanded. Challenge: - These programs should be expanded to cover more prisoners, and should include promotion of condom use and HIV testing, along with health education. - Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. These programs should target the prisonswith the highest prevalence of IDUs. NGO Priorities Challenge: The majority of NGO programs should prioritize MSM and IDUs. Vertical Transmission Status: HIV testing is offered to about 70% of pregnant women, and 90% of HIV+ pregnant women are offered ARV therapy as a prophylactic measure. Challenge: HIV testing should be offered to all pregnant women, and ARV prophylaxis should be given to all HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to HIV testing is limited. 60%of patients diagnosed with HIV presented at advanced stages of infection. Challenge: Anonymous diagnosis centers should be established in areas with the highest prevalence. Follow-up Tests Status: 80% of HIV/AIDS patients have had a CD4 and viral load count. Challenge: Strengthen and expand the laboratory network to provide greater coverage of diagnostic and monitoring tests. Psychological and social support and workplace integration Status: Activities are limited. Challenge: In collaboration with self-supported NGOs and social and labor ministries, programs should be organized that respond to these needs. Prophylaxis against opportunistic infections Status: Coverage is limited (55%) Challenge: Programs for continuous training of clinicians in the management and treatment of HIV/AIDS patients and associated infections are needed. 170 ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at 20%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and active surveillance systems are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. - HIV/AIDS Registry Status: Therehas been increased access to ARV treatment and the reduction in AIDS cases and mortality Challenge: Create a universal registry of HIV infection. ISSUESANDCHALLENGES: BLOODSAFETY Status: Altruistic,voluntaryandnon-remunerated donations combinedwith other forms of blood donation. 95% of the blood supply is tested. Challenge: - Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. - Blood testing should cover 100% of donated blood. This would be possible through improving and expanding the infrastructure of blood banks. 171 CHILE HIV/AIDS EPIDEMIC STATUS: Concentrated <5% in high-risk groups 0.19% of adult population estimated to be living with HIV/AIDS at the end of 1999 15,000 people estimated to be living with HIV/AIDS at the end of 1999 1,000 people estimated to have died from HIV/AIDS in 1999 Approximate HIV Prevalence in high-risk HIV Prevalence in pregnant women: groups 0.1% >10% MSM 5%-10% S >10% Heterosexual transmission of HIV is <5% increasing, although sex between men 5%-10% still accounts for most cases. <5% STI Clinic Patients Blood Donors: Re$ources: The national program receives <0.1% support from international agencies and finances HIV/AIDS NGOs. The HIV/AIDS program budget is one of the highest in the Southern Cone. Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Contaminated Injecting Drug Blood Products Unknown Heterosexual Use 1% 8% Transmission 4% 23% Mother-to-Child Major Mode of Transmission Transmission Sex between men 2% Sex between Men 62% 172 ISSUESANDCHALLENGES: Prevention General population Status: There have been few information/communication campaigns, and none of the campaigns thus far have promoted condom use. Challenge: Campaigns fighting discrimination and promoting condom use should be developed and implemented. Adolescents Status: There is currently no plan within the Ministry of Education for including sexual education, including HIV/AIDS education, in the school curriculum. Challenge: - Beginning in areas with high HIV prevalence, sexual education, HIV/AIDS education and drug education -should be introduced into the school curriculums, in collaboration with national education authorities. - With NGOs and youth-associations, programs targeting high-risk adolescents should be established. MSM Status: There are some occasional activities that only recently started and have limited coverage. Challenge: Programs should be developed, in collaboration with NGOs and members of the gay movement, focusing on promotion of HIV testing, health education and promotion of condom use. CSWs Status: Some programs underway. Challenge: It is necessary to expand programs for CSWs in large cities, and for male CSWs. These programs should help increase access to HIV testing, diagnosis and treatment of STIs and systematic condom use. IDUs Status: Harm reduction programs have recently begun and their scope is limited. Challenge: Programs are needed for needle exchange, promotion of HIV testing and condom use. Such activities could be carried out by NGOs, healthcare centers and centers for drug addicts. Prisoners Status: Prison programs are scarce and require expansion. Challenge: - These programs should be expanded to cover more prisoners, and should include promotion of condom use and HIV testing, along with health education. - Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. These programs should target the prisons with the highest prevalence of IDUs. Vertical transmission Status: It is unknown how many pregnant women are offered the HIV test, but ARV prophylaxis is offered to 100% of HIV+ pregnant women. Challenge:The HIV test should be offered to all pregnant women, and ARV prophylaxis should be given to all HIV+ pregnant women. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to the HIV test could improve. The main barriers to testing are the cost, and issues of social discrimination. Challenge: Anonymous HIV diagnosis centers are needed, and testing should be promoted in high-risk groups. Follow-up Tests Status: 72% of HIV/AIDS patients have had a CD4 and viral load count. 173 Challenge: The laboratory network should be strengthened and expanded to provide greater coverage of diagnostic and monitoring tests. Psychological and social support and workplace integration Status: Activities are limited. Challenge: In collaboration with self-supported NGOs and social and labor ministries, programs should be organized that respond to these needs. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries areneeded, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimated at 14%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and active surveillance systems are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and inprocedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel si tes and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. HIV/AIDS Registry Status: There has been increased access to ARV treatment and the reduction in AIDS cases and mortality Challenge: Createauniversalregistry of HIV infection. ISSUESANDCHALLENGES: Blood Safety Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 174 PARAGUAY HIV/AIDS EPIDEMIC STATUS: Concentrated Overall, data from Paraguay are scarce <5% in high-risk groups 0.11% of adult population estimated to be living with HIV/AIDS at the end of 1999 3,000 people estimated to be living with HIV/AIDS at the end of 1999 220 people estimated to have died from HIV/AIDS in 1999 Approximate HIV Prevalence in high-risk HIV Prevalence in pregnant women: groups <0.1% >10% >10% IDUs CSWs 5%-10% 5%-10% The estimated prevalence among military <5% <5% recruits is 1% Blood Donors: Re$ources: The national program receives 0.17% support from international agencies, but does not finance HIV/AIDS NGOs. The HIV/AIDS program budget is one of the highest in the Distribution of Modes of Transmission in Reported AIDS Cases (1984-1999) Contaminated Injecting DrugBlood Products Unknown Use 2% 11% 10% Heterosexual Transmission Mother-to-Child 39% Transmission 4% Major Mode of Transmission: Heterosexual sex and sex between men Sex between Men 34% 175 ISSUESANDCHALLENGES: Overall Status: The level of multisectoral agreement in the national program is low. There is little coherence in government or NGOs in the fight against HIV/AIDS. There is no national commission for the evaluation of the national HIV/AIDS program. Challenge: Establish more multisectoral collaboration and build links between the government and NGOs. Establish a national commission for evaluating the national HIV/AIDS program. ISSUESANDCHALLENGES: Prevention MSM Status: Programs have recently begun and require more strengthening and expansion. Challenge: In collaboration with NGOs and the gay movement, programs should be based on promotion of HIV testing, health education and promotion of condom use. CSWs Status: Some programs underway. Challenge: It is necessary to expand programs for CSWs in large cities. These programs should help increase access to HIV testing, distribute condoms and improve access and services at health centers and STI treatment centers. IDUs Status: Programs for IDUs are insufficient. Challenge: Programs are needed for needle exchange, promotion of HIV testing and condom use. Such activities could be carried out by NGOs, healthcare centers and centers for drug addicts. Prisoners Status: Prison programs are scarce and require expansion. Challenge: - These programs should be expanded to cover more prisoners, and should include promotion of condom use and HIV testing, along with health education. - Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. These programs should target the prisons with the highest prevalence of IDUs. Vertical transmission Status: It is unknown how many pregnant women are offered the HIV test or ARV prophylaxis. Challenge: Implement programs that evaluate the rate of HIV testing and actual cases in this population. NGO Priorities Challenge: NGO programs and projects should prioritize MSM. ISSUESANDCHALLENGES: Care Diagnosis Status: More than half of patients are diagnosed at the stage of AIDS or advanced HIV infection. The main barriers to testing are the lack of demand, social discrimination and availability of diagnosis centers. Challenge: Anonymous HIV diagnosis centers are needed, and the test should be available at STI treatment centers. Follow-up Tests Status: Only 55% of HIV/AIDS patients have had a CD4 and viral load count. Challenge: The laboratory network should be evaluated and strengthened to increase the number of laboratories providing diagnostic and monitoring tests. Treatment Status: One ou t of every 4 patients does not receive ARV therapy due to lack of financial resources. Forty- four percent of patients receive HAART. Challenge: Improve the percentage of patients receiving the treatment they need. 176 Psychological and social support and workplace integration Status: Activities are limited. Challenge: Self-supported community movements and social protection programs for PLWHA should be supported, in collaboration with social and labor ministries. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: No available data, but estimated to be moderate to high. Challenge: HIV/AIDS case notification systems should be more exhaustive, and systems for active surveillance are needed. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especiallyhigh-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training shou ld be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: BLOODSAFETY Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 177 URUGUAY HIV/AIDS EPIDEMIC STATUS: Concentrated >5% in at least one high-risk group 0.37% of adult population estimated to be living with HIV/AIDS at the end of 1999 6,000 people estimated to be living with HIV/AIDS at the end of 1999 150 people estimated to have died from HIV/AIDS in 1999 Approximate HIV Prevalence in high- HIV Prevalence in pregnant women: risk groups 0.23% >10% >10% MSM 5%-10% IDUs 5%-10% In 1993, 6% of military recruits were HIV-infected. S <5% <5% >10% Blood Donors:0.6% CSWs 5%-10% <5% Re$ources: The national program receives support from international agencies, and finances HIV/AIDS NGOs. Distribution of Modes of Transmission in Reported AIDS Cases (1983-1999) Contaminated Blood Products Injecting Drug Heterosexual 2% Use Transmission 26% 27% Mother-to-Child Major Mode of Transmission: Transmission Sex between men 4% Sex between Men 41% 178 ISSUESANDCHALLENGES: Prevention Young people and Adolescents Status:Coverage of sexual education and HIV/AIDS education is less than 50% in public schools. Challenge: - Coverage of school-based education programs should expand, especially in the cities that are most affected. - Programs for high-risk adolescents and young people who do not attend school should also be expanded. MSM Status: There are some occasional activities that only recently started andhave limited coverage. Challenge: Programs should be developed, in collaboration with NGOs and members of the gay movement, focusing on promotion of HIV testing, health education and promotion of condom use. CSWs Status: Some programs underway. Challenge: It is necessary to expand programs for CSWs in large cities. These programs should help promote HIV testing, distribute condoms to all CSWs and improve access and testing in health centers and STI treatment centers. IDUs Status: The level of HIV infection in IDUs is high, yet there are still no harm reduction programs in place. Challenge: Programs are needed for needle exchange, promotion of HIV testing and condom use, information dissemination and health education, as well as testing in drug addiction clinics. Such activities could be carried out by NGOs, healthcare centers and centers for drug addicts. Prisoners Status: Prison programs are scarce and require expansion. Challenge: - These programs should be expanded to cover more prisoners, and should include promotion of condom use and HIV testing, along with health education. - Harm reduction programs should be planned, based on needle exchange and instruction on how to clean instruments. These programs should target the prisons withthe highest prevalence of IDUs. NGO Priorities Challenge: In terms of financing, NGOs should prioritize IDU-based programs. ISSUESANDCHALLENGES: Care Diagnosis Status: Access to the HIV testing is limited by discrimination and lack of demand. 60% of patients are diagnosed in advanced stages of infection. Challenge: Anonymous HIV diagnosis centers are needed in areas of high prevalence. Treatment Status: 55% of HIV/AIDS patients are receiving HAART; 8% do not take HAART due to lack of financial resources. Challenge: Increase the percentage of patients who receive the treatment they need. Psychological and social support and workplace integration Status: Activities are limited. Challenge: In collaboration with NGOs and social and laborministries, programs for improving social and psychological services should be organized. ISSUESANDCHALLENGES: Epidemiological Surveillance Case definitions, notification circuits and procedures 179 Status: Not defined in working protocols, thus evaluation and corrective measures are highly labor intensive. Challenge: National protocols for HIV and AIDS registries are needed, specifying the procedures, functions and responsibilities at each level within the surveillance system. Protocols should also include plans for periodic evaluations of the system. Underreporting Status: Estimatedat10%-15%. Challenge: HIV/AIDS case notification systems should be more exhaustive, and already -existing systems for active surveillance should be expanded. Protection of Privacy Status: Current legislation for protection of personal information is not extensive enough to truly guarantee confidentiality of information throughout the diagnosis and treatment process. Challenge: Better norms are needed to ensure confidentiality of personal information. Sentinel Surveillance Status: Deficient in coverage of populations (especially high-risk populations), and in procedure. Challenge: Develop a plan for sentinel surveillance of HIV and risk factor behavior, specifying (i) populations to monitor; (ii) methods; (iii) evaluation system; and (iv) relationship to decision-making in terms of prevention activities. High-risk populations should always be prioritized. Training Status: Training in epidemiological surveillance has not been provided at all levels, and there is no integrated plan that consolidates information systems from the general population, sentinel sites and other sources of information on HIV/AIDS cases. Challenge: - An integrated information plan is needed to monitor the epidemic, through the national program as well as multisectoral collaborations. - Training should be provided to all personnel responsible for epidemiological surveillance, monitoring interventions and multisectoral evaluation. ISSUESANDCHALLENGES: BLOODSAFETY Status: Altruistic,voluntaryandnon-remunerated donations combined with other forms of blood donation. Challenge: Policies are needed to establish altruistic, voluntary and non-remunerated donations as the only option for donation or transfusion. 180 APPENDIX 2 COLLABORATORS IN THE STUDY NATIONALPROGRAM DIRECTORS Mabel Bianco ­ Argentina Vito Rivas Vargas ­ Bolivia Paulo Teixeira - Brazil Anabela Arredondo-Paz & Edith Ortiz Núñez - Chile Carlos Hernández - Colombia Ignacio Salom-Echeverria ­ Costa Rica Maria Helena Acosta ­ Ecuador Gladys de Bonilla ­ El Salvador Dori Lucas-Alecio ­ Guatemala Marco Alvarenga ­ Honduras Patricia Uribe-Zuñiga ­ Mexico Matilde Roman Rivas ­ Nicaragua Norma Garcia Paredes ­ Panama Marco Aguayo ­ Paraguay Lourdes Kunsunoki ­ Peru Margarita Serra ­ Uruguay Deisy Matos ­ Venezuela NGOs Argentina Silvia Kurlat - FASS ­ Federación Argentina de SIDA y Salud Gustavo Karaman - Asociación Civil Don Jaime de Nevares Rafael Fedra - Sigla Graciela Tozé - Intercambios Carlos Mendes - NEXO Bolivia Jeynel Lyons ­ Care, Bolivia Edgar Valdes ­ Instituto de Desarrollo Humano (IDH) Edwing Holguim ­ CAIASIDA (Centro Integral del Adolescente y SIDA) Violeta Ross ­ Mas Vida (Asociación Seropositivos) Liselote de Barragán ­ Fundación San Gabriel Brazil Rosa Beatriz Marinho ­ GAPA/BA Veriano Terto Jr. ­ ABIA Célia Ruthes ­ GAPA/RS J. Humberto Mello ­ RNP+ (Núcleo de São José do Rio Preto) Eduardo Luis Barbosa ­ GIV/SP Chile Daniel Palma ­ FRENASIDA Herminda González ­ Fundación Margen Bernardina Flores Rivas ­ Corporación Chilena de Prevención del Sida 181 Colombia Jennypher Calderon ­ Liga Colombiana de Lucha contra el SIDA Constanza Molina ­ Eco de libertad Sulma Manco ­ CORMUJER Fabián Medina ­ Fundación Darse Costa Rica Mariam Fernández Esquivel ­ Fundesida Maria Solano ­ Asociación Costarricense de Personas que Viven con VIH/SIDA Cristina Garita ­ Fundación VIDA Edgar Mora González Gonzalez ­ Fundación Niños de Dios Daria Suarez ­ CIPACDH Ecuador Orlando Herrera ­ Fundación Ecuatoriana Equidad Ana Cueva ­ Fundación Pájara Pinta Irene León ­ FEDAEPS Margarita Quevado ­ Kimirina Cecilia Gutierrez ­ Fundación Dios, Vida y Esperanza El Salvador Jorge Hernández ­ ADS (Asociación Demográfica Salvadoreña) Jorge Miranda ­ Asociación Atlacatl (AIDES) Cristina Roque ­ Asociación de Mujeres Flor de Piedra Ricardo Arturo ­ Fundación Olof Palme Francisco Cartagena ­ FUNDEGUADALUPE Julio Osegueda ­ FUNDASIDA Guatemala Annelise Salazar ­ Asociación de Salud Integral Gustavo Castellanos Aragón ­ Centro de Desarrollo Humano Cristina Calerón ­ Fundación Preventiva del Sida "Fernando Iturbe" Hugo Valladares Morales ­ Gente Nueva Erickson Salas-Cornejo ­ Gente Positiva Rubén Mayorga Sagastume ­ OASIS Honduras Sadith Caceres & Javier Cáliz ­ PRODIM Marco Alonza ­ Asociación Colectivo Violetta Martha Manley Rodríguez - Gaviota Rosa González - ASONAPVSIDAH Mexico Sandra Peniche Quintal ­ UNASSE Javier Martinez Badillo ­ PTSC Carlos de León ­ AVE Alicia Alexander ­ Amigos Previniendo el SIDA, A.C. Juan Hernández Chávez ­ Colectivo Sol, A.C., México Nicaragua Leonel Arguello Irigoyen ­ CEPS Norman Gutierrez Morgan ­ Centro para la Prevención y Educación del SIDA Rita Arauz ­ Fundación Nimehuatzin Hazele Fonseca Navarro ­ Xochiquetzal 182 Flor Alvarado ­ ASONVIHSIDA Ernesto López ­ Cruz Roja Nicaraguense Panama Alfonso Lavergne ­ APLAFA Maribel Coco ­ ANADESAC Orlando Quintero ­ Fundación Pro Bienestar y Dignidad de las Personas VIH/SIDA Ricardo Beteta ­ Hombre y Mujeres de Panamá Paraguay Mirta Ruiz ­ Fundación VENCER Pastor Martín Morán ­ REMAR Natalia Cerdido & Bernardo Puente ­ Grupo Luna Nueva Manuel Fresco & Maura Villasanati ­ PREVER Peru Guido Mazzotti ­ Asociación Vía Libre Domingo Cueto ­ PROSA Aldo Araujo ­ Movimiento Homosexual de Lima Carmen Murguia Pardo ­ Instituto de Educación y Salud Julia Campos Guevara ­ Centro de Estudios con la Juventud Eduardo Ticona Chavez ­ Hospital Nacional Dos de Mayo Uruguay Milka de Souza ­ FRANSIDA Maria Luz Osimani ­ IDES Patricia Ongay, Francisco Ottonelli & Maria Salgado ­ IELSUR Gloria Marino & Fernanda Roccati ­ ATRU Teresa Fernández Crepo ­ AMEPU Rosario Viana ­ ASEPO Venezuela Feliciano Reyna ­ Acción Solidaria Noris Ruiz ­ Agrupación de Mujeres Activistas Seropositivas Norelia Albarrán ­ Fundación Marozo Raiza Marí Liso ­ Resurrexit Renate Koch & Edgar Carrasco ­ Acción Ciudadana Contra el SIDA (ACCSI) PHYSICIANS Argentina Pedro Cahn ­ Fundación Huésped Omar Sued ­Hospital Fernández Raul Bortolozi ­ Hospital Alberdi Hugo Roland ­ Hospital Rawson Victor Bittar ­ Hospital Central, Mendonza Bolivia Ronald Andrade ­ Instituto Nacional de Laboratorios Carlos Guachalla- Hospital Obrero Saúl Pantoja ­ Caja Nacional de Salud 183 Brazil Eduardo Sprinz- Hospital Petrópolis Artur Kalicham ­ Hospital de São Paulo David Uip ­ Hospital das Clínicas e INCOR Jose Andrade Neto ­ Curitiba Claudio Palombo ­ Centro Previdenciário de Niterói Chile Perez Cortes ­ Fundación Arriarán Erna Ripio Moraga ­ Hospital Carlos Van Buren Marcelo Wolff Colombia Guillermo Parda ­ Fundación Santafé Berta Gomez - Clínica San Pedro Claver (Seguro Social) Chantal Aristizabal ­ Hospital Central Policía Nacional Otto Sussman ­ Hospital de San Ignacio Costa Rica Ricardo Boza Cordero ­ Hospital San Juan de Dios Maria Paz Leon Ignacio Salóm Oscar Porras Madrigal ­ Clínica de Infección por VHI, Hospital de Niños San José Ecuador Jacinto Vargas ­ Hospital Carlos Andrade Marin Richard Douce ­ Hospital Vozandes Xavier Ochoa ­ Hospital Vicente Corral Moscoso Fernando Mosquera ­ Hospital Carlos Andrade Marin El Salvador Jorge Panameño ­ Hospital de Especialidades del Seguro Social Ernesto Navarro Marín ­ Clínicas Médicas Rolando Cedillo ­ Hospital Nacional Rosales Viana ­ Hospital de Oncologia del Seguro Social Mario Gamero ­ Hospital Benjamín Bloom Guatemala Carlos Rodolfo Mejia Villatoro ­ Hospital Roosevelt Pedro Vilanueva Mirón ­ Infecto Centro Eduardo Arathon ­ Hospital General San Juan de Dios Honduras Dennis Padgett Moncada ­ Instituto Hondureño de SS Alvarado Matute Norma Solórzano ­ Instituto Nacional de Tórax Maribel Rivera Medina ­ Hospital Escuela México Patricia Volkow Samuel Ponce de Leon ­ Instituto Nacional de Ciencias Médicas Carlos Avila Rallo Aurora Orzechowski Nicaragua 184 Guillermo Porras Carlos Quant Panama Xavier Saenz- Llorens ­ Hospital del Niño Nestor Sosa ­ Royal Center Paraguay Perla Ortellado Manuel Arbo Adolfo Galeano ­ Instituto de Medicina Tropical Peru Carlos Seas Ramos ­ Facultad de Medicina & Instituto de Medicina Tropical Jose Ricardo Losno Garcia ­ Clínica San Borja Raul Salazar Castro - Hospital Almenara Pablo Grados Torres ­ Hospital Maria Auxiliadora Luis Cuellar Ponce de Leon ­ Instituto Nacional de Neoplásica Uruguay Ignacio Mirazo ­ Enfermedades y Infecto Contagiosas Edurado Savio ­ Facultad de Medicina Pablo Cappucio ­ Instituto de Higiene Venezuela Reginal Lopez ­ Unidad de Immunosuprimidos Manuel Guzmán Blanco ­ Centro Médico de Caracas Jenny Cavaza ­ Laboratorio CENTROMED Bernardo Vainrub ­ Hospital de Clínicas Anselmo Rossales ­ Instituto Venezolano de los Seguros Sociales 185 186 REFERENCES 1Diez AG, Grigaitis L., Burgos A.M., Revsin N. 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