World Bank Caribbean HIV Data Review 200
HIV in the Caribbean:
Understanding data and
drivers of the epidemic
HIV in the Caribbean: Understanding data and drivers of the epidemic
Table of Contents
Acronyms and Abbreviations.................................................................................................1
Foreword................................................................................................................................2
Introduction: Purpose and Methods.......................................................................................3
Epidemic, Response and Policy Synthesis....................................................................3
Purpose.................................................................................................................3
Methods................................................................................................................3
Context and challenges for data interpretation and this epidemiological analysis.......3
Background: HIV in the Caribbean.......................................................................................4
What we know about HIV/AIDS in the Caribbean.......................................................4
Country-Specific Data............................................................................................................7
Data Rich Countries......................................................................................................7
Haiti............................................................................................................................7
Dominican Republic...................................................................................................7
Jamaica.......................................................................................................................7
Data Intermediate Countries..........................................................................................8
Bahamas........................................................................................................................9
Country Overview and HIV/AIDS Context.........................................................9
Country Data........................................................................................................9
Epidemiological Studies.....................................................................................11
Status of Substance Abuse in the Bahamas........................................................12
Challenges..........................................................................................................13
Barbados......................................................................................................................15
Country Overview and HIV/AIDS Context.......................................................15
HIV-Related Funding.........................................................................................15
Challenges..........................................................................................................20
Guyana........................................................................................................................22
HIV/AIDS in Guyana.........................................................................................22
HIV Epidemiology.............................................................................................22
A. Men Who Have Sex with Men (MSM).........................................................23
B. Female Sex Workers (FSW)..........................................................................25
C. Youth.............................................................................................................27
E. Gold & Diamond Miners...............................................................................31
Suriname.....................................................................................................................36
Trinidad and Tobago...................................................................................................37
Country Overview and HIV/AIDS Context.......................................................37
HIV prevalence among specific populations.....................................................48
HIV-related funding...........................................................................................52
HIV Response and Interventions.......................................................................53
Data-Sparse Countries..........................................................................................................56
Aruba...........................................................................................................................56
ii
HIV in the Caribbean: Understanding data and drivers of the epidemic
Country Overview and HIV/AIDS Context.......................................................56
Country data.......................................................................................................56
Challenges..........................................................................................................58
Belize...........................................................................................................................60
2. Data Collection Procedures ands surveillance systems.................................60
3. Prevention efforts: past and present, successful and unsuccessful................60
4. Graphs with Trends re epidemiological status...............................................60
7. Data in specific groups: Prisoners and Pregnant Women..............................61
8. Co-infection TB/HIV.....................................................................................62
Netherlands Antilles: Bonaire, Curacao, Saba, St Eustatius and St Maarten.............63
Country Overview and HIV/AIDS Context.......................................................63
HIV-related funding...........................................................................................63
Mean Age at HIV Diagnosis:.............................................................................65
Challenges..........................................................................................................66
French Departments of the Americas..........................................................................67
Country Overview and HIV/AIDS Context.......................................................67
HIV-related funding...........................................................................................67
Guadeloupe........................................................................................................67
French Guiana....................................................................................................68
Martinique..........................................................................................................68
Challenges..........................................................................................................70
Turks and Caicos.........................................................................................................71
Country Overview and HIV/AIDS Context.......................................................71
Country data.......................................................................................................71
Challenges..........................................................................................................72
Organization of Eastern Caribbean States (OECS).....................................................73
BSS Survey Results.........................................................................................................
Antigua and Barbuda...................................................................................................74
Country Overview and HIV/AIDS Context.......................................................74
Country data.......................................................................................................74
Challenges..........................................................................................................74
Country response and interventions...................................................................75
Dominica................................................................................................................76
Country Overview and HIV/AIDS Context.......................................................76
Country data.......................................................................................................76
Challenges..........................................................................................................76
Country response and interventions...................................................................77
Grenada...................................................................................................................78
Country Overview and HIV/AIDS Context.......................................................78
Country data.......................................................................................................78
Challenges..........................................................................................................78
Country response and interventions...................................................................78
St. Kitts...................................................................................................................79
Country Overview and HIV/AIDS Context.......................................................79
Country data.......................................................................................................79
Challenges..........................................................................................................79
iii
HIV in the Caribbean: Understanding data and drivers of the epidemic
Social and Cultural Norms.................................................................................79
Institutional Capacity.........................................................................................79
Country response and interventions...................................................................80
Overview of MARP data collection.....................................................................................80
Regional Response...............................................................................................................82
Universal treatment access scale-up...................................................................83
Monitoring and evaluation.................................................................................83
Stigma and Discrimination.................................................................................83
Advocacy and Human Rights.............................................................................84
Behavior Change Communication and Social Marketing..................................84
Capacity building and infrastructure development............................................84
Data Considerations: What do the data tell us?...................................................................85
Conclusions..........................................................................................................................87
Recommendations................................................................................................................88
1. Establish data collection infrastructure needed to conduct a detailed epidemic,
policy and response synthesis.................................................................................88
2. Consider using donor resources to implement incidence testing in the region.......89
3. Build a regional prevention strategy to address HIV transmission among MSM and
CSW........................................................................................................................90
4. Eliminate obvious sources of transmission like MTCT and blood bank................90
PMTCT..............................................................................................................90
Blood safety.......................................................................................................90
4. Identify missed opportunities for provider initiated HIV testing and prevention...91
5. Insist on donor harmonization to ensure data driven and strategic allocation of
funds.......................................................................................................................91
References............................................................................................................................92
Appendices...........................................................................................................................93
Appendix 1. Caribbean Regional HIV Estimates.......................................................94
Appendix 2. Foreign Donor HIV Funding 2003-2007* (requires updating)............96
Appendix 3. Suggested probes for country surveillance programs.............................99
iv
HIV in the Caribbean: Understanding data and drivers of the epidemic
List of Figures
Figure 1. HIV Prevalence Rates, Caribbean 2001-2007......................................................3
Figure 2. Estimated Number of Adults and Children Living with HIV in the Ten
Larger Caribbean Countries.................................................................................4
Figure 3. Estimated Percent of Adults Living with HIV in the Caribbean:
Females-Males: 1990-2007..................................................................................4
Figure 4. New Cases of AIDS, By Sex and Year: 1985-2006.............................................9
Figure 5. HIV Newly Diagnosed Cases: HIV cases diagnosed (1st Quarter, 2008).............9
Figure 6. HIV Prevalence Among Prison Population: Bahamas 2003-2006.....................10
Figure 7. HIV Prevalence Among Pregnant Women. The Bahamas: 1993-2006.............11
Figure 8. Percentage Distribution of HIV Infections Reported Annually,
By Bahamian Citizenship: 1985-2006...............................................................12
Figure 9. Reported Cases of HIV By Year, Barbados: 1987-2007....................................14
Figure 10. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months.........15
Figure 11. Reported HIV Cases By Year and Sex, Barbados: 1984-2007..........................15
Figure 12. Barbados: Age Distribution of New Cases of HIV in Percentage
1994-2006-Impact of PMTCT Programs...........................................................16
Figure 13. Reported Cases of Deaths Due to AIDS, Barbados: 1987-2007........................17
Figure 14. Reported Cases of AIDS Deaths by Sex, Barbados: 1987-2007........................17
Figure 15. Other Behavioural Risks.....................................................................................19
Figure 16. Subpopulation Data............................................................................................22
Figure 17. Sexual Partners Among Men Who have Sex with Men.....................................23
Figure 18. Frequency of condom use in past 6 months among men
Who Have Sex with men 2003/2004 BSS+ Guyana..........................................24
Figure 19. Condom Use.......................................................................................................25
Figure 20. Condom use at last sex and behaviors in the past month as reported
by the 2003/2004 BSS+ among female Sex Workers in Guyana......................26
Figure 21. Studies pertaining to Youth in Guyana..............................................................27
Figure 22. Sexual Behavior among Youth...........................................................................28
Figure 23. Condom Use among Youth................................................................................29
Figure 24. Alcohol and Marijuana Use among Youth.........................................................30
Figure 25. Select Indicators from 2004 and 2006 Antenatal Clinic Surveys-Guyana.........32
Figure 26. Voluntary Counseling and Testing Practices.....................................................32
Figure 27. Percent ever tested and received results by key groups.....................................33
Figure 28. Number of Reported HIV Cases by Year and Gender.......................................37
Figure 29. Reported HIV Cases by Year and Gender (1983-2007).....................................38
Figure 30. Number of HIV Cases Reported in 2007 by Gender and Age Group................39
Figure 31. Reported Female HIV Cases by Age Group and Year (1983-1987)..................39
Figure 32. Reported HIV Cases by Exposure Category and Year (1983-2007)..................40
Figure 33. Number of Reported HIV Positive Cases by County and Year.........................41
Figure 34. Reported HIV Infections by County, 1983-2007 ...........................................41
Figure 35. HIV Incidence per 10,000 Population by County,
Trinidad and Tobago, 1983 - 2007
...........................................41
v
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 36. Maps of Reported HIV Infections by County, 1983-2007.................................42
Figure 37. Reported HIV and AIDS Cases by Year (1983 – 2007)....................................43
Figure 38. Reported AIDS Cases by Exposure Category and Year of Diagnosis...............44
Figure 39. Reported AIDS Cases by County, 1983-2007....................................................44
Figure 40. Reported AIDS Cases by County and Year.......................................................45
Figure 41. AIDS Cases and Deaths in Trinidad and Tobago, 1983 2007............................45
Figure 42. Reported AIDS Deaths by Age Group and Year (1983-2007)...........................46
Figure 43. Reported AIDS Deaths by County, 1983 – 2007...............................................46
Figure 44. Reported New Cases of HIV/AIDS: 1987-2007, Aruba....................................56
Figure 45. Reported Cases of HIV/AIDS: Sex Distribution, 1987-2007, Aruba................56
Figure 46. Reported Cases of HIV/AIDS: Mode of Transmission, 1987-2007, Aruba.......57
Figure 47. Nationality of Reported New HIV/AIDS Cases, 1987-2007, Aruba.................58
Figure 48. Adult HIV Prevalence Rate in the Larger Caribbean Countries........................60
Figure 49. Reported New Cases of HIV/AIDS by Year
in the Netherlands Antilles: 1985-2007.............................................................62
Figure 50. Reported Cases of HIV/AIDS By Island and by Sex.
The Netherlands Antilles: 1985-2007................................................................63
Figure 51. HIV Incidence per 1000 population-Netherlands Antilles, Caracao and
St Maarten: 2000-2007......................................................................................63
Figure 52. Mean Age at HIV Diagnosis: Combined-Males-Females,
Netherlands Antilles: 1997-2007.......................................................................64
Figure 53. Reported Cases of HIV-French Departments of the Americas: 2003-2005.......67
Figure 54. Number of Reported New Cases of HIV in Turks and
Caicos Islands: 2000-2007.................................................................................71
Figure 55. Seroprevalence Studies Among MSM...............................................................80
Figure 56. Seroprevalence Studies Among CSW................................................................80
Figure 57. Seroprevalence Studies Among Prisoners..........................................................80
Figure 58. Country Strategic Plan Matrix............................................................................81
Figure 59. Regional Funding Estimates by Priority.............................................................82
vi
HIV in the Caribbean: Understanding data and drivers of the epidemic
Acronyms and Abbreviations
AIDS
Acquired immune deficiency syndrome
ARV
Antiretroviral
BCC
Behavior change communications
BSS
Behavioral surveillance survey
CAREC
Caribbean Epidemiology Center
CARICOM
Caribbean Community
CBO
Community-based organization
CDARI
Caribbean Drug and Alcohol Research Institute
CHART
Caribbean HIV/AIDS Regional Training Initiative
CSME
Caribbean Single Market and Economy
CSW
Commercial sex worker
GFATM
Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV
Human immunodeficiency virus
MARP
Most at-risk populations
MOH
Ministry of Health
MSM
Men-who-have-sex-with-men
MTCT
Mother-to-child transmission of HIV
NGO
Non-governmental organization
OECS
Organization of Eastern Caribbean States
OI
Opportunistic infection
OVC
Orphans and other vulnerable children
PANCAP
Pan-Caribbean Partnership
PEPFAR
President's Emergency Plan for AIDS Relief
PLWHA
People Living with HIV/AIDS
PMTCT
Prevention of mother to child transmission
STI
Sexually-transmitted infection
TB
Tuberculosis
UNAIDS
United Nations Program on HIV/AIDS
VCT
Voluntary Counseling and Testing
1
HIV in the Caribbean: Understanding data and drivers of the epidemic
Foreword
This is the first ever attempt at a comprehensive, data-driven review of the HIV epidemic in
the Caribbean. Several reports have been published about the Caribbean but none have
specifically focused on a thorough review of data sources, data collection strategies and
detailed epidemiology of the HIV epidemic. In the past, the Caribbean epidemic has largely
been characterized as a generalized, heterosexual epidemic with a prevalence of >2%.
Recent UNAIDS regional estimates suggest both that previous estimates were somewhat
on the high side and that a decline in HIV infections has occurred among the general
population in at least some parts of the region. In addition, some data support the presence
of concentrated epidemic across the region but the exact relative contribution of
concentrated epidemics to the magnitude of the Caribbean epidemic is unknown, although
these are likely to account for the majority of HIV infections in most countries in the region.
In an effort to illustrate the diversity of the Caribbean epidemic, we highlight unique aspects
of the epidemic in some countries and suggest the need to develop a new paradigm for the
characterization of the epidemic. Absence of harmonized data collection makes it difficult
to accurately characterize the Caribbean’s regional epidemic. In addition, regional
surveillance data clearly show: 1. a few countries bear the greatest burden of cases in the
region and 2. country capacity for data collection varies across the region. Given the
purpose and nature of the epidemiological synthesis we elected to focus our data review
and detailed discussions for countries that with the greatest proportion of cases and that
have demonstrated stronger capacity to collect data and conduct research.
As is commonly known, the Caribbean region suffers from a limited human resource
capacity and infrastructure for systematic data collection both of which impact data
availability. The data in this report will certainly reflect these challenges. However, they
also will create an important and useful snapshot of the epidemic that hopefully will provide
a new framework for conceptualizing the epidemic and targeting programmatic efforts in
the region.
Excellent foreword!
2
HIV in the Caribbean: Understanding data and drivers of the epidemic
Introduction: Purpose and Methods
Epidemic, Response and Policy Synthesis
Purpose
The purpose of an HIV epidemiological synthesis is to assess and analyze new or recent
data to provide strategic direction for the program development and implementation. Data
sources are typically routine surveillance, biological and behavioral surveys, STI data,
program monitoring data and quantitative or qualitative research data. The synthesis also
tests and explores an existing hypothesis about the epidemic and discusses relevant databased policy implications.
For the Caribbean synthesis, we aimed to analyze HIV transmission patterns and
epidemiological and behavioral drivers in the Caribbean and to analyze the response in
relation to the analysis. The purpose of the Caribbean epidemic synthesis is to gain new
insights into the Caribbean epidemic beyond previously published data by analyzing
unpublished data and unexplored and unanalyzed data sources throughout the region.
In addition, for several years scientific leaders in both the Caribbean and the international
community have posited that similarly to Africa, the Caribbean epidemic is a generalized,
predominantly heterosexual one that without aggressive intervention has the potential to
undermine the social and economic development of the region. This data exploration
should test this hypothesis.
Methods
To obtain the most accurate and up-to-date overview of the epidemic, data were only
reviewed for 2003-2008. A data collection tool was developed to guide data collection.
Data were reviewed and collated from a variety of sources including demographic health
surveys, epidemiological and behavioral surveillance data, research studies and program
monitoring and evaluation data.
Hypotheses: Data review from previously published literature suggest the following
hypotheses could be tested through this synthesis:
a. The Caribbean, a region with the second highest rates of HIV in the world, has a
generalized epidemic that overlays multiple country-specific, concentrated
epidemics
b. HIV/AIDS data collection in the Caribbean is not robust enough to conduct a
comprehensive and in-depth epidemiological analysis that quantifies and fully
elucidates the epidemic drivers of the epidemic
Context and challenges for data interpretation and this
epidemiological analysis
Regional characterization of the epidemic is challenging due to social factors thought to
fuel the HIV epidemic. These include pervasive stigma and discrimination, sex trade,
gender inequality, limited access to care and treatment, substance use and the lack of
human rights based approaches to prevention. Each of these dynamics poses challenges
for appropriately characterizing the region’s epidemic.
3
HIV in the Caribbean: Understanding data and drivers of the epidemic
More importantly, for purposes of this synthesis, a few data-specific issues are worth
noting. First, most countries in the region suffer from inconsistent data collection. This
leads to regional variation in data collection practices. Second, for most countries there is
limited availability of strategic information such as surveillance, research or epidemiological
and program monitoring data. This creates difficulties in understanding the epidemic or
explaining epidemiological nuances across the region. Finally, while UNAIDS, through
routine projection exercises, has been instrumental in characterizing the epidemic and
projecting regional estimates and disease burden, they are able to do so with the
limitations described which impacts the ability to accurately characterize the epidemic. This
epidemiological data review is an attempt to further explore existing data and
understanding of the Caribbean epidemic.
Background: HIV in the Caribbean
What we know about HIV/AIDS in the Caribbean
Since HIV was first identified in the Caribbean 27 years ago, more than 300,000 infections
have been reported in the region. Since 2001, the regional HIV prevalence has hovered
between 1.0 and 1.6 with decreasing regional prevalence in the most recent years.
Figure 1. In 2007, an estimated 17,000 new infections were reported in the region
(UNAIDS 2008) with the majority of these infections occurring in Haiti, the Dominican
Republic and Jamaica. Figure 2. These countries also have the majority of PLWHA in the
region. (Also Figure 2! edit). Appendix 1 provides an epidemiological overview of the
regional HIV epidemic.
The Caribbean HIV epidemic has been characterized on numerous occasions (ref) and
while there are variations in statistical information from the region, most data suggest the
epidemic is largely heterosexual and primarily among persons ages 15-49. Of note is the
shift in the gender balance among reported cases. From 1990-2007, UNAIDS/WHO
estimated a 79% percent increase in the proportion of infections among females. Figure 3. (I
assume that’s the case? If so, that’s very difffernt from saying that there’s been such a huge
increase in the actual # of female infections, see what I mean?)
Figure 1. HIV Prevalence Rates, Caribbean 2001-2007
2
1.5
1
0.5
0
2001
2003
2005
2007
Prev alence
UNAIDS-Report on the Global AIDS Epidemic, 2008
4
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 2. New HIV Infections, 2007 (verify Jamaica, DR #s)
7000
6000
5000
4000
# HIV cases
(n=17,000)
3000
2000
1000
0
Haiti
DR Jamaica T&T
Bah Others
5
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 3. Estimated Number of Adults and Children Living with HIV in the Ten
LargerCaribbeanCountries
Estim ated Num ber of Adults and Children Living with HIV in the Ten Larger Caribbean
Countries. UNAIDS/WHO.2007
HAI
120000
DOR
62000
C o u n t ry
JAM
27000
TNT
14000
GUY
13000
SUR
6800
BHA
6200
CUB
6200
BEL
3600
BDO
2200
0
20000
40000
60000
80000
100000
120000
140000
Num be r of PLHIV
BHA: Bahamas, GUY: Guyana, SUR: Suriname, HAI: Haiti, BEL: Belize, JAM: Jamaica, TNT: Trinidad and
Tobago, BDO: Barbados, DOR: Dominican Republic, CUB: Cuba
Figure 4. Estimated Percent of Adults Living with HIV in the Caribbean: Females-Males: 1990-2007
Estimated Percentage of Adults Living with HIV in the Caribbean:
Females-Males: 1990-2007-UNAIDS/WHO
Females
Males
120%
100%
80%
60%
76%
70%
63%
59%
57%
24%
30%
37%
41%
43%
1990
1995
2000
2005
2007
40%
20%
0%
6
HIV in the Caribbean: Understanding data and drivers of the epidemic
Country-Specific Data
Country-Specific Data
As described, the burden of HIV/AIDS cases rests primarily in three countries, Haiti,
Dominican Republic and Jamaica. Figure 2. Perhaps as a result of funding and other
resources, these countries have also traditionally demonstrated an ability to consistently
generate HIV-related data. Both Haiti and the Dominican Republic have conducted a series
of demographic household surveys which provide the most rigorous and insightful
epidemiological information about the epidemic. Given these things, country data in this
report are stratified by data availability into three categories:
Data rich—DHS conducted within the last three years and/or well-established data
collection and research infrastructure. These countries include Haiti, DR and Jamaica
Data intermediate— No DHS data available but availability of systematic and consistent
reporting and collection of HIV surveillance data. Countries include Bahamas, Barbados,
Guyana, Suriname, Trinidad and Tobago, Suriname
Data sparse— Data collection capacity is limited by human resource challenges.
Availability of ANC surveys but sporadic collection of routine surveillance or other
epidemiological data. Countries include OECS, French territories, Belize
The following categories are reviewed for each country participating in the data review:
1. Country Overview and HIV/AIDS Context
2. Country data
3. Challenges
4. Country response and interventions
7
HIV in the Caribbean: Understanding data and drivers of the epidemic
Data Rich Countries
Haiti
Dominican Republic
Jamaica
Figure. Seroprevalence among MARPs, Jamaica!
This is kind of unclear? What countires (of the 3) are these stats from??
Year
% HIV Positive
Female sex workers
2005
9%
STD attendees
2007
3.6%
MSM
2007
31.8%
Substance abusers
1991-2003
4.6%
Prisoners
2006
3.3%
8
HIV in the Caribbean: Understanding data and drivers of the epidemic
Data Intermediate Countries
9
HIV in the Caribbean: Understanding data and drivers of the epidemic
Bahamas
Country Overview and HIV/AIDS Context
The Commonwealth of The Bahamas, population 316 000, is located 55 miles from the US
Florida coast. It consists of 700 islands and cays, only 29 of which are inhabited and 85%
of the population reside in New Providence and Grand Bahama. The country enjoys a
strong GDP largely due to US tourism and is considered on of the wealthiest Caribbean
countries. Despite this, Bahamas share similar constraints within it healthcare system to
other Caribbean countries. For example, 85% of the population of the Bahamas receive its
care through the public health system. The country’s approach to HIV can be summed up
by their motto, “There is no prevention without care”. This motto highlights their vision for
an integrated approach to prevention, treatment, care and support adopted within
the Bahamas.
Country Data
All public health services and programs are implemented through the MOH. The MOH
houses the National Health Information and Research Unit (NHIRU) that manages and
disseminates all public health and program evaluation data including epidemiological,
surveillance, M&E and research data.
The MOH has contracted with Public Agency of Canada (PHAC) to implement an
electronic public health information system (i-PHIS) at four sites. i-PHIS is designed to
improve data quality, timeliness and completeness of reporting. The MOH plans full
implementation during 2006-2007. (Bilali has this been implemented?)
Since 1994 HIV has been the leading cause of death among 15-49 year olds and in 2007,
approximately 3% of the adult population was living with HIV. (so where are the data for
2007 if we know 3% PLWA?). As of December 2006, the Bahamas had a cumulative total
of 10,841 reported HIV infections with 7036 persons living with HIV. Epidemiological trend
data show that HIV rates are consistently 1.5-2 times higher for men than women. In
addition, data show that while from 1989 to 1995 there was a consistent increase in the
number of newly infected persons, beginning in 1996, overall HIV rates have leveled or
declined. See Figure 4.
10
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 4. New Cases of AIDS, By Sex and Year: 1985-2006
New Cases of AIDS, By Sex and Year:1985-2006
Males
Females
300
250
200
150
100
2006
2005
2004
2 003
2002
2001
2 000
1999
1998
1997
1 996
1 995
1994
1 993
1 992
1991
1990
1 989
0
1 985- 1988
50
Source: 2008 UNGASS Country Report
Mode of transmission is not routinely collected or recorded. As a result, in the first quarter
of 2008 a data review was conducted for recently diagnosed HIV cases. Figure 5.
Important findings included:
1. Ninety-four cases were reported of which 56% were men and 4.5% were children.
2. Ninety percent of cases were age >24.
3. All reported adult cases were categorized as heterosexual
4. Four pediatric cases were reported with only one reported as MTCT. The
remaining three were classified as suspicious cases of MTCT
Figure 5. HIV Newly Diagnosed Cases: HIV cases diagnosed (1 st Quarter, 2008)
BAHAMAS
Homosexual
Bisexual
Heterosexual
MTCT
Others
Don’t
Know
Total
Females15-24
-
-
5
-
0
0
5
Females >24
-
-
29
-
0
0
29
Males15-24
0
0
3
-
0
0
3
Males>24
0
0
46
-
0
0
46
Children 25
years and 24 and mode of
transmission data are not routinely collected. Rates of MTCT is low as are those in persons
age 24.
Figure 9. Reported Cases of HIV By Year, Barbados: 1987-2007
Reported Cases of HIV By Year, Barbados: 1987-2007
250
200
150
100
50
0
16
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 10. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months
Sex and Age Group
Total
Females15-24
3 (6.40%)
Females >24
14 (30.0%)
Males15-24
2 (4.25%)
Males>24
27 (57%)
Children49years-old
120.00%
Percen tag e
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age Groups
From 2005 to 2007, of the 5061 pregnant women tested for HIV at ANC sites, 2516
(49.7%) were ages 15- 24 and 24 (.47%) were HIV-positive. Of the 24 HIV-positive
women, half were ages 15-24 years of age. Furthermore, 83% of the 15-24 year old HIVpositive women were 20-24 years of age. Since this age group represented only 28% of all
pregnant women but 83% of HIV-positive moms, these data suggest young women ages
20-24 are somehow at increased risk for HIV acquisition and are disproportionately
affected by HIV.
NEW INFECTIONS? Understanding that HIV infections among young people reflect new
infections, this observation leads to the conclusion that new HIV infections are occurring in
Barbados on an ongoing basis and prevention programs are not achieving the
required impact.
As a result of ART availability from 1998 to 2007 the number of AIDS-related deaths
declined by 80%,
18
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 13. Reported Cases of Deaths Due to AIDS, Barbados: 1987-2007
Reported Cases of Deaths due to AIDS, Barbados: 1987-2007
120
100
80
60
40
20
0
Source: 2008 UNGASS Country Report, Barbados
When examined by gender, beginning in 2002, the rates of AIDS deaths have declined
more precipitously among men. Figure 14. This decrease is intuitive given the availability
of ART. However, attributing the sharp decline in men to this intervention alone requires
these data also be examined in conjunction with the rates of treatment by gender.
Figure 14. Reported Cases of AIDS Deaths by Sex, Barbados: 1987-2007
Reported Cases of AIDS Deaths by Sex, Barbados:1987-2007
90
Females
Males
80
70
60
50
40
30
20
10
0
Source: 2008 UNGASS Country Report, Barbados
Modes of transmission are not well documented through routine surveillance. However,
KAB surveys have been conducted among MSM, CSW and men and these data provide
some insights into the dynamics and drivers of the epidemic.
19
HIV in the Caribbean: Understanding data and drivers of the epidemic
Sex workers and men who have sex with men
Seroprevalence studies have not been conducted for CSW and MSM residing in Barbados.
However, a 2007 KAB survey among these groups revealed high rates of testing with 85%
and 73% of MSM and CSWs surveyed were previously tested for HIV and aware of their
HIV status, respectively. While condom usage among CSW during last sexual encounter
was high at 80%, awareness about HIV was somewhat low since only 37% of respondents
rejected myths about HIV transmission and were aware of HIV preventive measures.
Beach boys are males CSW whose client base is predominantly tourists. Risk factors for
and contribution of this group to HIV transmission rates in Barbados are unknown.
Men’s Life Style Study
In 2007, a risk behavior survey was conducted among 400 heterosexual and 100
homosexual men, >15 years of age to assess unmet needs and socio-cultural
factors that contribute to HIV risk behavior. Important highlights include:
36% of males had been intoxicated between one and countless times during the
12 months preceding the survey, particularly during holidays/vacation or weekend
revelry
25% reported engaging in unprotected sexual intercourse at least once during the
past 12 months.
47% of all males reported having multiple sex partners
Among the heterosexual men, 46% used a condom during last sexual intercourse
with a non-regular sex partner
Among MSM, 62% have two or more partners and 65% reported using a condom
at last anal sex
65.7% of men found it acceptable that all women carry condoms, but only 4.1%
found it acceptable that only men should carry condoms
Regarding healthcare maintenance with a regular provider, 16.5% have a doctor
that they see regularly, 15% never see a doctor and 68.5% only seek medical
care when something is very wrong
Other behavioural risks are summarized in the Figure 15. The findings show that the
majority of both heterosexual and homosexual men have been tested for HIV test and
know the results. However, the percentage of men tested during the past 12 months was <
50%. In addition, the percentage of MSM reporting an STI episode was more than twice
that among heterosexual men with 18% of homosexual men reporting an STI compared to
7% of heterosexual men. The most nota
Understanding data and
drivers of the epidemic
HIV in the Caribbean: Understanding data and drivers of the epidemic
Table of Contents
Acronyms and Abbreviations.................................................................................................1
Foreword................................................................................................................................2
Introduction: Purpose and Methods.......................................................................................3
Epidemic, Response and Policy Synthesis....................................................................3
Purpose.................................................................................................................3
Methods................................................................................................................3
Context and challenges for data interpretation and this epidemiological analysis.......3
Background: HIV in the Caribbean.......................................................................................4
What we know about HIV/AIDS in the Caribbean.......................................................4
Country-Specific Data............................................................................................................7
Data Rich Countries......................................................................................................7
Haiti............................................................................................................................7
Dominican Republic...................................................................................................7
Jamaica.......................................................................................................................7
Data Intermediate Countries..........................................................................................8
Bahamas........................................................................................................................9
Country Overview and HIV/AIDS Context.........................................................9
Country Data........................................................................................................9
Epidemiological Studies.....................................................................................11
Status of Substance Abuse in the Bahamas........................................................12
Challenges..........................................................................................................13
Barbados......................................................................................................................15
Country Overview and HIV/AIDS Context.......................................................15
HIV-Related Funding.........................................................................................15
Challenges..........................................................................................................20
Guyana........................................................................................................................22
HIV/AIDS in Guyana.........................................................................................22
HIV Epidemiology.............................................................................................22
A. Men Who Have Sex with Men (MSM).........................................................23
B. Female Sex Workers (FSW)..........................................................................25
C. Youth.............................................................................................................27
E. Gold & Diamond Miners...............................................................................31
Suriname.....................................................................................................................36
Trinidad and Tobago...................................................................................................37
Country Overview and HIV/AIDS Context.......................................................37
HIV prevalence among specific populations.....................................................48
HIV-related funding...........................................................................................52
HIV Response and Interventions.......................................................................53
Data-Sparse Countries..........................................................................................................56
Aruba...........................................................................................................................56
ii
HIV in the Caribbean: Understanding data and drivers of the epidemic
Country Overview and HIV/AIDS Context.......................................................56
Country data.......................................................................................................56
Challenges..........................................................................................................58
Belize...........................................................................................................................60
2. Data Collection Procedures ands surveillance systems.................................60
3. Prevention efforts: past and present, successful and unsuccessful................60
4. Graphs with Trends re epidemiological status...............................................60
7. Data in specific groups: Prisoners and Pregnant Women..............................61
8. Co-infection TB/HIV.....................................................................................62
Netherlands Antilles: Bonaire, Curacao, Saba, St Eustatius and St Maarten.............63
Country Overview and HIV/AIDS Context.......................................................63
HIV-related funding...........................................................................................63
Mean Age at HIV Diagnosis:.............................................................................65
Challenges..........................................................................................................66
French Departments of the Americas..........................................................................67
Country Overview and HIV/AIDS Context.......................................................67
HIV-related funding...........................................................................................67
Guadeloupe........................................................................................................67
French Guiana....................................................................................................68
Martinique..........................................................................................................68
Challenges..........................................................................................................70
Turks and Caicos.........................................................................................................71
Country Overview and HIV/AIDS Context.......................................................71
Country data.......................................................................................................71
Challenges..........................................................................................................72
Organization of Eastern Caribbean States (OECS).....................................................73
BSS Survey Results.........................................................................................................
Antigua and Barbuda...................................................................................................74
Country Overview and HIV/AIDS Context.......................................................74
Country data.......................................................................................................74
Challenges..........................................................................................................74
Country response and interventions...................................................................75
Dominica................................................................................................................76
Country Overview and HIV/AIDS Context.......................................................76
Country data.......................................................................................................76
Challenges..........................................................................................................76
Country response and interventions...................................................................77
Grenada...................................................................................................................78
Country Overview and HIV/AIDS Context.......................................................78
Country data.......................................................................................................78
Challenges..........................................................................................................78
Country response and interventions...................................................................78
St. Kitts...................................................................................................................79
Country Overview and HIV/AIDS Context.......................................................79
Country data.......................................................................................................79
Challenges..........................................................................................................79
iii
HIV in the Caribbean: Understanding data and drivers of the epidemic
Social and Cultural Norms.................................................................................79
Institutional Capacity.........................................................................................79
Country response and interventions...................................................................80
Overview of MARP data collection.....................................................................................80
Regional Response...............................................................................................................82
Universal treatment access scale-up...................................................................83
Monitoring and evaluation.................................................................................83
Stigma and Discrimination.................................................................................83
Advocacy and Human Rights.............................................................................84
Behavior Change Communication and Social Marketing..................................84
Capacity building and infrastructure development............................................84
Data Considerations: What do the data tell us?...................................................................85
Conclusions..........................................................................................................................87
Recommendations................................................................................................................88
1. Establish data collection infrastructure needed to conduct a detailed epidemic,
policy and response synthesis.................................................................................88
2. Consider using donor resources to implement incidence testing in the region.......89
3. Build a regional prevention strategy to address HIV transmission among MSM and
CSW........................................................................................................................90
4. Eliminate obvious sources of transmission like MTCT and blood bank................90
PMTCT..............................................................................................................90
Blood safety.......................................................................................................90
4. Identify missed opportunities for provider initiated HIV testing and prevention...91
5. Insist on donor harmonization to ensure data driven and strategic allocation of
funds.......................................................................................................................91
References............................................................................................................................92
Appendices...........................................................................................................................93
Appendix 1. Caribbean Regional HIV Estimates.......................................................94
Appendix 2. Foreign Donor HIV Funding 2003-2007* (requires updating)............96
Appendix 3. Suggested probes for country surveillance programs.............................99
iv
HIV in the Caribbean: Understanding data and drivers of the epidemic
List of Figures
Figure 1. HIV Prevalence Rates, Caribbean 2001-2007......................................................3
Figure 2. Estimated Number of Adults and Children Living with HIV in the Ten
Larger Caribbean Countries.................................................................................4
Figure 3. Estimated Percent of Adults Living with HIV in the Caribbean:
Females-Males: 1990-2007..................................................................................4
Figure 4. New Cases of AIDS, By Sex and Year: 1985-2006.............................................9
Figure 5. HIV Newly Diagnosed Cases: HIV cases diagnosed (1st Quarter, 2008).............9
Figure 6. HIV Prevalence Among Prison Population: Bahamas 2003-2006.....................10
Figure 7. HIV Prevalence Among Pregnant Women. The Bahamas: 1993-2006.............11
Figure 8. Percentage Distribution of HIV Infections Reported Annually,
By Bahamian Citizenship: 1985-2006...............................................................12
Figure 9. Reported Cases of HIV By Year, Barbados: 1987-2007....................................14
Figure 10. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months.........15
Figure 11. Reported HIV Cases By Year and Sex, Barbados: 1984-2007..........................15
Figure 12. Barbados: Age Distribution of New Cases of HIV in Percentage
1994-2006-Impact of PMTCT Programs...........................................................16
Figure 13. Reported Cases of Deaths Due to AIDS, Barbados: 1987-2007........................17
Figure 14. Reported Cases of AIDS Deaths by Sex, Barbados: 1987-2007........................17
Figure 15. Other Behavioural Risks.....................................................................................19
Figure 16. Subpopulation Data............................................................................................22
Figure 17. Sexual Partners Among Men Who have Sex with Men.....................................23
Figure 18. Frequency of condom use in past 6 months among men
Who Have Sex with men 2003/2004 BSS+ Guyana..........................................24
Figure 19. Condom Use.......................................................................................................25
Figure 20. Condom use at last sex and behaviors in the past month as reported
by the 2003/2004 BSS+ among female Sex Workers in Guyana......................26
Figure 21. Studies pertaining to Youth in Guyana..............................................................27
Figure 22. Sexual Behavior among Youth...........................................................................28
Figure 23. Condom Use among Youth................................................................................29
Figure 24. Alcohol and Marijuana Use among Youth.........................................................30
Figure 25. Select Indicators from 2004 and 2006 Antenatal Clinic Surveys-Guyana.........32
Figure 26. Voluntary Counseling and Testing Practices.....................................................32
Figure 27. Percent ever tested and received results by key groups.....................................33
Figure 28. Number of Reported HIV Cases by Year and Gender.......................................37
Figure 29. Reported HIV Cases by Year and Gender (1983-2007).....................................38
Figure 30. Number of HIV Cases Reported in 2007 by Gender and Age Group................39
Figure 31. Reported Female HIV Cases by Age Group and Year (1983-1987)..................39
Figure 32. Reported HIV Cases by Exposure Category and Year (1983-2007)..................40
Figure 33. Number of Reported HIV Positive Cases by County and Year.........................41
Figure 34. Reported HIV Infections by County, 1983-2007 ...........................................41
Figure 35. HIV Incidence per 10,000 Population by County,
Trinidad and Tobago, 1983 - 2007
...........................................41
v
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 36. Maps of Reported HIV Infections by County, 1983-2007.................................42
Figure 37. Reported HIV and AIDS Cases by Year (1983 – 2007)....................................43
Figure 38. Reported AIDS Cases by Exposure Category and Year of Diagnosis...............44
Figure 39. Reported AIDS Cases by County, 1983-2007....................................................44
Figure 40. Reported AIDS Cases by County and Year.......................................................45
Figure 41. AIDS Cases and Deaths in Trinidad and Tobago, 1983 2007............................45
Figure 42. Reported AIDS Deaths by Age Group and Year (1983-2007)...........................46
Figure 43. Reported AIDS Deaths by County, 1983 – 2007...............................................46
Figure 44. Reported New Cases of HIV/AIDS: 1987-2007, Aruba....................................56
Figure 45. Reported Cases of HIV/AIDS: Sex Distribution, 1987-2007, Aruba................56
Figure 46. Reported Cases of HIV/AIDS: Mode of Transmission, 1987-2007, Aruba.......57
Figure 47. Nationality of Reported New HIV/AIDS Cases, 1987-2007, Aruba.................58
Figure 48. Adult HIV Prevalence Rate in the Larger Caribbean Countries........................60
Figure 49. Reported New Cases of HIV/AIDS by Year
in the Netherlands Antilles: 1985-2007.............................................................62
Figure 50. Reported Cases of HIV/AIDS By Island and by Sex.
The Netherlands Antilles: 1985-2007................................................................63
Figure 51. HIV Incidence per 1000 population-Netherlands Antilles, Caracao and
St Maarten: 2000-2007......................................................................................63
Figure 52. Mean Age at HIV Diagnosis: Combined-Males-Females,
Netherlands Antilles: 1997-2007.......................................................................64
Figure 53. Reported Cases of HIV-French Departments of the Americas: 2003-2005.......67
Figure 54. Number of Reported New Cases of HIV in Turks and
Caicos Islands: 2000-2007.................................................................................71
Figure 55. Seroprevalence Studies Among MSM...............................................................80
Figure 56. Seroprevalence Studies Among CSW................................................................80
Figure 57. Seroprevalence Studies Among Prisoners..........................................................80
Figure 58. Country Strategic Plan Matrix............................................................................81
Figure 59. Regional Funding Estimates by Priority.............................................................82
vi
HIV in the Caribbean: Understanding data and drivers of the epidemic
Acronyms and Abbreviations
AIDS
Acquired immune deficiency syndrome
ARV
Antiretroviral
BCC
Behavior change communications
BSS
Behavioral surveillance survey
CAREC
Caribbean Epidemiology Center
CARICOM
Caribbean Community
CBO
Community-based organization
CDARI
Caribbean Drug and Alcohol Research Institute
CHART
Caribbean HIV/AIDS Regional Training Initiative
CSME
Caribbean Single Market and Economy
CSW
Commercial sex worker
GFATM
Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV
Human immunodeficiency virus
MARP
Most at-risk populations
MOH
Ministry of Health
MSM
Men-who-have-sex-with-men
MTCT
Mother-to-child transmission of HIV
NGO
Non-governmental organization
OECS
Organization of Eastern Caribbean States
OI
Opportunistic infection
OVC
Orphans and other vulnerable children
PANCAP
Pan-Caribbean Partnership
PEPFAR
President's Emergency Plan for AIDS Relief
PLWHA
People Living with HIV/AIDS
PMTCT
Prevention of mother to child transmission
STI
Sexually-transmitted infection
TB
Tuberculosis
UNAIDS
United Nations Program on HIV/AIDS
VCT
Voluntary Counseling and Testing
1
HIV in the Caribbean: Understanding data and drivers of the epidemic
Foreword
This is the first ever attempt at a comprehensive, data-driven review of the HIV epidemic in
the Caribbean. Several reports have been published about the Caribbean but none have
specifically focused on a thorough review of data sources, data collection strategies and
detailed epidemiology of the HIV epidemic. In the past, the Caribbean epidemic has largely
been characterized as a generalized, heterosexual epidemic with a prevalence of >2%.
Recent UNAIDS regional estimates suggest both that previous estimates were somewhat
on the high side and that a decline in HIV infections has occurred among the general
population in at least some parts of the region. In addition, some data support the presence
of concentrated epidemic across the region but the exact relative contribution of
concentrated epidemics to the magnitude of the Caribbean epidemic is unknown, although
these are likely to account for the majority of HIV infections in most countries in the region.
In an effort to illustrate the diversity of the Caribbean epidemic, we highlight unique aspects
of the epidemic in some countries and suggest the need to develop a new paradigm for the
characterization of the epidemic. Absence of harmonized data collection makes it difficult
to accurately characterize the Caribbean’s regional epidemic. In addition, regional
surveillance data clearly show: 1. a few countries bear the greatest burden of cases in the
region and 2. country capacity for data collection varies across the region. Given the
purpose and nature of the epidemiological synthesis we elected to focus our data review
and detailed discussions for countries that with the greatest proportion of cases and that
have demonstrated stronger capacity to collect data and conduct research.
As is commonly known, the Caribbean region suffers from a limited human resource
capacity and infrastructure for systematic data collection both of which impact data
availability. The data in this report will certainly reflect these challenges. However, they
also will create an important and useful snapshot of the epidemic that hopefully will provide
a new framework for conceptualizing the epidemic and targeting programmatic efforts in
the region.
Excellent foreword!
2
HIV in the Caribbean: Understanding data and drivers of the epidemic
Introduction: Purpose and Methods
Epidemic, Response and Policy Synthesis
Purpose
The purpose of an HIV epidemiological synthesis is to assess and analyze new or recent
data to provide strategic direction for the program development and implementation. Data
sources are typically routine surveillance, biological and behavioral surveys, STI data,
program monitoring data and quantitative or qualitative research data. The synthesis also
tests and explores an existing hypothesis about the epidemic and discusses relevant databased policy implications.
For the Caribbean synthesis, we aimed to analyze HIV transmission patterns and
epidemiological and behavioral drivers in the Caribbean and to analyze the response in
relation to the analysis. The purpose of the Caribbean epidemic synthesis is to gain new
insights into the Caribbean epidemic beyond previously published data by analyzing
unpublished data and unexplored and unanalyzed data sources throughout the region.
In addition, for several years scientific leaders in both the Caribbean and the international
community have posited that similarly to Africa, the Caribbean epidemic is a generalized,
predominantly heterosexual one that without aggressive intervention has the potential to
undermine the social and economic development of the region. This data exploration
should test this hypothesis.
Methods
To obtain the most accurate and up-to-date overview of the epidemic, data were only
reviewed for 2003-2008. A data collection tool was developed to guide data collection.
Data were reviewed and collated from a variety of sources including demographic health
surveys, epidemiological and behavioral surveillance data, research studies and program
monitoring and evaluation data.
Hypotheses: Data review from previously published literature suggest the following
hypotheses could be tested through this synthesis:
a. The Caribbean, a region with the second highest rates of HIV in the world, has a
generalized epidemic that overlays multiple country-specific, concentrated
epidemics
b. HIV/AIDS data collection in the Caribbean is not robust enough to conduct a
comprehensive and in-depth epidemiological analysis that quantifies and fully
elucidates the epidemic drivers of the epidemic
Context and challenges for data interpretation and this
epidemiological analysis
Regional characterization of the epidemic is challenging due to social factors thought to
fuel the HIV epidemic. These include pervasive stigma and discrimination, sex trade,
gender inequality, limited access to care and treatment, substance use and the lack of
human rights based approaches to prevention. Each of these dynamics poses challenges
for appropriately characterizing the region’s epidemic.
3
HIV in the Caribbean: Understanding data and drivers of the epidemic
More importantly, for purposes of this synthesis, a few data-specific issues are worth
noting. First, most countries in the region suffer from inconsistent data collection. This
leads to regional variation in data collection practices. Second, for most countries there is
limited availability of strategic information such as surveillance, research or epidemiological
and program monitoring data. This creates difficulties in understanding the epidemic or
explaining epidemiological nuances across the region. Finally, while UNAIDS, through
routine projection exercises, has been instrumental in characterizing the epidemic and
projecting regional estimates and disease burden, they are able to do so with the
limitations described which impacts the ability to accurately characterize the epidemic. This
epidemiological data review is an attempt to further explore existing data and
understanding of the Caribbean epidemic.
Background: HIV in the Caribbean
What we know about HIV/AIDS in the Caribbean
Since HIV was first identified in the Caribbean 27 years ago, more than 300,000 infections
have been reported in the region. Since 2001, the regional HIV prevalence has hovered
between 1.0 and 1.6 with decreasing regional prevalence in the most recent years.
Figure 1. In 2007, an estimated 17,000 new infections were reported in the region
(UNAIDS 2008) with the majority of these infections occurring in Haiti, the Dominican
Republic and Jamaica. Figure 2. These countries also have the majority of PLWHA in the
region. (Also Figure 2! edit). Appendix 1 provides an epidemiological overview of the
regional HIV epidemic.
The Caribbean HIV epidemic has been characterized on numerous occasions (ref) and
while there are variations in statistical information from the region, most data suggest the
epidemic is largely heterosexual and primarily among persons ages 15-49. Of note is the
shift in the gender balance among reported cases. From 1990-2007, UNAIDS/WHO
estimated a 79% percent increase in the proportion of infections among females. Figure 3. (I
assume that’s the case? If so, that’s very difffernt from saying that there’s been such a huge
increase in the actual # of female infections, see what I mean?)
Figure 1. HIV Prevalence Rates, Caribbean 2001-2007
2
1.5
1
0.5
0
2001
2003
2005
2007
Prev alence
UNAIDS-Report on the Global AIDS Epidemic, 2008
4
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 2. New HIV Infections, 2007 (verify Jamaica, DR #s)
7000
6000
5000
4000
# HIV cases
(n=17,000)
3000
2000
1000
0
Haiti
DR Jamaica T&T
Bah Others
5
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 3. Estimated Number of Adults and Children Living with HIV in the Ten
LargerCaribbeanCountries
Estim ated Num ber of Adults and Children Living with HIV in the Ten Larger Caribbean
Countries. UNAIDS/WHO.2007
HAI
120000
DOR
62000
C o u n t ry
JAM
27000
TNT
14000
GUY
13000
SUR
6800
BHA
6200
CUB
6200
BEL
3600
BDO
2200
0
20000
40000
60000
80000
100000
120000
140000
Num be r of PLHIV
BHA: Bahamas, GUY: Guyana, SUR: Suriname, HAI: Haiti, BEL: Belize, JAM: Jamaica, TNT: Trinidad and
Tobago, BDO: Barbados, DOR: Dominican Republic, CUB: Cuba
Figure 4. Estimated Percent of Adults Living with HIV in the Caribbean: Females-Males: 1990-2007
Estimated Percentage of Adults Living with HIV in the Caribbean:
Females-Males: 1990-2007-UNAIDS/WHO
Females
Males
120%
100%
80%
60%
76%
70%
63%
59%
57%
24%
30%
37%
41%
43%
1990
1995
2000
2005
2007
40%
20%
0%
6
HIV in the Caribbean: Understanding data and drivers of the epidemic
Country-Specific Data
Country-Specific Data
As described, the burden of HIV/AIDS cases rests primarily in three countries, Haiti,
Dominican Republic and Jamaica. Figure 2. Perhaps as a result of funding and other
resources, these countries have also traditionally demonstrated an ability to consistently
generate HIV-related data. Both Haiti and the Dominican Republic have conducted a series
of demographic household surveys which provide the most rigorous and insightful
epidemiological information about the epidemic. Given these things, country data in this
report are stratified by data availability into three categories:
Data rich—DHS conducted within the last three years and/or well-established data
collection and research infrastructure. These countries include Haiti, DR and Jamaica
Data intermediate— No DHS data available but availability of systematic and consistent
reporting and collection of HIV surveillance data. Countries include Bahamas, Barbados,
Guyana, Suriname, Trinidad and Tobago, Suriname
Data sparse— Data collection capacity is limited by human resource challenges.
Availability of ANC surveys but sporadic collection of routine surveillance or other
epidemiological data. Countries include OECS, French territories, Belize
The following categories are reviewed for each country participating in the data review:
1. Country Overview and HIV/AIDS Context
2. Country data
3. Challenges
4. Country response and interventions
7
HIV in the Caribbean: Understanding data and drivers of the epidemic
Data Rich Countries
Haiti
Dominican Republic
Jamaica
Figure. Seroprevalence among MARPs, Jamaica!
This is kind of unclear? What countires (of the 3) are these stats from??
Year
% HIV Positive
Female sex workers
2005
9%
STD attendees
2007
3.6%
MSM
2007
31.8%
Substance abusers
1991-2003
4.6%
Prisoners
2006
3.3%
8
HIV in the Caribbean: Understanding data and drivers of the epidemic
Data Intermediate Countries
9
HIV in the Caribbean: Understanding data and drivers of the epidemic
Bahamas
Country Overview and HIV/AIDS Context
The Commonwealth of The Bahamas, population 316 000, is located 55 miles from the US
Florida coast. It consists of 700 islands and cays, only 29 of which are inhabited and 85%
of the population reside in New Providence and Grand Bahama. The country enjoys a
strong GDP largely due to US tourism and is considered on of the wealthiest Caribbean
countries. Despite this, Bahamas share similar constraints within it healthcare system to
other Caribbean countries. For example, 85% of the population of the Bahamas receive its
care through the public health system. The country’s approach to HIV can be summed up
by their motto, “There is no prevention without care”. This motto highlights their vision for
an integrated approach to prevention, treatment, care and support adopted within
the Bahamas.
Country Data
All public health services and programs are implemented through the MOH. The MOH
houses the National Health Information and Research Unit (NHIRU) that manages and
disseminates all public health and program evaluation data including epidemiological,
surveillance, M&E and research data.
The MOH has contracted with Public Agency of Canada (PHAC) to implement an
electronic public health information system (i-PHIS) at four sites. i-PHIS is designed to
improve data quality, timeliness and completeness of reporting. The MOH plans full
implementation during 2006-2007. (Bilali has this been implemented?)
Since 1994 HIV has been the leading cause of death among 15-49 year olds and in 2007,
approximately 3% of the adult population was living with HIV. (so where are the data for
2007 if we know 3% PLWA?). As of December 2006, the Bahamas had a cumulative total
of 10,841 reported HIV infections with 7036 persons living with HIV. Epidemiological trend
data show that HIV rates are consistently 1.5-2 times higher for men than women. In
addition, data show that while from 1989 to 1995 there was a consistent increase in the
number of newly infected persons, beginning in 1996, overall HIV rates have leveled or
declined. See Figure 4.
10
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 4. New Cases of AIDS, By Sex and Year: 1985-2006
New Cases of AIDS, By Sex and Year:1985-2006
Males
Females
300
250
200
150
100
2006
2005
2004
2 003
2002
2001
2 000
1999
1998
1997
1 996
1 995
1994
1 993
1 992
1991
1990
1 989
0
1 985- 1988
50
Source: 2008 UNGASS Country Report
Mode of transmission is not routinely collected or recorded. As a result, in the first quarter
of 2008 a data review was conducted for recently diagnosed HIV cases. Figure 5.
Important findings included:
1. Ninety-four cases were reported of which 56% were men and 4.5% were children.
2. Ninety percent of cases were age >24.
3. All reported adult cases were categorized as heterosexual
4. Four pediatric cases were reported with only one reported as MTCT. The
remaining three were classified as suspicious cases of MTCT
Figure 5. HIV Newly Diagnosed Cases: HIV cases diagnosed (1 st Quarter, 2008)
BAHAMAS
Homosexual
Bisexual
Heterosexual
MTCT
Others
Don’t
Know
Total
Females15-24
-
-
5
-
0
0
5
Females >24
-
-
29
-
0
0
29
Males15-24
0
0
3
-
0
0
3
Males>24
0
0
46
-
0
0
46
Children 25
years and 24 and mode of
transmission data are not routinely collected. Rates of MTCT is low as are those in persons
age 24.
Figure 9. Reported Cases of HIV By Year, Barbados: 1987-2007
Reported Cases of HIV By Year, Barbados: 1987-2007
250
200
150
100
50
0
16
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 10. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months
Sex and Age Group
Total
Females15-24
3 (6.40%)
Females >24
14 (30.0%)
Males15-24
2 (4.25%)
Males>24
27 (57%)
Children49years-old
120.00%
Percen tag e
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age Groups
From 2005 to 2007, of the 5061 pregnant women tested for HIV at ANC sites, 2516
(49.7%) were ages 15- 24 and 24 (.47%) were HIV-positive. Of the 24 HIV-positive
women, half were ages 15-24 years of age. Furthermore, 83% of the 15-24 year old HIVpositive women were 20-24 years of age. Since this age group represented only 28% of all
pregnant women but 83% of HIV-positive moms, these data suggest young women ages
20-24 are somehow at increased risk for HIV acquisition and are disproportionately
affected by HIV.
NEW INFECTIONS? Understanding that HIV infections among young people reflect new
infections, this observation leads to the conclusion that new HIV infections are occurring in
Barbados on an ongoing basis and prevention programs are not achieving the
required impact.
As a result of ART availability from 1998 to 2007 the number of AIDS-related deaths
declined by 80%,
18
HIV in the Caribbean: Understanding data and drivers of the epidemic
Figure 13. Reported Cases of Deaths Due to AIDS, Barbados: 1987-2007
Reported Cases of Deaths due to AIDS, Barbados: 1987-2007
120
100
80
60
40
20
0
Source: 2008 UNGASS Country Report, Barbados
When examined by gender, beginning in 2002, the rates of AIDS deaths have declined
more precipitously among men. Figure 14. This decrease is intuitive given the availability
of ART. However, attributing the sharp decline in men to this intervention alone requires
these data also be examined in conjunction with the rates of treatment by gender.
Figure 14. Reported Cases of AIDS Deaths by Sex, Barbados: 1987-2007
Reported Cases of AIDS Deaths by Sex, Barbados:1987-2007
90
Females
Males
80
70
60
50
40
30
20
10
0
Source: 2008 UNGASS Country Report, Barbados
Modes of transmission are not well documented through routine surveillance. However,
KAB surveys have been conducted among MSM, CSW and men and these data provide
some insights into the dynamics and drivers of the epidemic.
19
HIV in the Caribbean: Understanding data and drivers of the epidemic
Sex workers and men who have sex with men
Seroprevalence studies have not been conducted for CSW and MSM residing in Barbados.
However, a 2007 KAB survey among these groups revealed high rates of testing with 85%
and 73% of MSM and CSWs surveyed were previously tested for HIV and aware of their
HIV status, respectively. While condom usage among CSW during last sexual encounter
was high at 80%, awareness about HIV was somewhat low since only 37% of respondents
rejected myths about HIV transmission and were aware of HIV preventive measures.
Beach boys are males CSW whose client base is predominantly tourists. Risk factors for
and contribution of this group to HIV transmission rates in Barbados are unknown.
Men’s Life Style Study
In 2007, a risk behavior survey was conducted among 400 heterosexual and 100
homosexual men, >15 years of age to assess unmet needs and socio-cultural
factors that contribute to HIV risk behavior. Important highlights include:
36% of males had been intoxicated between one and countless times during the
12 months preceding the survey, particularly during holidays/vacation or weekend
revelry
25% reported engaging in unprotected sexual intercourse at least once during the
past 12 months.
47% of all males reported having multiple sex partners
Among the heterosexual men, 46% used a condom during last sexual intercourse
with a non-regular sex partner
Among MSM, 62% have two or more partners and 65% reported using a condom
at last anal sex
65.7% of men found it acceptable that all women carry condoms, but only 4.1%
found it acceptable that only men should carry condoms
Regarding healthcare maintenance with a regular provider, 16.5% have a doctor
that they see regularly, 15% never see a doctor and 68.5% only seek medical
care when something is very wrong
Other behavioural risks are summarized in the Figure 15. The findings show that the
majority of both heterosexual and homosexual men have been tested for HIV test and
know the results. However, the percentage of men tested during the past 12 months was <
50%. In addition, the percentage of MSM reporting an STI episode was more than twice
that among heterosexual men with 18% of homosexual men reporting an STI compared to
7% of heterosexual men. The most nota