The HIV/AIDS Epidemic in the Caribbean

INTRODUCTION

The HIV/AIDS epidemic has become a major developmental problem affecting every country worldwide and the Caribbean in particular, where the epidemic is the worst in the Western Hemisphere and second in magnitude only to that in Sub-Saharan Africa.

As the epidemic has spread throughout the region, the primary mode of transmission has been sexual, shifting from being predominantly homosexual in the early years, to a mosaic of homo/bi- and heterosexual forms. Transmission via contaminated blood or intravenous drug use represents a small percentage. Perinatal transmission represents 6% of the cumulative reported AIDS cases, which is high compared to the United States or Western Europe, and reflects the pattern of primarily heterosexual transmission. The epidemic has also shifted to younger populations, in particular young females.

The major feature of the epidemic is the growing number of people living with HIV/AIDS and affected families requiring care and support. The changing profile of the epidemic has already begun to impact dramatically, not only on the health sector, but also on life expectancy and the economic resources in the Region in terms of loss of human potential and productivity.

MAGNITUDE OF THE PROBLEM:

 1982 - first AIDS case described in Jamaica
 1982 to 1999, 17,016 AIDS cases reported to CAREC.
 1991 to 1999, the number of new AIDS cases per year tripled from 869 cases to 2,590.
 1998 to 1999, a 25% increase in the reported incidence.
 10% to 70% of AIDS underreported, depending on the country.
 CAREC estimates the likely total of AIDS cases to date in its Member Countries (CMCs) of between 22-26,000.

1999

 2% of Caribbean adults in the sexually active age group living with HIV/AIDS.
 57,000 adults and children newly infected with HIV (UNAIDS estimates).
 360,000 adults and children living with HIV/AIDS in the wider Caribbean. This latter figure is probably closer to 500,000.
 At least 140 persons died of AIDS every month in the CMCs. (CAREC estimates)
 Between 780 to 1,170 infants (2 to 3 per day) were infected with HIV via mother-to-child transmission (MTCT). (CAREC estimates)
 In 2010 CAREC estimates that because of AIDS, overall child mortality in the region could increase by 60%.

“1998 REPORTED AIDS CASES”.

 70% persons 15 - 44 years
 50% persons 25 - 34 years
 No.1 cause of death in persons 15-45 years
 Up to 25% of beds on medical wards occupied by patients living with HIV/AIDS.
 Annual case fatality ratio of 63% for last five years among reported AIDS cases.
 Among AIDS cases 2 males to 1 female. Ratio already close to 1:1 in Haiti, Jamaica, Bahamas, Guyana, etc.).

"GROUPS AT RISK"

 Patients with sexually transmitted infections
 Female commercial sex workers,
 Men who have sex with men

"PREVALENCE RATE 7% AND 45% IN ALL CMCS".

 2 - 3% percent pregnant Caribbean women infected.
 In the Western Hemisphere, the Caribbean #1 in HIV and AIDS among women.
 Women 15 to 24 years HIV prevalence is 2 to 4 times higher than in all other female age groups and 3 to 6 times higher than males of same age group.

AIDS IMPACT ON THE CARIBBEAN ECONOMY

TRINIDAD AND TOBAGO
 4.2% GDP LOST
 10.3% DECLINE IN SAVINGS
 15.6% DECLINE IN INVESTMENT

JAMAICA
 6.4% GDP LOST
 23.5% DELCINE IN SAVINGS
 17.4% DECLINE IN INVESTMENT

The Caribbean region could lose 5% of its GDP because of AIDS.

CAREC and the Health Education Unit of the University of the West Indies optimistic scenario for 2005.

FACTORS DRIVING THE HIV/AIDS EPIDEMIC

The single most important environmental factor driving the epidemic is the impoverishment of large population groups in an overall context of moderate economic growth in the Caribbean. Poverty in the region is pervasive and multidimensional. This includes various kinds of poverty: social, (e.g. lack of parental caring and family/community relationships); financial (low or non-existent incomes); educational (ignorance, lack of information and skills). Poverty and poor socialisation of young people in particular, are the root causes of major societal pathologies such as teenage pregnancies, drug abuse, and violence. The latter two are also having negative repercussions on tourism, which is the mainstay of the region’s economy.

ECONOMIC AND DEVELOPMENTAL FACTORS

 Poverty, grossly inequitable income distribution and unemployment

 Rapid urbanisation, creating “ghettos”

 Globalisation and trade conglomerates, creating internal pressures on small island economies

 Migration and tourism, removing social control and providing incentives for risky behaviour

 Lack of a genuine inter-sectoral response and limited involvement of the private sector.

SOCIAL AND CULTURAL AND UNDERLYING BEHAVIOURS

 Globalisation with cultural penetration, distorting value systems, including the fostering of materialism

 Dysfunctional gender relations including male insecurity, resulting in anti-social behaviour

 Lack of general education and, specifically, sex education and sex negotiation skills for young people, and marginalisation of young people

 Cultural and religious sexual taboos contrasting with social norms that promote sex

 Discrimination and stigmatisation of PLWHA, sex workers, MSM, and other vulnerable groups

 Multiple sexual partners, low condom access and usage, and reluctance to promote condom usage

 Low tolerance to MSM, causing hiding and mixing of sex partners

 Commercial sex work of various types: full-time (career), part-time (ranging from school girls through employed women to married women)

 Substance abuse, leading to risky behaviours: crack, cocaine and alcohol abuse

BIOMEDICAL, LEGAL, ETHICAL AND ACCESS TO CARE

 Lack of access to health care for some populations

 Lack of standards and systems of care, treatment and support and referral procedures for PLWHA

 Attitude of health care workers towards PLWHA: judgmental, fearful, reluctance to treat

 Continued spread of other sexually transmitted infections (STIs)

 Illegal status of vulnerable groups (sex workers and MSM), driving them underground

 Lack of legislation addressing issues surrounding PLWHA (including discrimination in the workplace, pre-employment testing for HIV, insurance and visa applications) and ensuring that minimum standards of care are part of human rights of PLWHA.

RESPONSE TO THE HIV/AIDS EPIDEMIC

During the last 12 years, the regional response to the HIV/AIDS epidemic has been co-ordinated by PAHO and managed by CAREC through technical co-operation with Member Countries. Priority areas were identified, and some successes have been achieved at regional and national levels:

 Every CAREC Member Country has a functioning national AIDS programme, although many need strengthening to effectively address the challenge, and national health reform programmes need to preferentially maintain and strengthen these and other effective national public health programmes.

 The regional blood supply is protected.

 Regional HIV/AIDS/STI surveillance systems exist, which give a reasonable understanding of the trends and impact. There is much room for improvement in some countries, and surveillance data need to be used more for disease prevention and control.

 People living with HIV/AIDS have been included in policy decision-making at regional level, although in most countries stigma and discrimination, and human rights violations continue to undermine prevention efforts.

 Knowledge about the disease in the general population is generally good, but the translation of that into widespread behaviour change needs much more work.

 Condom use is increasing, though still far short of where we need to be, and, in some instances, number of sexual partners is decreasing (e.g. Jamaica).

For the last two years, with CARICOM’s involvement, the regional response to the HIV epidemic is being expanded to include more regional institutions and involve new donors. This process has led to the development of a regional AIDS Strategic Plan.

The funding of the regional response to date has been supported mainly by bilateral and multilateral agencies, but the gap remains large in what is needed, and country core support for regional institutions (such as CAREC) needs strengthening, as donors tend not to support these.

The WHO Global Programme on AIDS supported national responses to the epidemic until the end of 1995. To compensate for the gap left by WHO-GPA and ensure that resources are adequate to support the prevention and control efforts at all levels, resource mobilisation needs to include national levels as well as all development agencies.

OUTLOOK FOR THE FUTURE

As research advances, the molecular dynamics of the virus, its variability, structural complexity and disease potential, as well as host immune reactions, are better understood. Spectacular scientific breakthroughs have resulted in highly active anti-retroviral therapies. As part of a worldwide effort to find effective and affordable vaccines against HIV, Phase 2 HIV vaccine trials are beginning in Haiti and Trinidad and Tobago. These two developments point the way to a possible future profile of the epidemic: preventable, treatable, chronic disease syndrome.

Because AIDS is a social and economic development issue, neither national development nor people’s well-being will be attained if the young, productive human capital is under constant threat of dying. Therefore acting today will have an impact beyond health and individual well being.

Focussing efforts on those most likely to acquire and spread the disease is equally important. Building country capacity to care and support PLWHA is a major priority at this time, as well as efforts targeting youth, commercial sex workers and men who have sex with men. However this can only be achieved within a framework of a long-term, strong (well financed) and sustained commitment of decision-makers at national and regional levels and the international community, to support national and regional responses to the HIV/AIDS epidemic.

SOURCE: CAREC HIV/AIDS/STI Strategic Plan, 2001-2005.

HIV/AIDS IN JAMAICA

 40 out of every 1,000 Jamaicans are infected with HIV/AIDS.
 1982 to September 2000, 4,786 HIV/AIDS cases have been reported.
 1986 the first case of HIV/AIDS infected female reported
 2000, 388 women infected with the virus.
 Men 50+ have a 2.5 times higher risk of infection than women in the same age group.
 The rate of infection in women has been outpacing men over the last three years
 16 out of every 1,000 pregnant women in Jamaica are infected with HIV.
 1 out of 15 men reported with AIDS had sex both with women and men.