Understanding data and
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
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
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
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
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
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 (1
stQuarter, 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 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
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
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.
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 data-based 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
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
UNAIDS-Report on the Global AIDS Epidemic, 2008
0 0.5 1 1.5 2
2001 2003 2005 2007
Figure 2. New HIV Infections, 2007 (verify Jamaica, DR #s)
0
1000
2000
3000
4000
5000
6000
7000
Haiti
DR Jamaica T&T
Bah Others
Figure 3. Estimated Number of Adults and Children Living with HIV in the Ten Larger Caribbean Countries
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
1990 1995 2000 2005 2007
Females Males
Estimated Number of Adults and Children Living with HIV in the Ten Larger Caribbean Countries. UNAIDS/WHO.2007
0 20000 40000 60000 80000 100000 120000 140000
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
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%
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?)
Figure 4. New Cases of AIDS, By Sex and Year: 1985-2006
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 (1st Quarter, 2008)
BAHAMAS Homosexual Bisexual Heterosexual MTCT Others Don’t
Know Total
Source: National Surveillance and Information Unit
New Cases of AIDS, By Sex and Year:1985-2006
Epidemiological Studies
HIV Trends Among Prisoners
From 2003-2006 a total, 10 166 prisoners were tested for HIV. Of these, 230 (2.3%) were HIV-positive. Review of annual testing data revealed little year-to-year variation.
Figure 6. HIV Prevalence Among Prison Population: Bahamas 2003-2006
Source: DPH Surveillance Report, Bahamas, 2007
HIV Prevalence Among Men who have Sex with Men:
In 2007 the first HIV seroprevalence survey via snowball sampling was conducted among MSM in Bahamas?, which showed an 8.18% prevalence rate. The survey also revealed differences in HIV prevention knowledge by age with 57% and 36% of MSM age > 25 years and <25 years, respectively, demonstrating a comprehensive knowledge of HIV prevention measures.
HIV Trends Among Pregnant Women
The Bahamas MOH has a well-established reputation throughout the region for its PMTCT program. Although the HIV prevalence among pregnant women declined between 1993 and 1997, with a the prevalence rate of 3% for several years, Bahamas is suspected to have one of the highest prevalence rates among pregnant women in the Caribbean.
Figure 6. In 2006, the HIV prevalence rate among pregnant women ages 15-24 was 1.26%. Public health authorities suspect the current HIV transmission rate is maintained by the prevalence of repeat pregnancies among HIV-positive women. (Why aren’t these women on RX? Are they lost to follow-up? Not in care)
HIV Prevalence Among Prison Population: Bahamas 2003-2006
2.40% 2.30% 2.40%
2.00%
0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00%
Figure 7. HIV Prevalence Among Pregnant Women. The Bahamas: 1993-2006
Source: 2008 UNGASS Report
Status of Substance Abuse in the Bahamas
Substance abuse has been documented in Bahamas largely through the Community Counseling and Assessment Centre which treated 3,181 cases of drug abuse from 2000 and 2006. In addition, the epidemic began in 1983 with a high number of HIV/AIDS cases among crack-cocaine users. Despite this, no seroprevalence studies have been
conducted nor has the impact of drug use on HIV transmission been explore in this group.
STIs
Data for STIs is inconsistently available. In 2007, 266 cases of Chlamydia and 51 cases of gonorrhea were reported with zero cases of syphilis, herpes, trichomoniasis or chancroid reported. Gender and age data were not collected and no concomitant HIV testing data are available for STI cases.
CARE
In 2006, 1,252 HIV-positive adults, 573 (46%) men, 679 (54%) women and 108 children were receiving ART. The estimated adult and pediatric coverage are 48.5% and 92%, respectively. HIV treatment programs have resulted in an appreciable decline AIDS-related deaths with 18.4% in 1996 compared to 8.8% in 2005.
In terms of quality of treatment, the percentage of adults and children with HIV infection known to be on treatment 12 months after initiation of antiretroviral therapy was 69.66% in 2006 i.e. almost 30% of patients are lost to follow-up or die during the 12 months they initiated ART.
Challenges to providing universal access to ART include: insufficient human resources and infrastructure for care, fear of stigma and discrimination, low literacy among persons living with HIV and centralization of the ART services.
HIV Prevalence Among Pregnant Women The Bahamas:1993-2006
Challenges
Human Resources
National authorities highlight the limited human resources as a serious challenge to an effective HIV response. The magnitude of this problem has not been
systematically explored.
Immigration
Migration plays a significant role in the history of HIV in the Bahamas. In the beginning of the epidemic, non-Bahamians accounted for the majority of reported HIV cases. Beginning in 2002, 25% of new cases were reported among non-Bahamians, primarily Haitians but with some Jamaicans and Dominicans identified.
Figure 8. Percentage Distribution of HIV Infections Reported Annually, By Bahamian Citizenship: 1985-2006
Source: 2008 UNGASS Report
HIV Response and Interventions
Although evaluation components have not been designed and implemented for most HIV-related responses, Bahamas can boast of several programmatic successes in the response to the HIV epidemic. First, the PMTCT programs has led to a reduction as described in MTCT. Since 2003, no HIV-positive children have been born to mothers receiving ART during pregnancy. Second, integrated VCT services are available in all community health clinics. However the impact of this program has not been evaluated. Third, blood donor screening was initiated in 1985HIV screening and in 2006, 100% all donated blood was screened for HIV. Fourth, contact tracing and partner notification is a key component of the national response. Counselors have been trained to identify partners of HIV-positive patients but the impact of these activities require evaluation. Fifth, the Youth Ambassadors for Positive Living and Ministry of Education’s Health and Family Life Education developed an educational curriculum targeting youth, young adults and the general population. Finally, the MOH has developed outreach programs for CSW and MSM. In 2007 only 48% of MSM were reached by prevention programs and 45% of MSM reject myths and have a comprehensive knowledge of HIV prevention measures. During that year, 60.47% of MSM have been tested for HIV and who know their results and also 69% reported having used a condom during last anal sex. It is recognized by national
Percentage Distribution of HIV Infections Reported Annually, By Bahamian Citizenship:1985-2006
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Barbados
Country Overview and HIV/AIDS Context
Barbados is the most easterly island in the Caribbean chain. Its population is estimated at 270,000 with blacks being the predominant race. One of the major events in the cultural calendar is the ‘Crop Over’ festival, a culmination of weeks of activity. The country’s economic base includes tourism, agriculture, small and international business and manufacturing.
HIV-Related Funding
Country Data
Data collection and publication is the responsibility of the Surveillance Unit at the
National HIV/AIDS Programme, Ministry of Health, National Insurance and Social Security. Standardized forms are used to report cases of HIV or AIDS. Data are collected from testing sites, the public HIV clinic, the Ladymeade Reference Unit and private clinicians and sent to the Surveillance Unit for collation, analysis and publication on a semi-annual basis.
In 2007, an estimated 2% of the adult population is living with HIV. From 1984 to the end of 2007, 3 408 cumulative cases of HIV were reported to MOH Epidemiology and Surveillance department. Reported cases of HIV increased until the year 2000, after which the following seven years revealed a 26% reduction with 219 cases in 2000 and 163 cases in 2007. Figure 9. The majority of cases occur in adults age > 24 and mode of
transmission data are not routinely collected. Rates of MTCT is low as are those in persons age <25. Of the 47 cases diagnoses, 57% of cases were reported in men age >24.
Figure 9. Reported Cases of HIV By Year, Barbados: 1987-2007
Reported Cases of HIV By Year, Barbados: 1987-2007
Figure 10. HIV Newly Diagnosed Cases: HIV cases diagnosed in the last 4 months
Sex and Age Group Total
Females15-24 3 (6.40%)
Source: 2008 UNGASS Country Report, Barbados
Trends in reported cases of HIV by year and sex show that males have been more affected than females. Until 2006 the male to female sex ratio consistently remained above one with an increase in male cases again in 2007. Explanations for these fluctuations are unclear.
Figure 11. Reported HIV Cases By Year and Sex, Barbados: 1984-2007
Reported HIV Cases By Year and Sex, Barbados: 1984-2007
0
Source: 2008 UNGASS Country Report, Barbados
PMTCT
REVIEW ORIGINAL SUBMISSION RE: MTCT
[Expanding their coverage rate and reaching 85% and 95% of their target in 2006 and 2007, respectively. This brought the rate of mother-to-child transmission to below 3% in 2007. ]
Figure 12. Barbados: Age Distribution of New Cases of HIV in Percentage 1994-2006-Impact of PMTCT Programs
Barbados: Age Distribution of New Cases of HIV in Percentage 1994-2006-Impact of PMTCT Programs
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Age Groups
P
er
ce
n
ta
g
e
0-4years-old 5-14years-old 15-49years-old >49years-old
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 HIV-positive 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.
Figure 13. Reported Cases of Deaths Due to AIDS, Barbados: 1987-2007
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
0 10 20 30 40 50 60 70 80
90 Females Males
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.
Reported Cases of Deaths due to AIDS, Barbados: 1987-2007
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
Figure 15. Other Behavioural Risks
Behavioural Markers Heterosexuals MSM Total
Ever taken an HIV test 57% 73% 61%
Know results 76% 85% 78%
HIV test in last 12 months 30% 47% 34%
STI in last 12 months 7% 18% 10%
STI contact: one night stand 29% 63% 48%
STI contact: spouse/regular partner 29% 13% 20%
Barbados is a popular tourist destination which places it a cross roads of sex tourism. However, no survey has been conducted to assess the magnitude tourism on the local epidemic. Anecdotally, the community is aware of a network of MSM that through organized social gatherings like parties, has been able to attract MSM from around the Caribbean, the United States and United Kingdom. The contribution of these social and sexual networks to the local epidemic has not been examined.
Challenges
Human Resources
National authorities have identified human resources issues as critical to an effective HIV response. Efforts are underway to support mobilization of civil society organizations to ensure they continue to play their role in the national response to HIV. The multisectoral approach is being promoted and line ministries are carrying out their plans of action as part of the national strategic plan.
Limited M&E capacity
The infrastructure for consistent data collection, analysis and use is limited. However, the country is being supported by UNAIDS and CDC-GAP to strengthen M&E and
surveillance capacity.
Immigration
There is no mechanism to track, quantify and document the influence of migration on HIV transmission in Barbados. However, data from clinical treatment serve as a proxy and provide some clues. For example, from January to June 2007, among newly registered HIV-patients at LRU, 66% were Barbados nationals and 34% were from other Caribbean countries. It is unclear if non-national PLWHA are traveling to Barbados in search of quality HIV care or if they are legal residents of Barbados. If the latter is true, this has implications for the availability of resources for Barbados nationals.
HIV Response and Interventions
The prevention of HIV transmission through transfusion of contaminated blood or blood products is under control. In 2006 and 2007, 100% of donated blood units were screened under in accordance with quality standards of practice.
Guyana
Region 1: Barima-Waini
Region 2: Pomeroon-Supenaam
Region 3: Essequibo Islands – West Demerara
Region 4: Demerar-Mahaica (contains the capital, Georgetown)
Region 5: Mahaica-Berbice
Region 6: East Berbice-Corentyne
Region 7: Cuyuni-Mazaruni
Region 8: Potaro-Siparuni
Region 9: Upper Takutu-Upper Essequibo
Region 10: Upper Demerara-Berbice
HIV/AIDS in Guyana
At the end of 2005, UNAIDS estimated that the prevalence of HIV infection among adults in Guyana was 2.5 percent. The HIV/AIDS epidemic in Guyana is thought to be a low-level, generalized epidemic. The first case of AIDS in Guyana was reported in 1987.
HIV Epidemiology
General Population
UNAIDS estimates that 2.5 percent of adults (15-49 years) were infected with HIV in 2005, which accounts for 11,000 people living with HIV, although this estimate is likely to be on the high side. (Do we want to discuss why this is probabyl so? And perhaps even make a (gentle/diplomatic) critique of the error in that the GAIS didn’t include sero-testing,
apparently because stakeholders feared that “prevalence would be too low, and could affect funding,” as that email suggested??)
The 2005 Guyana AIDS Indicator Survey (2005 GAIS) has shown that 98 percent of adults have heard of AIDS. Knowledge of two important means of avoiding HIV transmission – using condoms and limiting sex to one uninfected partner – is high, 76 percent in women and 81 percent in men. Almost 9 out of 10 Guyanese adults know that people infected with HIV do not necessarily show signs of infection and about half of adults in Guyana have a comprehensive knowledge of HIV/AIDS transmission and prevention: 50 percent of women and 45 percent of men know condom use and limiting sex to one uninfected partner as HIV prevention methods; are aware that a healthy looking person can have the AIDS virus; and reject the two most common local misconceptions.
was 18.4 years and 18.0 years for men. Nine percent of men and one percent of women reported having had more than one sexual partner in the last 12 months. About one-third of men (35%) and quarter of women (21%) reported having sex with a partner who was neither a spouse nor who lived with the respondent in the past 12 months.
CONCURRENCY???Of these half of women and two-thirds of men reported using a condom the last time they had higher-risk sex.
Two percent of women and three percent of men reported having had an abnormal genital discharge and less than one percent of women and men reported having had a genital sore/ulcer in the 12 months preceding GAIS.
Subpopulation Data
Although Guyana is thought to have a generalized HIV epidemic, HIV prevalence has been shown to be higher among specific populations such as MSM, CSW, youth and gold miners.
Figure 16. Subpopulation Data
Exposure Category Year Number tested for HIV HIV Prevalence
Female sex workers 2003/2004 305 26.6%
Men who have sex with men 2003/2004 80 21.3%
Drug users 2006 172 16.9%
Gold & Diamond Miners 2004 504 3.9%
A. Men Who Have Sex with Men (MSM)
In Guyana, MSM activity is a criminal offense and MSM perceive it to be a homophobic society. Forty percent of MSM reported experiencing recent police harassment. The 2003/2004 Behavioral Surveillance Survey was conducted among MSM using time location sampling. (ref) This study assessed:
1. HIV-related knowledge 2. Drug and alcohol use
3. Sexual behavior
4. Condom use
5. Sexually transmitted infections
Investigators recruited 331 participants in Region 4 using time location cluster sampling. Eligible participants were men who reported oral or anal sex with another man in the previous six months. Among the 80 participants who were tested for HIV, 21.3% were positive.
Knowledge
Sexual Behavior
The sexual lifestyle of MSM in Guyana is predominantly described in terms of casual relations, rapidly changing partners and multiple partnerships generally. MSM had an average of 3 to 4 female sex partners in the past six months. 83.7% had ‘ever’ had sex with a woman and 12.3% were currently married or living with a female and 25% reported between 1 and 3 children. According to the survey, the men tended to have multiple and concurrent non-regular sex partners and commercial sex partners. Need to find the data on this! Figure X shows the number and types of partners in the last six months reported. 57.4% reported having 2+ commercial sex partners in the past 6 months and only 22.2% reported having just one regular partner in the past 6 months. 61.2% of MSM had a regular partner. However, WHAT PERCENTAGE! even those with a regular partner assumed that their partner had other lovers. “It was found that the so called ‘regular partners’ are often multiple and changing”. CONCURRENCY data? In addition, 32.3% of the men had been forced to have sex in the past year.
Figure 17. Sexual Partners Among Men Who have Sex with Men
Condom use
The reported level of condom use at last sex was higher with non-regular than with regular partners and likewise ‘every time’ in the past six months. For example, condom use was 83.8%, 80.7%, and 68.1% with a commercial, non-regular, and a regular sex partner at last sex (Figure 18). Over 2/3 (71.6%) reported condom use at last sex with a female.
Condom use with a regular partner was reported as always (62.7%), sometimes (22.4%), and never (14.9%). Among clients, condom use was reported as always (80.0%), sometimes (12.8%), and never (7.2%).
Figure 18. Frequency of condom use in past 6 months among men Who Have Sex with men 2003/2004 BSS+ Guyana
Drug and alcohol use
The prevalence of alcohol and drug use was high with 63% alcohol use in the past month and 15.7% reporting daily usage. Sixty percent reported ever using drugs such as marijuana, cocaine or heroin while 52% reported daily marijuana use and 2.5 reported injecting drugs in the past year.
Sexually transmitted infections
Among MSM, ‘ever’ having a sexually transmitted infection may provide some information about the potential occurrence of higher risk behavior. Of the men interviewed, 17.8% and 4.2% reported having genital and anal discharge in the past year, respectively.
Approximately eleven percent reported they had a penile ulcer while 4.2% reported an anal ulcer during the last year.
B. Female Sex Workers (FSW)
Like MSM activity, sex work is an illegal and stigmatized profession in Guyana. Although two studies have been conducted among Guyanese FSW in the last 5 years, The
2003/2004 Round 1 BSS+ among FSW provides the most comprehensive information on risk behaviors of FSW in Guyana. The BSS collected data for the following areas:
1. Knowledge
2. Sexual behavior
3. Condom usage
4. Drug and alcohol use 5. STIs
Frequency of condom use in past 6 months
among Men Who Have Sex with Men
FSWs are at considerably high risk for HIV infection and transmission. The 2003-4 survey among FSW in Guyana (BSS+) demonstrated an 26.6% HIV seroprevalence.
Seroprevalence studies among Guyanese FSW from 1993, 1997 and 2000 also revealed high HIV prevalence in this group with 20%, 45% and 30% testing positive, respectively.
Knowledge
While 100% of female sex workers had heard of HIV, only 37% reported incorrect beliefs about HIV. In addition, 30% were unaware of the availability of HIV medications. Attitudes of stigma were prevalent since 70% would not buy food from an HIV infected vendor and 38% believed that HIV infected persons should be isolated from society.
Drug and alcohol use
Alcohol use is prevalent since 88% of drink regularly while working and 34.5% report always being under the influence of alcohol during sex with clients. Thirteen percent and 4.3% of HIV-positive and HIV-negative persons, respectively, reported exchanging sex for drugs in the previous 12 months.
NEED BETTER DATA here.
Sexual Behavior
There are other sexual behavior and socio-demographic characteristics such as years of sex work, age, socio-economic status, number of clients per week, and drug use habits that have shown to increase a sex worker’s vulnerability. Where are the data?
Nearly ¼, (23.3%) of FSW reported their current live-in spouse/partner currently has another partner (BSS+). CONCURRENCY AGAIN!
Condom use
Reported condom use was high with commercial sex partners, but much lower with non-commercial sex partners in the BSS+ (Figure 19). Condom use at last sex was 89.3% and 46% among commercial and non-commercial sex partners, respectively.
Figure 19. Condom Use
Always Sometimes Never Total
Regular partner 61.3% 15.0% 23.8% 80
Commercial partner 94.1% 4.9% 1.0% 102
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
Sexually transmitted infections
Of FSWs surveyed, 64% had a history of STI, 25% had syphilis (15.4% in the BSS+), and 45% had genital discharge (Persaud et al., 2000). HIV infection was found to be
significantly associated with a positive serological test for syphilis (OR=7.56; 95%CI=2.7-21.97) and history of having received treatment for syphilis (OR=2.93; 95%CI=1.12-7.8) (Persaud et al., 1999). Also, having a vaginal ulcer in the past 12 months was significantly associated with HIV infection (OR=4.0; 95%CI=1.4-12.0) (Allen et al., 2006).
C. Youth
The 2003/2004Round 1 BSS+ among in-school and out-of-school as well as the AIS provides information on the risk behaviors of youth in Guyana (Figure 21).
Condom use at last sex and behaviors in the past month as reported by the 2003/2004 BSS+
among female Sex Workers in Guyana
0 10 20 30 40 50 60 70 80 90 100
At last sex Every time Almost every time
Sometimes Never
Condom Use
P
e
rc
e
n
t
Figure 21. Studies pertaining to Youth in Guyana
Study Year Author Title Sample Size Region Methodology
2003/
1-7, 9, 10 Multistage cluster sampling among youth urban and rural youth
2005 Guyana
Ministry of Health
AIDS Indicator Survey 658 All Two-stage sample
design
The BSS+ among out-of-school youth was conducted in regions on the basis of regional distribution of HIV/AIDS cases. Persons 15-24 years old who were not in school, not married, and not cohabitating in a common-law relationship were included in the study.
Measures of Risk Behavior
Knowledge
The majority of participants (93.8%) were aware of HIV/AIDS. For example, only 23.7% of in-school youth reported that they would buy from and HIV infected vendor and are willing to care for a relative with HIV/AIDS.
Sexual Behavior
Figure 22. Sexual Behavior among Youth
Ever had sex 1,230 30.6% 908 46%
Sexually active in past 12 months
among those who ever had sex 373 63.5% 418 68.4%
Had commercial sex partner in last 12 months
189 24.3% 418 1.2%
Had noncommercial sex partner
in past 12 months 93.6% male (n=109)86.4% female
(n=103)
99.3% male (n=?) 100% female
(n=?)
Among in-school youth, males reported a higher rate of having 2 or more noncommercial sex partners in the past year (55.1%) than females (17.5%) and a small percentage of males (15-19yrs) in both in-school and out-of-school reported having had a male sexual partner (1.9% and 2.0%, respectively).
In terms of sexual behavior, in-school youth reported higher rates of commercial sex work. Approximately one quarter (46/189) of the sexually active survey participants reported at least one commercial sex partner in the last 12 months. Interestingly, both male and females reported (29/98, 29.6% males and 17/91, 18.7% females). This behavior was not as prevalent in out-of-school youths (3.0%, ages 15-24).
Age-mixing in sexual relationships may be a major factor in the spread of HIV/AIDS among youth. In the AIS survey, 8% of women 15-19 reported sex with a man 10 or more years older than themselves in the last 12 months.
Condom usage
Figure 23. Condom Use among Youth
In-School Youth (15-19)
Out-of-School Youth (15-19)
Total M F Total M F
Condom use at
first sex 56.8% 51.0% 64.1% 64.8% 59.3% 71.8%
Total 373 206 167 398 221 177
Condom use at last sex with a commercial partner
53.1% 55.0% 60.0% 80.0% 75.0% 100.0%
Total 32 20 10 5 4 1
Condom use at last sex with a noncommercial partner
72.7% 75.7% 69.3% 60.7% 72.8% 47.8%
Total 157 87 70 285 147 138
Used condom every time with noncommercial partners over the past 12 months
52.8% 57.4% 47.5% 69.5% 70.0% 68.8%
Total 114 66 48 154 90 64
Drug and Alcohol Use
Figure 24. Alcohol and Marijuana Use among Youth
In-School Youth (15-19)
Out-of-School Youth (15-24)
Alcohol Use Everyday 0.8% 2.2%
At least once per week 14.9% 32.4%
Less than once per week or never
65.1% 65.5%
Don’t know 19.1%
-Total 634 878
Marijuana Use Daily in past month 4.6% 35.6%
Once weekly in past month 20% 34.4%
Less than once weekly in past
month 46.2% 30%
Never 29.2%
-Total 65 90
Sexually Transmitted Infections
Among sexually active in-school youth, 6.8% reported abnormal genital discharge in the past 12 months (9.7% females and 4.5% males), and 7.9% reported a genital ulcer or sore in the past 12 months with similar rates among males and females.
E. Gold & Diamond Miners
The gold and diamond mining industry in Guyana employs thousands of men in hundreds of mines in remote interior regions. Areas with high concentrations of men with steady incomes generally attract commercial sex workers and commercial sex takes place at most ‘landings’, logistical bases supporting mines within the area. In 2004 a study was
conducted among miners in Guyana. Five hundred thirty nine miners from 45 mines were enrolled and 504 (%) were counseled and tested for HIV and syphilis using rapid tests, and provided on-site test results. The HIV prevalence was 3.9%.
Knowledge
HIV knowledge among miners was high with 77.7% aware that condoms were protective from HIV/AIDS 89% aware that a healthy looking person could be infected with HIV. Stigma exists among miners as evidenced by 53.4% who would not continue to buy food from an HIV infected shopkeeper.
Sexual Behavior and condom usage
Drug and alcohol use
Substance use was high. Most miners reported ‘ever’ drinking alcohol (92.4%), 49.6% had ever used marijuana, and 8.3% had ever used cocaine. None of the respondents reported injection drug use during the past 12 months.
Sexually Transmitted Infections
During the preceding year, 13.3% of miners had STI symptoms (ulcer or discharge) and less than half of those with symptoms received treatment. Syphilis prevalence was 6.4% among miners. In a multivariate model, having a positive treponemal syphilis test
(reflecting the prevalence of life-time history of syphilis) was significantly associated with HIV infection (adjusted OR=6.1;CI=1.8-20.8).
minimal. 15.2% reported ever using drugs (marijuana, cocaine, heroine), with
Non-Injection Drug Users
In October-November 2006, the Canadian Society for International Health study, assessed the relationship between drug use behavior and HIV prevalence. The study was
conducted in Georgetown among 172 cocaine users. 155 men and 17 women participated.
Of the 172 participants, 29 (16.9%) tested positive for HIV (9 females and 20 males). Sixty-one participants reported a history of STI. HIV-positive and HIV- negative drug users had similar risk behaviors. Risk behaviors among HIV positive drug users such as casual sex and sharing crack pipes increase the likelihood of transmitting HIV to non-infected partners.
Due to lip burns and mouth sores common among crack users, sharing crack pipes (65.5% and 52.9%, HIV+ and HIV-, respectively) may increase the likelihood of transmitting HIV and hepatitis C.
Unprotected casual sex in the last 6 months occurred among 90.9% of the HIV positive respondents versus 66.1% among HIV negative respondents. 79.3% of HIV+ drug users already knew their HIV+ status before the study.
Pregnant Women
There have been few recent studies examining HIV prevalence among pregnant women in Guyana. Pregnant women are usually considered a proxy for the general population and thus are recommended to survey to estimate the prevalence of HIV in the general population. Traditionally these surveys sample first time antenatal clinic (ANC) attendees and use blood left-over from other ANC related tests to test for HIV (unlinked anonymous testing). There are available data from three studies 1997, 2004 and 2006. We present data from all three studies, however we only compare data from 2004 and 2006.
In 2004, the ANC surveillance was expanded to include more ANC across the country. Data for half of the sample came from the PMTCT program and the other half was obtained from employing unlinked anonymous testing methodology. The adjusted HIV prevalence among ANC attendees was 2.3%. The age group with the highest prevalence (3.31%) was 35-39 year olds. Prevalence among the urban population was 3.4% and rural was 1.9%
prevalence (3.08%) was 40-44 year olds (small sample size). Prevalence among the urban population was 2.8% and rural was 1.1%
Figure 25 shows comparisons from 2004 and 2006 ANC studies.
Figure 25. Select Indicators from 2004 and 2006 Antenatal Clinic Surveys-Guyana
ANC Surveillance 2004 2006
HIV prevalence (adjusted) 2.3% 1.5%
HIV prevalence among 15-24 year olds 2.03% 1.07%
Urban HIV prevalence 3.4% 2.01%
Syphilis prevalence 2.42% 0.63%
A. Voluntary Counseling and Testing Services
Utilization of VCT - FSW
According to the BSS+, only 28.4% indicated HIV testing was available in their community. Of those that had ever had an HIV test (244/450), 64.3% had their HIV test in the past year and 85.2% had received their results. Those that did not know the results of their last HIV test were found to have a higher number of partners per day and never used contraception (Allen et al., 2006). Over a third (36.4%) of HIV+ sex workers had never had an HIV test (Allen et al., 2006).
Voluntary Counseling and Testing (VCT) Practices – In- and Out-of-School Youth
Only approximately half of youth interviewed stated they had access to VCT in the
community and very few had ever had an HIV test. Among, in-school youth there was little varying information when stratified by sex. However, among out-of-school youth, 22.1% females versus 12.8% males had ever had an HIV test. The receipt of pre- and post-test counseling was low as well as voluntary act to take the test.
Figure 26. Voluntary Counseling and Testing Practices
VCT
In-School Youth
(15-19) Out-of-School Youth (15-24)
n % n %
Has access to VCT in the community 630 54.6 809 55.1
Has ever had an HIV test 78 6.8 259 17.6
Had taken the test voluntarily 49 62.8 155 55.6
Collected their results - - 230 89.8
Received pre- and post-test counseling - - 62 24.0
Had most recent HIV test within the past year
- - 168 64.9
Youth
Only approximately half of youth interviewed stated they had access to VCT in the community and very few had ever had an HIV test. Among, in-school youth there was little varying information when stratified by sex. However, among out-of-school youth, 22 percent females versus 13 percent males had ever had an HIV test.
Employees of sugar industry
Nearly one-third of respondents knew of a place in the community to access HIV testing; while only 17 percent had ever had an HIV test (52% voluntary, 48% required). 85 percent returned for their results and over half (55%) had been tested within the past year. The low utilization rates support the respondent’s low perception of their personal risk of HIV infection (91.4%).
Figure 27. Percent ever tested and received results by key groups
Ever tested (%) Tested and received results (%)
Female sex workers 54.2 46.2
Men who have sex with men 43.8 38.4
In-school youth 6.8
-Out of school youth 17.6 15.6
Employees of sugar industry 16.7 13.7
Member of uniformed services 48.2 45.3
General population
Only 34 percent of respondents knew of a place in the community to access an HIV test. Less than half of respondents (48.2%) had ever had an HIV test, and nearly half (43.9%) reported they had been required to take that test; however, the majority of those tested had returned for their results. There was little variation among males and females, except 67 percent of females reported their HIV test in the past year versus 55 percent males.
Tuberculosis patients
Seventy-nine (31%) of the 253 patients reported knowing their HIV-infection status before starting TB treatment and were not retested for HIV. Of the 79, 57 (84%) reported a positive HIV status. Of the remaining 174 patients with unknown HIV status before
diagnosis of TB, 127 (73%) were offered HIV counseling and testing, and 115 (91%) of the 127 agreed to be tested.
General population
Pregnant women attending antenatal clinics
Suriname
Trinidad and Tobago
Country Overview and HIV/AIDS Context
Trinidad and Tobago is the most southern country in the chain of Caribbean islands, just 7 miles from the Venezuelan coast. It has an area of 5,128 sq km. In 2007, the population of Trinidad and Tobago was approximately 1.3 million. The country is composed of seven counties, of which St. George is the most densely populated. In 2006 the literacy rate among those aged 15 years and older was estimated to be 99%.
Country data
The first cases of HIV/AIDS in
Trinidad and Tobago were diagnosed and reported in 1983. During the period 1983-2007, there has been a total of 18,735 reported HIV infections, with 10,509 (56%) being male and 7,520 (40%) being female. The 18,735 cases consisted of 1,321 (7%) cases aged less than 15 years, 15,693 (84%) cases aged 15 years old and older, 1,225 (6%) with no age recorded and 496 (3%) with no age and gender recorded [Table 1].
In the last eight years, the cumulative total of HIV cases has more than doubled, with the annual incidence increasing from 816 per 100,000 population in 2000 to 1,441 per 100,000 population in 2007. During 2007, on average, 4 new cases of HIV/AIDS were reported everyday.
Figure 28. Number of Reported HIV Cases by Year and Gender
Year of Test Male Female
Male to female ratio
Gender not reported
Total Reported Cases
Number
Cumulative cases
1983 8 0 All males 0 8 8
1984 27 0 All males 0 27 35
1985 95 17 5.59 2 114 149
1986 104 31 3.35 1 136 285
1987 136 40 3.40 4 180 465
1988 172 57 3.02 12 241 706
1989 146 84 1.74 18 248 954
1990 188 93 2.02 5 286 1240
1991 280 153 1.83 9 442 1682
1992 401 195 2.06 18 614 2296
1993 442 176 2.51 8 626 2922
1994 382 218 1.75 23 623 3545
1995 424 229 1.85 31 684 4229
1996 507 309 1.64 51 867 5096
1997 571 390 1.46 36 997 6093
1998 551 386 1.43 28 965 7058
1999 625 466 1.34 33 1124 8182
2000 546 331 1.65 39 916 9098
2001 543 434 1.25 85 1062 10160
2002 651 527 1.24 31 1209 11369
2003 852 827 1.03 39 1718 13087
2004 757 635 1.19 53 1445 14532
2005 777 616 1.26 43 1436 15968
2006 700 669 1.04 50 1419 17387
2007 624 637 0.97 87 1348 18735
Total 10509 7520 706 18735
Figure 29. Reported HIV Cases by Year and Gender (1983-2007)
Data source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
In 2007, almost 18% (236 of 1,348) of reported HIV cases were among young people aged 15-24 years [Figure 30]. In 2007, there was a disproportionately higher number of infected younger females compared to young males. In 2007, only 25% (60 of 236) of new HIV cases among adolescents and young adults occurred in males, while females accounted for 73% (172 of 236) of these cases (gender was not reported for 2%) [Figure 30]. Additionally, young men accounted for only 10% (60 of 624) of new HIV cases among males overall, while young females accounted for 27% (172 of 637) of new cases among females overall. HIV infections are showing the fastest increase among young adult females aged 15-29 years, increasing from 16% of all newly diagnosed adult female cases in 1983-1987 to 65% in 2003-2007 [Figure 31]. The higher rate of HIV detection among younger females may be partly due to more opportunities for HIV screening in young women (e.g. Prevention of Mother to Child Transmission (PMTCT) programme).
0
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year
Figure 30. Number of HIV Cases Reported in 2007 by Gender and Age Group
Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
Figure 31. Reported Female HIV Cases by Age Group and Year (1983-1987)
0
Sexual exposure continues to be the main mode of HIV transmission in Trinidad and Tobago. In 1983, all of the eight diagnosed HIV/AIDS cases reported sexual exposure as their risk of having HIV, with five (62.5%) being men who have sex with men (MSM), and three (37.5%) being men who have sex with men and women (MSMW). Starting in the late 1980’s heterosexual exposure became the major risk for both sexes [Figure 32]. It should be noted however, that on average, only 42% of HIV cases reported on their exposure risk. During the period 1983-2007, intravenous drug use and blood transfusions accounted for 0.06% and 0.03% of all HIV cases respectively. This represents 9 cases due to
intravenous drug use and 4 cases due to blood transfusions during the period 1998-2002. There were no cases due to either of these two exposures outside of this time period.
Figure 32. Reported HIV Cases by Exposure Category and Year (1983-2007)
0 MSMW - Men who have sex with Women and Men MSW - Men who have sex with Women WSM - Women who have sex with men Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
Figure 33. Number of Reported HIV Positive Cases by County and Year
County 1983-1987 1988-1992 1993-1997 1998-2002 2003-2007
Total
Number /100,000 Pop1
St George West 158 716 1295 1487 1713 5369 3469
St George Central 66 301 660 950 917 2894 1840
St George East 47 182 351 681 1019 2280 699
Total for St George 312 1199 2306 3118 4782 11717 1836
Caroni 22 65 162 271 412 932 405
St Andrew 5 30 87 129 195 446 693
Nariva/ Mayaro 2 13 28 33 35 111 332
St Patrick 8 35 108 140 188 479 260
Victoria 21 106 212 402 400 1141 774
Tobago 20 55 204 340 391 1010 1867
Not stated 116 328 690 843 2096 4073
Total 465 1831 3797 5276 7366 18735 1385²
1Rate/100,000 County population based on the 2000 census ² Rate/100,000 population using 1,352,369 as denominator. Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
Figure 34. Reported HIV Infections by County, 1983-2007 Figure 35. HIV Incidence per 10,000 Population by County, Trinidad and Tobago, 1983 - 2007
Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
56%
Legend <0.1 0.1-0.2 0.3-0.4 0.5-0.6 0.7-0.8 0.9-1.0 1.0-2.0 >2.0
Figure 36. Maps of Reported HIV Infections by County, 1983-2007
St. George
Caroni
St. Andrew/ St. David
Victoria St. Patrick
Nariva/ Mayaro
1983 - 1987 1988 - 1992 1993 - 1997
1998 - 2002 2003 - 2007
Note: Average incidence of AIDS per year over 5-year period by county reported
The proportion of new cases with AIDS at first diagnosis peaked in the early 2000s and decreased since then in both males and females. In 1983, 100% of all diagnosed HIV were AIDS cases [Figure 37]. In 2002, when the combination ARV became available, the proportion of AIDS cases at first diagnosis decreased to 38% among the males and 32% among the females.
Figure 37. Reported HIV and AIDS Cases by Year (1983 – 2007)
Source: Trinidad and Tobago, Ministry of Health, National Surveillance Unit, May 2008
Overall, the cumulative number of cases of AIDS at first diagnosis peaked in the age group 30-34 years (17%), followed by 35-39 years old (15%) [Figure X]. Recent analysis of 1,512 patients from a resource-poor setting showed that the mean survival time from seroconversion to ART eligibility was 5.67 years (95% confidence interval 2.85-9.96). Given this average period of time from HIV infection to AIDS, Trinidad and Tobago data suggest approximately 20-29 years as the most likely age of HIV infection. It is worth noting that 9% of all AIDS cases at first diagnosis are among those aged 20-24 years, indicating a probable period of infection of younger than 15 years [Figure X].
During the period 1983-1987, men who have sex with men (MSM) was the largest exposure category among AIDS cases (57%), and this decreased to 5% during the period 2003-2007. Heterosexual exposure however, has increased over time [Figure 9]. Among heterosexual females (WSM), the proportion of AIDS cases rose from 12% in 1983-1987 to 42% in 2003-2007. Among the male heterosexuals (MSW), it increased from 11% in 1983-1987, to 51% in 2003-2007 [Figure 38]. However, it should be noted, that only 57% of AIDS cases reported on their exposure risk. During the period 1983-2007, intravenous drug use and blood transfusions accounted for 0.1% and 0.06% of all AIDS cases respectively. This was as a result of 5 cases due to intravenous drug use and 3 cases due to blood transfusions during the period 1998-2002. No cases in these exposure categories were reported outside of this time period.
0
