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The status of HIV in the Caribbean

Zero Discrimination. Zero New HIV Infections. Zero AIDS Related Deaths

This report was produced under the supervision of Ernest Massiah, Director, UNAIDS Caribbean Regional Support Team. The research and writing of the report was coordinated by Bilali Camara who supervised the team responsible for production of the report. The team includes Maxine Jackson-Ghent and Cheryl Oâ&#x20AC;&#x2122;Neil who provided administrative and editorial support. Thanks to the following individuals for their suggestions and written contributions to this publication: Sir George Alleyne, Christine Barrow (UWI), Carol Jacobs (CBMP Barbados), Carl Browne (PANCAP), Kevin Harvey (Jamaica), Robert Carr (ICASO), Roger Mc Lean (UWI), Claudette Francis (Psychologist), Maria Tallarico (UNDP), Sheila Stuart (UN-ECLAC), Susan Timberlake, Michel de Groulard, Anita Navarro, Ruben del Prado, and Walter Saba (UNAIDS).

THE STATUS OF HIV IN THE CARIBBEAN All rights reserved. Publications produced by UNAIDS can be obtained from the office of the UNAIDS Caribbean Regional Support Team (CAR-RST). Requests for permission to reproduce or translate UNAIDS publications-whether for sale or non-commercial distribution- should also be addressed to the office of the UNAIDS Caribbean Support Team at the address below or by fax, at +1-8686238516, or email: rst-car@unaids.org

WHO Library Cataloguing-in-Publication Data THE STATUS OF HIV IN THE CARIBBEAN UNAIDS/2010 1. Acquired immunodeficiency syndrometreatment, care and support. 2. HIV infectionstherapy. 3. HIV infections-statistics. 4. HIV infections-prevention. 5. Delivery of health care. 6. Human Rights. 7. Caribbean Region. 8. UNAIDS Programme Effectiveness and Country Support Department ISBN 978-976-8210-42-5 (NLM classification WC 503.4 DC3)

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Disclaimer: Photographs in this report do not necessarily represent the situation, opinions, or beliefs of the persons depicted, and in no way imply their HIV status.

The mention of specific companies or of certain manufacturersâ&#x20AC;&#x2122; products does not imply that they are endorsed or recommended by UNAIDS in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of products are distinguished by initial capital letters.

UNAIDS Caribbean Regional Support Team. 3 A Chancery Lane, UN House. P.O. Box 812. Port-of-Spain, Trinidad and Tobago. West Indies

www.unaidscaribbean.org

The Status of HIV in the Caribbean

iii List of Abbreviations iv Executive Summary 1

I. The HIV Epidemic in the Caribbean

II. National Government and Civil Society Responses to HIV

III. The Social Drivers of the Epidemic

IV. Achievements

V. Challenges

VI. The Future of the HIV Response

26 Annex I Funding the Caribbean HIV Response from GFATM and PEPFAR 27 Annex II Funding the Caribbean HIV Response from the World Bank

List of Abbreviations AIDS ART CARICOM CDC CCM CCNAPC CD4 CHART CIDA COIN COPRESIDA CRN+ CRTA CSWC CVC DFID DHS FSW GFATM GTZ HIV IASC IAWG IBRD

Acquired Immune Deficiency Syndrome Antiretroviral Treatment Caribbean Community Centers for Disease Control Country Coordinating Mechanism Caribbean Coalition of National AIDS Programme Coordinators Cluster of Differentiation 4 Caribbean HIV/AIDS Regional Training Network Canadian International Development Agency Centro de Orientación e Investigación Integral Consejo Presidencial del Sida Caribbean Regional Network of People Living with HIV/AIDS Caribbean Regional Trans in Action Caribbean Sex Worker Coalition Caribbean Vulnerable Communities Department for International Development Data and Health Surveys Female Sex Workers Global Fund to Fight AIDS, Tuberculosis and Malaria Deutsche Gesellschaft für Technische Zusammenarbeit Human Immunodeficiency Virus Inter-Agency Standing Committee Inter-Agency Working Group International Bank for Reconstruction and Development

IDA ILO KfW LAC MARP MSM PAHO PANCAP PEPFAR PLHIV PMTCT SW UNAIDS UNDP UNESCO UNFPA UNGASS UNICEF UNIFEM UNODC USAID WFP WHO

International Development Association International Labour Organization Kreditanstalt für Wiederaufbau Latin America and the Caribbean Most-At-Risk Population Men Who Have Sex with Men Pan American Health Organization Pan Caribbean Partnership Against HIV and AIDS US President’s Emergency Plan for AIDS Relief People Living with HIV/AIDS Prevention of Mother-to-Child Transmission Sex Workers Joint United Nations Programme on HIV/ AIDS United Nations Development Programme United Nations Educational, Scientific and Cultural Organization United Nations Population Fund United Nations General Assembly United Nations Fund for Children United Nations Development Fund for Women United Nations Office on Drugs and Crime United States Agency for International Development World Food Programme World Health Organization

the status of HIV in the CARIBBEAN

iii

Executive Summary

fter almost 30 years, the HIV epidemic is still largely affecting most-at-risk populations, and the number of new HIV infections has not significantly declined over the last 10 years. HIV now affects women and men equally, and remains the leading cause of death among people aged 20-59.

Early successes were achieved in the area of blood safety and universal precautions; recently scaling up antiretroviral treatment coverage among adults and children has resulted in a 40% decrease in AIDS-related mortality, and high coverage rates for HIV testing and prevention of mother-to-child transmission of HIV achieved an 18% reduction of new HIV infections among children from 2001 to 2008. But, persistent challenges remain. Prevention programmes have not significantly reduced the number of new infections. The long term cost of this is simple: there will be an increasing number of people who will need treatment in the future if prevention is not scaled up. Furthermore, treatment costs are likely to increase as newer, more effective medications with fewer side effects come on to the market. HIV prevalence is highest among men who have sex with men and sex workers. Yet, this epidemiological

evidence has not significantly influenced expenditure patterns. The majority of persons in these population groups are not reached by prevention efforts. Colonial laws, repealed by the British, still criminalise sexual behaviours and orientations, and help perpetuate notions of immorality and illegality and hinder Caribbean citizens from exercising some of their most basic rights: freedom of movement without fear of violence, and the right to health care. The change in the gender profile of the epidemic over the last 30 years is evidence of the generational impact of the norms of masculinity and femininity in Caribbean societies. The economic climate, deep pockets of poverty, and a new information age have altered patterns of sexual behaviour and increased womenâ&#x20AC;&#x2122;s vulnerability to HIV. Transactional sex, the exchange of sex for security have caught the regionâ&#x20AC;&#x2122;s leaders off guard as adolescent and female sexual behaviours are different from what was assumed to prevail at the start of the epidemic. Over the last decade, the region has received over US$1.3 billion for its HIV programmes; with the current financial and economic crises donor governments have less fiscal space, and as budgets tighten, external resources for HIV are likely to decline. Caribbean countries, many of which are classified as Upper Middle Income, are now less eligible for development assistance. Increasingly, and within the short-term, the financial cost of the regionâ&#x20AC;&#x2122;s HIV programmes is likely to be passed on to national governments. The financial model for supporting HIV programmes in the region

must be reconsidered, new efficiencies are needed, the unit cost of doing business must be reduced, and the effectiveness of programmes must be increased. The future of the HIV epidemic will depend on how well the Caribbean will address these identified challenges. Leadership is needed to:

one Ensure continued funding for HIV. Over the last decade the region received more than US$1.3 billion in external funding for HIV. That era is over. The amount of external funding available for HIV has fallen, particularly for Upper Middle Income Countries. Governments need to better estimate the costs of supporting existing HIV responses, identify how these needs can be financed by national resources, and adopt measures that will help contain future costs.

two

Improve prevention. A Prevention Revolution is needed. If the number of new cases of HIV is not reduced, the number of people needing treatment will increase. Effective prevention is necessary to reduce treatment costs. The voice of Caribbean leaders must be heard to shape the discourse around sex, sexuality, sexual orientation, morality and sex, and young peopleâ&#x20AC;&#x2122;s sexuality if the silence, shame and fear of open, informed discussion are to be broken. We need to use combination prevention approaches, evidence informed options,

that can reach the populations most affected, with clear, unambiguous information, support and services. As resources become scarcer, prevention funding must be allocated to the most effective interventions, and to the most affected target populations.

three Revitalise treatment. Treatment is part of prevention. The stigma attached to HIV prevents people from seeking treatment. This must be removed. The systems for delivering treatment must be made more efficient. Caribbean governments must place increased emphasis on lowering the cost of treatment and engage more actively in price negotiations with pharmaceutical companies. And, civil society must be supported to help expand the reach of treatment, care and support as part of a new approach to prevention.

four Remove punitive laws and diminish stigma and discrimination. Laws that perpetuate stigma and discrimination and limit access to health care and fuel the spread of HIV are not in the national interest.

four four

the status of HIV in the CARIBBEAN

five Improve the efficiency of resource allocation. Not enough is being spent on prevention efforts that work. Countries need to review where funds are being spent, and what impact programmes are having to determine whether the most costeffective interventions are being supported.

six Strategic Information. Data are needed to characterise the epidemic, its trends and key drivers. These would help identify priority areas for intervention and monitor the progress and impact of programmes.

Résumé

près presque 30 ans d’existence dans les Caraïbes, l’épidémie de VIH touche encore largement les populations les plus à risque et le nombre de nouvelles infections à VIH n’a pas diminué de façon significative au cours des10 dernières années. Le VIH touche aujourd’hui les femmes et les hommes de manière égale et est la principale cause de décès chez les 20-59 ans. Les premiers succès ont été réalisés dans le domaine de la sécurité transfusionnelle et des précautions universelles; récemment l’extension de la couverture des traitements antirétroviraux chez les adultes et les enfants a entraîné une diminution de 40% de la mortalité liée au sida. Les taux de couverture élevés pour le dépistage du VIH et la prévention de la transmission de la mère à l’enfant du VIH ont eu pour résultat une réduction de 18% des nouvelles infections chez les enfants entre 2001 et 2008. Mais, les défis persistent. Les programmes de prévention n’ont pu réduire de façon significative le nombre de nouvelles infections, ce qui entraine à long terme une augmentation du nombre de personnes qui auront besoin de traitement. En outre, les coûts de traitement

sont susceptibles d’augmenter à mesure que de nouveaux médicaments plus efficaces avec moins d’effets secondaires arrivent sur le marché. La prévalence du VIH est plus élevée chez les hommes ayant des rapports sexuels avec des hommes et des travailleuses du sexe. Mais, cette réalité épidémiologique n’a suscité aucune augmentation des ressources allouées aux interventions dirigées vers ces groupes. C’est ainsi que la majorité des personnes les plus à risque ne sont pas touchées par les efforts de prévention. De plus, les lois coloniales, abrogées par l’administration britannique, criminalisent encore les comportements et les orientations sexuels. Elles contribuent à perpétuer les notions d’immoralité et d’illégalité et empêchent les citoyens des Caraïbes d’exercer leurs droits les plus fondamentaux comme, par exemple la liberté de mouvement sans craindre la violence ou le droit aux soins de santé. Le changement dans le profil épidémiologique au cours des 30 dernières années est la preuve de l’impact générationnel des normes de masculinité et de féminité dans les sociétés des Caraïbes. La situation économique avec des poches profondes de pauvreté et une nouvelle ère dans le domaine de l’information ont modifié les schémas de comportement sexuel et augmente la vulnérabilité des femmes au VIH. Les rapports sexuels transactionnels, l’échange de rapports sexuels pour la sécurité ont pris les dirigeants de la région au dépourvu, de même que les comportements sexuels des adolescents et des femmes, qui diffèrent par rapport aux prédictions faites au début de l’épidémie.

the status of HIV in the CARIBBEAN

vii

Au cours de la dernière décennie, la région a reçu plus de 1,3 milliards de dollars pour ses programmes sur le VIH, mais avec la crise financière et économique, les pays donateurs ont moins d’espace fiscal, et comme leurs budgets se resserrent, les ressources extérieures pour le VIH sont susceptibles de baisser. Les pays Caribéens, dont beaucoup sont classés comme à revenu moyen supérieur, sont aujourd’hui moins éligibles pour l’aide au développement. De plus en plus, et dans un court terme, le coût financier des programmes VIH de la région sera remis aux gouvernements nationaux. C’est pourquoi, le modèle financier d’appui aux programmes VIH dans la région doit être revu car de nouvelles approches sont nécessaires, le coût unitaire des interventions doit être réduit, et l’efficacité des programmes doit augmenter. L’avenir de l’épidémie de VIH dépendra de la façon dont les Caraïbes feront face à ces défis. Un leadership fort est nécessaire pour:

viii

un Assurer la poursuite du financement pour le VIH. L’époque où la région recevait 1,3 milliard de dollars est révolue. Le montant des financements externes disponible pour le VIH a baissé, en particulier pour les pays à revenu moyen supérieur. Les gouvernements ont besoin, pour mieux estimer les coûts des programmes, de déterminer comment ces besoins peuvent être financés par des ressources nationales et adopter des mesures qui contribueront à contenir les coûts futurs.

deux Améliorer la prévention. Une révolution de la prévention est nécessaire. Si le nombre de nouveaux cas de VIH n’est pas réduit, le nombre de personnes nécessitant un traitement va augmenter. Une prévention efficace est nécessaire pour réduire les coûts de traitement. La voix des dirigeants des Caraïbes doit être entendue dans les discussions sur le sexe, la sexualité, l’orientation sexuelle, la moralité et la sexualité des jeunes, de sorte que le silence, la honte et la peur de discussion ouverte et informée puissent prendre fin. Il faut utiliser une combinaison des approches de prévention efficaces qui atteignent les populations les plus touchées avec une information claire, le soutien

sans équivoque et l’accès aux services. Comme les ressources se raréfient, le financement de prévention doit être utilisé pour les interventions les plus efficaces et pour les populations cibles les plus touchées.

trois Revitaliser le traitement. Le traitement fait partie de la prévention. La stigmatisation liée au VIH empêche les personnes atteintes de se faire soigner, il s’agit là d’une barrière à faire disparaitre. Le système d’administration du traitement doit être plus efficace. Les gouvernements des Caraïbes doivent mettre davantage l’accent sur la réduction du coût du traitement et s’engager plus activement dans les négociations sur les prix avec les compagnies pharmaceutiques. La société civile doit être soutenue pour étendre la couverture du traitement, des soins et du soutien dans le cadre d’une nouvelle approche de prévention.

cinq Améliorer l’efficacité de l’allocation des ressources. Les ressources allouées aux activités de prévention efficaces sont insuffisantes. Les pays doivent revoir la répartition des dépenses et l’impact des les programmes pour déterminer les interventions les plus rentables à prendre en charge.

six L’information stratégique. Plus de données sont nécessaires pour caractériser l’épidémie, ses tendances et les facteurs sous-jacents. Ceci permettra d’identifier les domaines prioritaires d’intervention et de suivre les progrès et l’impact des programmes.

quatre Supprimer les lois répressives et réduire la stigmatisation et la discrimination. Les lois qui perpétuent la stigmatisation et la discrimination, limitent l’accès aux soins de santé et contribuent à la propagation du VIH, elles ne servent pas l’intérêt national.

the status of HIV in the CARIBBEAN

Resumen

espués de 30 años, la epidemia de VIH sigue afectando de manera considerable a las poblaciones en mayor riesgo y el número de nuevas infecciones no ha disminuído significativamente en la última década. La epidemia ahora afecta a hombres y mujeres por igual y continua siendo la causa principal de mortalidad en personas de 20 a 59 años. Los primeros éxitos en la lucha contra la epidemia se han logrado en el área de bioseguridad en bancos de sangre y en la adopción de precauciones universales. Recientemente, la ampliación de cobertura con tratamientos antiretrovirales entre adultos y niños ha resultado en una reducción del 40% en la mortalidad por causas relacionadas al SIDA. Asimismo, entre el año 2001 y el 2008, la alta cobertura de las pruebas de despistaje del VIH y la prevención de la transmisión del virus de la madre al hijo han logrado reducir en 18% el número de nuevas infecciones por VIH entre los niños. Sin embargo, los retos continúan. Los programas de prevención no han reducido significativamente el número de nuevas infecciones y el costo a largo plazo de esta realidad es claro: en el futuro habrá un núme-

ro creciente de personas que necesitarán tratamiento si los programas de prevención no amplían su cobertura. Se añade a esto el posible aumento en los costos de tratamiento cuando los medicamentos nuevos, más eficaces y con menos efectos secundarios salgan al mercado. La prevalencia de VIH es mayor entre hombres que tienen sexo con hombres y en trabajadoras sexuales. Sin embargo, esta evidencia epidemiológica no ha influenciado de manera significativa la estructura de la inversión en la respuesta al VIH. La mayoría de personas en estos grupos poblacionales no son alcanzadas por los esfuerzos de prevención. Las leyes coloniales -traídas por los británicos, pero ya derogadas en su país - todavía criminalizan ciertas conductas y orientaciones sexuales, ayudando a perpetuar las nociones de inmoralidad e ilegalidad y obstaculizando que los ciudadanos del Caribe ejerzan libremente algunos de sus más básicos derechos tales como la libertad de movimiento sin temor a la violencia y el derecho al cuidado de su salud. El cambio en el perfil de género de la epidemia en los últimos 30 años evidencia el impacto que las normas de masculinidad y feminidad han tenido en las nuevas generaciones y en las sociedades del Caribe. El clima económico, los grandes bolsones de pobreza y la nueva era de la información han alterado los patrones de conducta sexual y aumentado la vulnerabilidad de la mujer frente al VIH. El sexo transaccional y el intercambio de sexo por seguridad han tomado por sorpresa a los líderes de la región puesto que las conductas sexuales

de los adolescentes y de las mujeres son diferentes de lo que se suponía prevalente en el inicio de la epidemia. Durante la última década, la región ha recibido más de $1.3 billones de dólares para sus programas de VIH. Con la actual crisis económica y financiera, los gobiernos donantes tienen menos espacio fiscal y, en la medida que los presupuestos se ajusten, los recursos externos para el VIH se podrían reducir. Varios de los países del Caribe están clasificados como de ingreso medio alto y, por tanto, su elegibilidad como sujetos de asistencia para el desarrollo se ha reducido. Es probable que de manera progresiva y en el corto plazo, el costo financiero de sostener los programas de VIH en la región sea transferido a los gobiernos nacionales. El modelo financiero para apoyar programas de VIH en la región debe ser reconsiderado. Se necesitará mayor eficiencia, mayor efectividad y una reducción en el costo unitario de las operaciones. El futuro de la epidemia de VIH en la región dependerá en gran parte de lo bien que el Caribe pueda responder a los retos identificados. Se necesitará liderazgo para:

uno Asegurar la continuidad de financiación para la respuesta al VIH. Durante la última década, la región recibió más de $1.3 billones de dólares en fondos externos para la respuesta al VIH. Esa época ha terminado. El monto de fondos externos disponibles para responder a la epidemia se ha reducido y particularmente para los países de ingreso medio alto. Los gobiernos necesitan mejorar la estimación de los costos de sostener la actual respuesta al VIH; identificar cómo estos costos pueden ser cubiertos con recursos nacionales; y adoptar medidas que ayuden a contener costos futuros.

dos Mejorar la prevención. Se necesita una revolución en la prevención. Si el número de nuevos casos de VIH no se reduce, el número de personas que necesitará tratamiento aumentará. La prevención efectiva es necesaria para reducir los costos de tratamiento. Si se desea romper el silencio, la vergüenza y el miedo a la conversación franca y abierta sobre temas de sexo, sexualidad, orientación sexual, sexualidad juvenil, y sexo y moral, la voz de los líderes del Caribe debe ser escuchada y dar forma a ese discurso. Necesitamos usar una combinación de estrategias de prevención basadas en evidencias que pueda alcanzar a las poblaciones

the status of HIV in the CARIBBEAN

más afectadas con información clara, apoyo y servicios. En la medida que los recursos se vuelvan escasos, los fondos para prevención deberán asignarse a las intervenciones más efectivas y dirigidas a los grupos mas afectados.

tres Revitalizar el tratamiento. El tratamiento es parte de la prevención. El estigma asociado al VIH es una barrera para que los individuos busquen tratamiento. Esto debe cambiarse. Los sistemas para la entrega de tratamiento deben hacerse más eficientes. Los gobiernos del Caribe deben poner mayor énfasis en reducir los costos del tratamiento e involucrarse más activamente en la negociación de los precios con las compañías farmacéuticas. La sociedad civil debe ser apoyada en su esfuerzo de expandir la cobertura de tratamiento, cuidado y apoyo como parte de una nueva aproximación a la prevención.

cuatro Remover leyes punitivas y disminuir el estigma y la discriminación. Las leyes que perpetúan el estigma y la discriminación, que limitan el acceso al cuidado de la salud y que favorecen la diseminación del VIH no son de interés nacional.

cinco Mejorar la eficiencia en la asignación de recursos. No se ha invertido suficiente en esfuerzos de prevención efectivos. Los países necesitan revisar dónde se están invirtiendo los fondos y el impacto que estos programas están teniendo. Así podrán determinar si, en efecto, se están apoyando las intervenciones de mayor costo efectividad.

seis Información estratégica. Se necesitan datos para poder caracterizar la epidemia, sus tendencias y los factores clave que la impulsan. Esto ayudará a identificar las áreas prioritarias de intervención y monitorear el progreso y el impacto de los programas.

xii

I The HIV Epidemic in the Caribbean

The AIDS epidemic in the Caribbean officially began in 1981 when the first cases of AIDS were recorded in Haiti. However, retrospective analysis of patients affected by Kaposiâ&#x20AC;&#x2122;s sarcoma has shown that the first cases of AIDS had already been documented in 1979.1 Cases of AIDS had also been documented among Haitians living in the United States at that time.2 In 1982, cases were reported in Jamaica and Bermuda 3 and, by 1987, all Caribbean countries had reported at least one case. By 2001 there were 210, 000 people living with HIV/AIDS (PLHIV) and, in 2008, it was estimated that there were between 210,000 and 270,000 PLHIV in the wider Caribbean4.

1 Jean William Pape. AIDS in Haiti, 1980-1996. The University of West Indies Press. The Caribbean AIDS Epidemic, 1999, pp-226-42. ISBN 976640-088-1. 2 M. Thomas P. Gilbert, Andrew Rambaut, Gabriela Wlasiuk, et al. The Emergence of HIV/AIDS in the Americas and Beyond. www.pnas.org. 3 Caribbean Epidemiology Centre. Status and Trends. Analysis of the Caribbean HIV/AIDS Epidemic 1982-2002. 2004. ISBN 976-8114-23-1. 4 UNAIDS/WHO. AIDS Epidemic Update. 2009.

the status of HIV in the CARIBBEAN

Table 1: Estimated Number of PLHIV and Adult HIV Prevalence in 2007

Increased access to antiretroviral treatment (ART) has led to a decrease in the mortality associated with AIDS. Since 2001, there has been a 40% decline in AIDS-related mortality in the Caribbean (see Figure 1). Access to treatment has meant that people are living longer, healthier, productive lives. Currently, 51% people who need treatment are able to access it, though 49% cannot. Despite the gains associated with antiretroviral treatment (ART), HIV/AIDS remains a significant cause of mortality in the Caribbean. It is the leading cause of death among men and women aged 20-59, at 15.7% and 14.5% of deaths respectively (see Table 2).5 The Caribbean Epidemiology Centre (CAREC) reports

Country

Estimated PLHIV

Bahamas Barbados Belize Cuba Dominican Republic Guyana Haiti Jamaica Suriname Trinidad and Tobago

6,200 2,200 3,600 6,200 62,000 5,900 120,000 27,000 6,800 14,000

Total

226,900

Adult HIV Prevalence 3.0% 1.2% 2.1% 0.1% 1.1% 1.2%* 2.2% 1.6% 2.4% 1.5%

Source: UNAIDS. 2008 Report on the Global AIDS Epidemic. * UNAIDS/WHO estimates for 2009.

Figure 1: Estimated Number of AIDS-Related Deaths and Number of New HIV Infections 2001-2008 25000 21000

20000

Number

The largest number of PLHIV is on the island of Hispaniola, where the combined number of PLHIV in Haiti and the Dominican Republic is 182,000. This accounts for approximately 70% of all PLHIV in the Caribbean. In the English-speaking Caribbean, Jamaica has the largest number of PLHIV, with an estimated 27,000 PLHIV. However, the data on adult HIV prevalence offers a different perspective (see Table 1). The Bahamas (3%) has the highest adult HIV prevalence, followed by Suriname (2.4%) and Haiti (2.2%). Though there is wide variation in the number of PLHIV in the Caribbean, 9 out of the 10 larger countries have generalised epidemics, with prevalence over 1% among the adult population.

15000 12000 10000 5000 0

2001

Years

2008

Estimated Number of New HIV Infections Estimated Number of AIDS-Related Deaths Source: UNAIDS 2009. AIDS Epidemic Update.

5 PAHO/WHO. Health Conditions and Trends. 2007.

Table 2: Leading Causes of Death in the Caribbean Among Adults Aged 20-59 Males

Females

HIV/AIDS

15.7%

HIV/AIDS

14.5%

Ischaemic heart disease Homicide Diabetes Suicide

10.2% 6.2% 6.2% 5.9%

Diabetes 10.9% Ischaemic heart disease 7.9% Cerebrovascular disease 6.7% Malignant neoplasm of the breast 5%

Source: PAHO/WHO. Health Conditions and Trends. 2007.

that, overall, AIDS-related illnesses were the fourth leading cause of death among Caribbean women and fifth leading cause among Caribbean men in 2007.6 Between 2001 and 2008, there was no significant decline in the number of new HIV infections. Only a 4.8% decline was observed during that period. This statistic has not changed and, with the increase in life expectancy of PLHIV, there was a 9% increase in PLHIV in the same period. These overall prevalence figures hide important and evolving dynamics. First, it is estimated that the number of females living with HIV is increasing. Women â&#x20AC;&#x201C; and especially young women â&#x20AC;&#x201C; account for 50% of all PLHIV. In 1990, 35% of the total number of PLHIV were female. In 2008, females represented

50% of all PLHIV in the Caribbean. But there is wide variation by country in the estimates of females living with HIV, ranging from 26% in the Bahamas to 59% in Belize, Guyana and Trinidad and Tobago. Second, HIV prevalence is highest among men who have sex with men (MSM) and among sex workers. Among female sex workers (FSW) HIV prevalence is high compared to the prevalence in the adult population. From 2006-2008, the figures varied from 2.7% in the Dominican Republic to 27% in Guyana. This population plays an important role in the spread and acquisition of HIV, e.g. in Jamaica 25% of reported cases of AIDS indicated unprotected sex with FSW as mode of acquisition of their HIV infection. The HIV prevalence among MSM varied from 6.1% in the Dominican Republic to 32% in Jamaica. As

6 UNAIDS. Report on the Global AIDS Epidemic. 2008.

the status of HIV in the CARIBBEAN

demonstrated in Figure 2, HIV prevalence among men who have sex with men is very high.7 As HIV is affecting excluded populations, prevalence is high among populations whose behaviours are considered illegal or immoral and who have limited access to HIV services. In 2008, among crack cocaine users, another high risk group, the HIV prevalence

varied between 7% and 5% in St Lucia and Jamaica respectively.8 Crack cocaine users often sell sex to support their habit and engage in unsafe sexual behaviours that increase both their own risk and the risk of the public. Prisoners have also been affected by HIV. The lack of consistent access to prevention and treatment in penal settings increases their risk

Figure 2: Comparing Adult HIV Prevalence in 2007 and HIV Prevalence Among Caribbean MSM (2005-2008) 35.00%

31.80%

HIV Prevalence

30.00% 25.00%

21.00%

20%

20.00% 15.00% 10.00% 5.00%

1.10%

8.20%

7.00%

6% 1.50%

1.60%

2.40%

3.00%

2.50%

0.00%

DOR

TNT

JAM

Country

SUR

Adult HIV Prevalence

GUY

BAH

HIV Prevalence Among MSM

Source: UNAIDS. 2008 Report on the Global AIDS Epidemic and National HIV Seroprevalence Surveys.

7 While there is no population-based prevalence for MSM, given the difficulty of establishing the size of this population in Caribbean countries, the data presented are the best available. The comparison to the adult population is illustrative of the potential size of the epidemic among MSM. 8 UNAIDS. Keeping Score II. A progress Report Towards Universal Access to HIV Prevention, Treatment, Care and Support in the Caribbean, 2008. ISBN 978 92 9 173726 0.

and HIV prevalence levels of between 2% and 5% have been reported in the prison populations of St Lucia and Guyana, respectively. Young people should be considered a priority in national responses to HIV9, because young people are MSM, SW and part of MARPs. Particular attention should be paid to young females since DHS data10 has consistently shown that, in the Dominican Republic and Haiti for example, this population is up to 2 to 3 times more likely to be affected by HIV than young males in the same age group.11 Young people can be receptive to behavioural change. Correct knowledge, attitudes, beliefs and practices about human sexuality, HIV and other sexually transmitted infections will help them to protect themselves against HIV.12 It will also contribute to the reduction of homophobia, stigma and discrimination against PLHIV and the most-at-risk-populations (MARPs). It must be recognised that HIV has a spatial dimension. Caribbean HIV epidemics are particularity acute in specific areas in a country. For example, data from

Jamaica show that HIV is highest in the parishes of St James, Kingston and St Andrew. In Haiti, HIV is highest in the departments of Nord and Les Nippes and in the Dominican Republic, HIV is higher in rural (1%) than urban areas (0.7%).

9 UNGASS Reports: Antigua and Barbuda, Bahamas, Barbados, Belize, Cuba, Dominica, Dominican Republic, Grenada, Guyana, Haiti, Jamaica, St Kitts and Nevis, St Lucia, St Vincent and the Grenadines, Suriname, and Trinidad and Tobago. 2004-2006-2008 . 10 EMMUS IV. IHE-MSPPP-GHESKIO. 2007. 11 COPRESIDA, Endesa 2007. Dominican Republic. 12 UNICEF. Young People and HIV/AIDS. Opportunity in Crisis. 2006.

the status of HIV in the CARIBBEAN

The responses of national governments and civil society organisations to the HIV epidemic have demonstrated some success. At the government level there is evidence of successful coordination efforts, strategic planning and monitoring and evaluation. Funding to national governments from external donors has played a critical role in the capacity of governments to respond. However, the number of external donors in the region has decreased. Civil society has mobilised to address the needs of PLHIV and MARPs and to advocate on their behalf. Partnership between national governments and civil society has yielded some results but greater collaboration is needed.

II National Government and Civil Society Responses

National Government Responses All countries in the region have established national coordinating bodies as part of their response to HIV/ AIDS. The function and location of these coordinating bodies vary. Barbados, Belize, the Dominican Republic and Trinidad and Tobago established National AIDS Commissions under the leadership of the President or Prime Ministers’ Office. Other countries have located the HIV response under the leadership of Ministries of Health. No analyses have been conducted on the impact of the location of the coordinating mechanism within national governments in the Caribbean. However location should not be equated with functional capacity. In countries where the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is involved, an additional coordinating mechanism – the Country Coordinating Mechanism (CCM) – has been established. These countries have all tried to accommodate, without duplication, the project funded mechanism (the CCM) and the national coordinating body. In Haiti, in the absence of a functioning national coordinating body, the CCM has played a larger role than originally envisaged. National Strategic Plans have been developed in most countries of the region. A 2009-2010 review of National Strategic Plans by PANCAP revealed that of the 16 countries, only 10 have plans, 8 have costed plans, 6 have implementation plans and 5 have plans with monitoring and evaluation frameworks. The plans are generally comprehensive in addressing all areas that

Box 1

Regional Support Mechanisms Two regional mechanisms were also established to support national responses to HIV. The Pan Caribbean Partnership (PANCAP) was established in 2001 by the Caribbean Heads of Government and put under the leadership of CARICOM. Thereafter the Caribbean Coalition of National AIDS Programme Coordinators (CCNAPC) was established. The Caribbean Regional Network of PLHIV (CRN+), which had already been in existence, is supporting the work of CCNAPC and PANCAP. Throughout the years, other regional networks and agencies have become involved in providing support to the national response to HIV. These include: the Organisation of Eastern Caribbean Sates, Caribbean Vulnerable Communities Coalition (CVC), Caribbean Conference of Churches (CCC), the Caribbean Business Coalition, the University of West indies (UWI) and the Caribbean Health Research Council (CHRC). Since the inception of the HIV epidemic, UNAIDS and co-sponsors (PAHO/WHO, World Bank, UNICEF, UNDP, UNESCO, ILO, WFP, and UNFPA) have been providing ongoing technical and financial support to the HIV responses at the regional and country levels.

the status of HIV in the CARIBBEAN

require national attention. There are implementation challenges in areas such as policy issues and stigma and discrimination. Reengineering the response at the primary health care level is an issue â&#x20AC;&#x201C; as is the lack of capacity for prevention evaluation. Each Caribbean country has established a national monitoring and evaluation (M&E) unit. The issues are capacity of monitoring and evaluation and how to rethink M&E in small settings. During the past 8 years, over US$1.3 billion was provided by donors to support the regional and country responses to HIV (see Annex I and II). In the mid 2000s the Caribbean had extensive donor support (CIDA DFID, GTZ, France, European Union, USAID, CDC, KfW and World Bank). However, there are currently only three significant donors in the region: the GFATM, PEPFAR and GTZ/KfW (see List of Abbreviations). While coordination, planning, monitoring, evaluation and funding have contributed to the overall national efforts of Caribbean countries, there are several areas in need of improvement. Some of these are listed below. Achieving multisectorality In many instances, getting non-health ministries and the private sector involved in the national response has been very difficult. This should be addressed to ensure that national responses are comprehensive, effective and sustained. Overall, across the region, private sector involvement has been ad hoc and limited.

Giving voice to the voiceless Despite regional advocacy efforts, PLHIV, most-at-risk populations and young people have a limited voice and impact, at the national level, on resource allocation and programme planning decisions. Involving faith-based organizations The faith-based community has provided care and support. However, open opposition from some groups to prevention strategies (for example, condom use) and public statements about gay men, sex work and homosexuality have limited the effect of national responses. Developing less vertical approaches Many AIDS programmes became too vertical, and healthoriented. Governments now acknowledge that this is not cost-effective, efficient or a good public health strategy. Scaling up technical support Caribbean countries still face significant bottlenecks to scaling up their HIV response and to using available resources more effectively. It is of utmost importance to scale up harmonised technical support and maximise utilisation of existing tools and resources. Strengthening monitoring and evaluation Many of the survey methods available are not suitable for small settings. In some countries sample sizes are too small. Thus, data are not always available for decision making.

Civil Society Responses Since the earliest days of the epidemic in the Caribbean, communities have been organising in response to the care, treatment, support and prevention needs of

their communities. Early pioneers such as Jamaica AIDS Support, Mamio Namen Foundation and Maxi Linder Foundation in Suriname and the AIDS Action Foundation in St Lucia have been providing care and information. As advocates and community voices they brought to their countries’ attention the issues facing people living with HIV and dying of AIDS. These community voices found strong partners in government as well as the private sector and this has led to collaborative efforts such as those found at the Maxi Linder Foundation in Suriname and the Caribbean Drug and Alcohol Research Institute in St Lucia. Populations addressed by civil society organizations include those listed below.

People Living with HIV (PLHIV) The involvement of PLHIV in the national and civil society responses to HIV has been increasing through the Caribbean Regional Network of PLHIV (CRN+) and local networks at country level. CRN+ has been leading regional and international advocacy on behalf of Caribbean PLHIV for the past 10 years. This network supports efforts to protect the human rights of PLHIV and to improve their lives and access care, support and treatment at the community level. Beyond the English-speaking Caribbean, civil society organisations have played an important role in public health provision, particularly in most-at-risk populations (MARPs). Over the decade other sub-regional and regional organisations have emerged.13 Stigma and discrimination are two major challenges facing Caribbean PLHIV and this is widespread in communities, in the health sector and in the work place. Regional efforts continue through the International Labour Organization (ILO), UNAIDS, national AIDS control programmes and national PLHIV organisations. Sex Workers (SW) There are no comprehensive health programmes targeting sex workers in the CARICOM region, despite large and diverse sex worker communities. Traditional programming for sex workers is aimed almost exclusively at female sex workers. However, the sex worker community also includes men who sell sex to women, men who sell sex to men, and transgender sex workers. At the country level, there are only a handful of self-organised and autonomous sex worker groups (for example in Guyana,

13 For example, Caribbean Vulnerable Communities (CVC), Centro de Orientación e Investigación Integral (COIN), Caribbean HIV/AIDS Regional Training Network (CHART) and Caribbean Coalition of National AIDS Programme Coordinators (CCNAPC).

the status of HIV in the CARIBBEAN

Haiti, Jamaica, Grenada and Suriname). At the regional level, the Caribbean Sex Worker Coalition (CSWC) is an embryonic organisation which already played a role in bringing the diverse voices of sex workers to the policy and national programme development arena. The group has done this in partnership with Caribbean Vulnerable Communities (CVC), UNFPA, UNIFEM and the Caribbean Coalition of National AIDS Programme Coordinators (CCNAPC). Success stories in this area exist in the region. In the Dominican Republic, prevention programmes promoting 100% condom use resulted in a significant reduction of HIV prevalence among female sex workers from an average of 9% in 2000 to 2.7% in 2007. Men who have Sex with Men (MSM) Caribbean gay and other MSM communities have a long history of organising to respond to HIV, with peer groups working in all Caribbean countries. These groups are linked through autonomous regional peer support networks and they regularly collaborate and share information on programming and opportunities. The greatest barrier to access to prevention and care programming for these communities is stigma and discrimination, which in some cases has risen to the level of human rights abuses. This drives a great many MSM underground and into heterosexual relationships as a means of social and economic survival, and away from health services where their needs can be effectively met.

Transgender Persons This community has long been invisible at the regional level and therefore does not benefit from support for their human rights, prevention programmes or health services. There is an emerging regional network of transgender persons (the Caribbean Regional Trans in Action (CRTA)) and individual transgender activists are working with civil society groups to gain greater visibility for barriers to their healthcare. In the Caribbean, the impact of HIV on this specific population group has never been measured. However, recent surveys conducted among sex workers have reported the involvement of transgender individuals in the sex trade in many countries, especially in the tourism sector. The networks of transgender persons must be strengthened at national and regional levels. People Who Use Drugs Despite relatively low levels of reported injecting drug use, studies have shown that the use of certain drugs increases the risk of HIV transmission. Drug users have been largely ignored in most Caribbean prevention work, with notable exceptions in Jamaica and St. Lucia. Although drug use is also a facilitating factor for risky behaviours among vulnerable populations, most programmes that address the needs of other vulnerable populations ignore the issues of drug use. While UNODC/CARICOM has recently supported work to address this gap, overall prevention work with substance users in the Caribbean remains underrecognised and under-funded. Unfortunately, the prevailing approach to drug issues has largely been punitive.

III The Social Drivers of the Epidemic

The challenges faced by Caribbean societies in addressing the HIV epidemic are compounded by societal factors which deserve special mention. The epidemic is driven, in part, by social, structural and ideological factors. The social drivers of the epidemic are those norms and beliefs that guide our interpretation and response to HIV. They determine the lens through which we view HIV/ AIDS and the frameworks which guide our response.

the status of HIV in the CARIBBEAN

The Individual Risk Model Initially, the “risk” model provided the framework for the Caribbean response to HIV and AIDS and it is still prevalent today. “Risk” connoted individual, unsafe sexual practices, including inconsistent condom use and multiple partners. The growing awareness of the shortcomings of the public-health-with-ABC policy for the prevention of HIV opened the discourse to an understanding of “vulnerability” and the structural determinants of sexual behaviours. The “vulnerability” model raised questions about how exposure to HIV is socially constructed by unequal power relations, gender inequities, and gender-based violence; and the lived realities of stigma, discrimination and social exclusion. It opened the way to a search for the drivers of HIV in wider social, economic, cultural and political realities of the Caribbean14.

Populations “at risk” The model of abstinence until marriage, and heterosexual monogamy thereafter, had the effect of labelling and stigmatising “high risk” sexually dissident groups, including men who have sex with men (MSM), sex workers and promiscuous youth. This led to the assumption that mainstream society was immune to

HIV once persons stayed clear of these “vectors”.15 However, though they might be socially excluded, persons in these groups are not sexually excluded. Sex workers have husbands and partners and many of the sexual partners of MSM are bisexual husbands. The perception of risk should not be limited to stigmatised groups.

Power, gender and youth Existing gender and cultural norms feed into an ideology that privileges feminine abstinence, virginity and respectability and cements unequal power relations. These norms undermine resilience and safe sexual and relationship decision-making. Well established patterns include early sexual debut among both boys and girls – historically normative, but now reinforced by peer pressure and media promotion of a “bashment and bling” subculture of youth centred on sexual identity, sexual expression and sexual performance.16

Stigma, discrimination and social exclusion The discourse of vulnerability also exposes drivers of HIV in stigma and social exclusion; economic dependency, migration and poverty. Through this lens,

14 Christine Barrow, Marjan de Bruin and Robert Carr, eds. Sexuality, Social Exclusion and Human Rights: Vulnerabilities in the Caribbean Context of HIV. Jamaica: Ian Randle Publishers Ltd., 2009. 15 Ruth C. White and Robert Carr. Homosexuality and HIV/AIDS Stigma in Jamaica. Culture, Health & Sexuality, July-August 2005, 7(4): 34759. 16 Christine Barrow. “Contradictory Sexualities: Empowerment or Vulnerability for Adolescent Girls in Barbados”. In C. Barrow, M. de Bruin and R. Carr (eds.) Sexualities, Social Exclusion and Human Rights: Vulnerabilities in the Caribbean Context of HIV, 215-238. Jamaica: Ian Randle Publishers Ltd., 2009.

attention shifts somewhat to persons engaging in highrisk behaviours. MARPs are generally associated with specific high risk-behaviours, but wider environmental factors also drive HIV infection. Arguably, the HIV stigma is strengthened by perceptions of immorality. So-called “deviant” sexuality combines with “fault” to heighten stigma against MSM and gay men, “irresponsible, promiscuous” persons living with HIV, and sex workers who engage in ‘sex-for-money’. Persons in these vulnerable groups are seen to have chosen the wrong path in life and are stereotyped as stubbornly refusing to conform to the society’s moral codes.

these persons to hide their sexual orientations and practices, and to refuse to disclose their HIV status. Once exposed, they become targets of discrimination perpetuated by employers and health care workers, families and communities. MSM and PLHIV continue to be ostracised in their societies. Social marginalisation reduces the capacity for self and group organisation and advocacy for basic human rights.

Caribbean HIV response has been less successful in stemming the tide of HIV. Research and policy need to address the role of power, social inequality and gender inequities, as well as social exclusion, stigma and violence in driving HIV. The research agenda to support responsive policy and programming for Box 2 HIV prevention must deconstruct vulnerability Impact of Stigma and Discrimination to reveal how the wider environment shapes The median CD4 count at registration among males diagnosed with HIV in Barbados sexual practices among 17 declined from 231 in 2003 to 168 in 2008 , resulting in high mortality. This is attributed MARPs and persons to the stigma and discrimination associated with HIV in the context of a centralised engaging in high-risk AIDS treatment delivery facility. People may delay their access to treatment when it is behaviours, as well as the understood that those who enter a centralised facility are being tested or treated for HIV/ general population. Apart AIDS. from HIV prevalence, we know little about sexuality Stigma undermines HIV prevention, testing and among these groups or how social conditions and treatment-seeking behaviour, the quality of care social prejudices undermine resilience and deny them for PLHIV and support from families, friends and social protection and human rights. communities. The expectation of stigma drives

17 A. Kumar, S. Fonde, T. Roach. Demographics, clinical profile and outcome among the HIV-infected persons hospitalized in the HAART era in Barbados. West Indian Med J 2010; 59 (Suppl.2):26.

the status of HIV in the CARIBBEAN

Human Rights

Figure 3: Penalties for Practising Homosexual Acts in Selected Caribbean Countries

The national constitution of every Caribbean state claims to protect all citizens. Despite these claims, colonial laws and policies that legalise stigma and discrimination still exist. These have been characterised by some as “state sponsored stigma and discrimination”. Indeed, in 11 Caribbean states18 laws exist that prohibit homosexual acts (see Figure 3)19 and/or sex work. Very few countries have explicit antidiscrimination laws20 and where they exist, they are not fully used because of the risk of disclosure of one’s sexual orientation, sexual practices or HIV status during the search for redress in the legal system. In some instances, mandatory HIV testing without consent occurs during recruitment for the protective services, entry into prison, applications for citizenship, health or life insurance, in clinical settings for particular conditions, and during pregnancy. The extent of preemployment screening is not known despite the fact that it has been reported to be widespread21.

Source: Maurice Tomlinson. XVIII International AIDS Conference, Vienna, July 2010.

18 Antigua and Barbuda, Barbados, Belize, Dominica, Grenada, Guyana, Jamaica, St Kitts and Nevis, St Lucia, St Vincent and the Grenadines and Trinidad and Tobago. 19 Maurice Tomlinson. Resolving to Save Lives. HIV/AIDS Prevalence among MSM in the Caribbean and OAS Resolutions 2435, 2504 and 2600. XVIII International AIDS Conference, Vienna, July 2010. 20 PANCAP/CARICOM/World Bank. Prostitution, Sex Work and Transactional Sex in the English, Dutch and French speaking Caribbean. A Literature Review of Definitions, Laws and Reaserch. 2009. 21 D.T. Simeon. An Overview of the HIV Epidemic in the Caribbean. XVIII International Conference, Vienna, July 2010.

Success was achieved in the Caribbean very early on, in the area of blood safety and universal precautions, with countries reducing and controlling these categories of transmission. In addition, ART coverage was scaled up. The antiretroviral treatment (ART) coverage rose from 1% in 2004 to 51% in 2008, resulting in a 40% reduction in the number of AIDSrelated deaths in that year. In the area of paediatric AIDS treatment, the coverage has reached 55% and this has contributed to the reduction of AIDS-related mortality. Progress has also been made in voluntary counselling and testing over the past 5 years. In 11 Caribbean countries, more than 90% of pregnant women are tested for HIV every year. In Haiti, 1,000,000 people were tested for HIV between 2008 and 2009: among these were approximately 300,000 pregnant women. Finally, in the region, prevention of mother-to-child transmission (PMTCT) coverage is 52%. This has reduced the number of new infections among children by 18%. The rapid uptake of PMTCT in Jamaica, from 2004-2007, is shown in Figure 4.

IV Achievements

Figure 4: PMTCT Coverage Rate in Jamaica: 2004-2007

2007 2006 2005 2004

10%

20%

30%

40%

50%

Coverage Rate

60%

70%

80%

90% Source: UNAIDS. Keeping Score II. 2008.

the status of HIV in the CARIBBEAN

Box 3

Is Prevention Working for the Caribbean? In the Dominican Republic, prevention programmes are showing some impact among young people.22 The HIV prevalence in that population group declined significantly between 2002 and 2007. This example should be replicated in the rest of the Caribbean. (Source: COPRESIDA-UNGASS Report 2008) HIV Prevalence Among Young People 15-24 Years-Old in the Dominican Republic: DHS 2002 and 2007 0.80% 0.70%

Prevalence

0.60%

0.70% 0.60%

0.50% 0.40%

0.40%

Females

0.30%

Total

0.20%

Males

0.40%

0.10% 0.00%

2002

Years

2007

22 Daniel T. Halperin, E. Antonio de Moya, Eddy Perrez-The, Gregory Pappas, Jesus M. Garcia Calleja. Understanding the HIV Epidemic in the Dominican Republic: A prevention Success in the Caribbean. JAIDS. April 2009.

V Challenges

Despite the success of HIV/ AIDS interventions in the region, considerable challenges remain. Access to prevention and care are chief among the issues facing MARPs and PLHIV. Sustainability of programmes and allocation of resources are key factors affecting the viability of national and civil society responses.

the status of HIV in the CARIBBEAN

Access to HIV Prevention by MARPs Most-at-risk populations, despite the negative impact of the HIV epidemic among them, do not receive a response commensurate with the severity and depth of the epidemic in those groups (see Table 3). Most MARPS are not being reached by prevention programmes: the focus of prevention is not where prevalence is highest. The lack of appropriate interventions among MARPs explains, in part, the high HIV prevalence among Caribbean MSM, and sex workers.

Access to quality care for PLHIV In 2008, 15 Caribbean countries reported on the survival rate one year after patients had started antiretroviral treatment. Among these countries, over half had not reached a 90% rate, the minimum acceptable level under international standards. Simply put, in 53% of countries more than 10% of patients die

before the end of the first year after they have started treatment. There are multiple reasons to explain this statistic: low standards of care, including lack of knowledge among care providers or lack of adherence to treatment; limited access to treatment, due to stigma and discrimination towards PLHIV or MARPs in the health care system; and, importantly, the late appearance for treatment.

Sustainability of National AIDS Programmes During the period 2006-2007, a total of 12 countries and territories reported on all national spending on AIDS. The expenditure in this period totalled US$189 million23. The majority of these resources were external. In the case of Haiti, 96% of the resources were from the PEPFAR and GFATM. External funding is not likely to be sustained in the long term, particularly in Upper Middle Income Countries.

Table 3: Percentage of MARPs not reached by Prevention Programmes in 2008 Country

Percentage MSM not reached by Prevention Programmes

Percentage FSW not reached by Prevention Programmes

Bahamas Cuba Guyana Jamaica

52% 44% 83% NA

NA 35% 72% 40%

Source: UNAIDS. Keeping Score II. 2008. NA: not available.

AIDS Spending by Sources of Funding

Figure 5: Caribbean AIDS Spending BY Source of Funding Seven Country Reports 2008

The 2008 data from national spending on AIDS have shown variations between countries on sources of funding. For example in Trinidad and Tobago 96.5% of all AIDS spending in 2006 and 2007 came from the public sector, while in Haiti for the same period only 0.6% of the spending came from that sector. Overall, national spending assessments in seven countries have shown that 72% of all spending were from external sources (bilateral or multilateral).

Bahamas, Barbados, Cuba, Dominican Republic, Haiti, Jamaica, Trinidad and Tobago.

Amount Spent

250,000,000 200,000,000 163,491,000 or 72%

150,000,000 100,000,000 50,000,000

Allocation Choices

85%

47%62,783,000

0 Public Spending

Not enough money is being spent on prevention . In 6 countries reporting detailed expenditure, 50% of allocated funds were spent on care and treatment, 21% on programme management (i.e. office budget, salaries and other administrative costs) and 21% on prevention. Other areas such as research, social protection, human rights and care for orphans received between 1% and 3% of the funds allocated (see Figure 6).25 24

5. Incentives for Human Resources 4. Programme Management and Administration Strengthening

or 28%

External Funding

Source: 2008 UNGASS Country Reports. 65%

Figure 6: Caribbean AIDS Spending Profile: Six Country Reports 85% 2008 6. Social Protection and Social Services excluding Orphans and Vulnerable Children

8. Research excluding operations research

1. Prevention

21%

3. Orphans and Vulnerable Children

Source: UNAIDS. 2008 Report on the Global AIDS Epidemic.

50%

2. Care and Treatment

24 UNAIDS. What Countries need. Investments needed for 2010 targets. ISBN 978-92-9173-750-5 25 UNAIDS Global Report on AIDS.2008. ISBN 978 92 9173 713 0.

the status of HIV in the CARIBBEAN

Natural Disasters: Haiti – The Post-earthquake Challenge The earthquake of 12 January, 2010 occurred in the departments which are home to 68,000 PLHIV – just over half the total number of PLHIV in Haiti26 – and where the bulk of the health infrastructure supporting the national response to HIV was to be found. In 2009, there were 24,000 PLHIV on ART in these departments.27 The impact of the earthquake on health infrastructure was immense and there are now over 1.3 million displaced people living in temporary camps. The earthquake exacerbated the existing challenges and created new ones. The camps have reported gender-based violence, unwanted pregnancies among

young girls, rape, exploitation of minors and an increase in the sex trade and violence towards MSM and SW, who are being blamed for the earthquake. These conditions increase vulnerability and the risk of HIV transmission. In the absence of a functioning National AIDS Commission, duplications and gaps in the HIV response are occurring and this is limiting the effectiveness of resources. There is an acute need for health services and programmes as well as water, sanitation and employment. The immediate need is to protect vulnerable populations in camps, strengthen national AIDS coordination efforts, provide for displaced populations and rebuild the infrastructure to ensure that populations living in camps – and other displaced populations – have access to quality services28.

26 UNAIDS/WHO. HIV Estimates 2008. 27 Ministère de la Santé Publique et de la Population. Bulletin Semestriel. Programme National de Lutte contre les IST/VIH/SIDA. PLNS. 2009. 28 UNAIDS. Helping Haiti Rebuild its AIDS Response. 2010

VI The Future of the HIV Response

There are several key issues which must be addressed if there is to be significant reduction in new HIV infections and improved quality and access to prevention, treatment and care in the region.

the status of HIV in the CARIBBEAN

Sustainability External funds to support HIV have declined and are likely to continue to do so in the coming years. Programme delivery costs must be reduced and new sources of funding must be explored. Activities and strategies to achieve HIV prevention must target areas of highest infection and they must be based on proven successes. If prevention is not successful, there will be an increase in the number of people who will need treatment over the long term. As new drugs are needed, added to that are the new WHO standards which will increase the number of PLHIV who will need treatment, the costs for treatment will continue to increase. Therefore governments need to model future demand and to project the financial cost of HIV programmes.

Prevention Prevention efforts must focus on the populations with the highest prevalence. The failure to significantly reduce the number of new cases demonstrates the need for a change in strategy, away from individualistic approaches to more structural approaches.

Examples include changes in legislation, changes in the training of health workers, and an expansion of prevention strategies appropriate to the target populations. In the Caribbean, this would mean a shift in coverage of programming to focus on key populations at risk of HIV, as well as people living with HIV. Key populations include gay men and other men who have sex with men and also with women. More research is needed on what works, at what cost and for which populations.

Focus on MARPs Halting the impact of HIV among MARPs can change the trajectory of the epidemic in the Caribbean. Bisexuality is common across the region and gay and bisexual men have high rates of vaginal and anal sex with both their female and male partners.29 Clients of male and female sex workers and transgender

Box 4

Bridging Populations 70 percent of Men who have Sex with Men in the Dominican Republic are having sex with women. In Trinidad and Tobago 25 percent of Men who have Sex with Men are married to women. Therefore, to be successful it is imperative to consider the needs of these bridging populations into consideration in national responses to HIV.

29 Daniel T. Halperin, E. Antonio de Moya, Eddy Perrez-The, Gregory Pappas, Jesus M. Garcia Calleja. Understanding the HIV Epidemic in the Dominican Republic: A prevention Success in the Caribbean. JAIDS. April 2009.

persons are members of the “general population”30 and are bridging populations with the entire society,31 especially the Caribbean female population.32

Gender The vulnerability of women to HIV infection appears to be increasing, yet few resources and programmes are dedicated to address their particular needs. Programmes to change harmful gender norms that condone violence against women and coercive sex should be instituted, including parenting skills and working with justice system reform to build police capacity to address domestic violence and rape. Gender norms among men must also be addressed.

Human Rights State laws33 are often a reflection of religious beliefs and socio-cultural norms in communities. A multi-pronged approach is therefore necessary to address human rights issues – from changing the old colonial laws that criminalise sexual behaviour and orientations, to creating less homophobic societies and communities and an environment which is empowering and supportive of all MARPs.

Criminalisation can be addressed by law reform aimed at the removal of punitive laws. More needs to be done to create and support effective outreach to MARPs. In programming terms, this means investing major resources in peer-led outreach programmes. It also means investing sufficient resources to change the social and legal environment to support such outreach, as well as the behaviour change and uptake of services that should result.

Stigma and Discrimination Training of health care workers to reduce stigma and discrimination against people living with HIV and key populations is also needed, as the health care settings in the Caribbean are prime sources of stigma. Health care workers would also benefit from training in confidentiality, informed consent and universal precautions as well as the ability to detect and address domestic violence. Where outreach services are hampered by police action, it would be useful to sensitise police to HIV in terms of their own vulnerability and to highlight the important role they can play in providing a protected space for outreach programmes for men who have sex with men, sex workers and people who use drugs.

30 PANCAP/CARICOM. Prostitution, Sex Work and Transactional Sex in the English-Dutch-and French Speaking Caribbean. A Literature Review of Definitions, Laws and Research. 2009. 31 Jose Tor-Alfonso, Nelson Varas-Diaz. Pna. Resumen Ejecutivo. Enero 2005. 32 RK Lee, C. Poon King et al. Risk behaviours for HIV among men who have sex with men in Trinidad and Tobago. XVI International AIDS Conference. 2006. Abstract CDD 0366. 33 Maurice Tomlinson. Resolving to Save Lives: HIV/AIDS Prevalence Among MSM in the Anglophone Caribbean and OAS Resolutions 2435,2504 and 2600. XVIII International AIDS Conference, Vienna, July 2010.

the status of HIV in the CARIBBEAN

People living with HIV can be a force for change but serious investment must be made in their Positive Health, Dignity and Prevention. This includes programmes to build capacity in legal literacy (knowing their rights), and having legal assistance and a means of redress when they suffer discrimination. It also means serious investment in HIV in the workplace programmes to reduce discrimination found there.

Strategic Information Capacity to strengthen data collection, analysis and use efforts should be built. Strategic information must be used to guide decision making. Finally, and most importantly, the future of the HIV response must be driven by the political leadership. This will guide a comprehensive and far-reaching approach to the issues affecting prevention, treatment and care among all populations in the region.

Political leadership is needed in six areas:

two Improve prevention. A Prevention Revolution is needed. If the number of new cases of HIV is not reduced, the number of people needing treatment will increase. Effective prevention is necessary to reduce treatment costs. The voice of Caribbean leaders must be heard to shape the discourse around sex, sexuality, sexual orientation, morality and sex, and young peopleâ&#x20AC;&#x2122;s sexuality if the silence, shame and fear of open, informed discussion are to be broken. We need to use combination prevention approaches, evidence informed options, that can reach the populations most affected, with clear, unambiguous information, support and services. As resources become scarcer, prevention funding must be allocated to the most effective interventions, and to the most affected target populations.

the status of HIV in the CARIBBEAN

Annex I Funding the Caribbean HIV Response from GFATM and PEPFAR

HIV/AIDS-related financial commitment in the Caribbean has been substantial and, according to GFATM, funding from the US Government and to the region over the last 8 years approached US$1.3 billion. The vast majority of regional funding has come from international donor agencies (see Table below). Donor

Country

GFATM

Haiti Cuba Dominican Republic Jamaica PANCAP OECS CRN+ Belize Guyana Suriname

184,765,291 49,949,887 87,498,690 63,899,272 12,046,368 8,898,774 3,662,376 4,573,976 38,027,143 9,110,099

142,563,163 49,949,887 70,939,016 38,693,576 10,320,657 8,375,201 2,383,418 2,147,773 22,037,862 7,711,711

PEPFAR Dominican Republic Guyana Haiti UWI Regional Belize

462,431,876 31,900,000 125,800,000 446,200,000 7,500,000 52,000,000 2,405,000 665,805,000

355,122,264

Total Approved

Amount Approved

1,128,236,876

* new grant to PANCAP is not included here: US$34,000,000 **new grant to the Caribbean is not included here: US$100,000,000

Disbursed Amount

Annex II Funding the Caribbean HIV Response from the World Bank Total IBRD/IDA Commitments to HIV/AIDS in the Caribbean: World Bank-2001-2013 Country

Status Committed

Disbursed

Type

Barbados I Barbados II Dominican Republic Grenada Guyana Jamaica I Jamaica II PANCAP St Lucia St Kitts & Nevis St Vincent & the Grenadines Trinidad and Tobago

Closed Active Closed Closed Closed Closed Active Closed Closed Closed Active Closed

15,150,000 6,247,500 24,984,712 2,599,192 10,330,385 10,600,000 2,789,868 8,554,694 6,218,334 3,359,902 5,457,467 18,450,304

IBRD IBRD IBRD IDA/IBRD IDA IBRD IBRD IDA IDA/IBRD IBRD IDA/IBRD IBRD

Total IBRD: Loans

IDA: Grants

15,150,000 35,000,000 25,000,000 4,660,000 10,000,000 10,600,000 10,000,000 9,000,000 6,400,000 4,050,000 7,000,000 20,000,000

Start Date

End Date

2001 2008 2001 2002 2004 2002 2008 2004 2004 2003 2004 2003

2007 2013 2008 2009 2010 2008 2012 2010 2010 2009 2010 2010

156,860,000 IBRD/IDA: Loans & Grants

Source: World Bank-financed HIV projects in the Caribbean: lessons for working with Small States.IBRDCAB36585

*Additional resources spent in the Caribbean from the World Bankâ&#x20AC;&#x2122;s internal budget and trust funds are not reflected in this table. Recently closed projects in PANCAP, St. Lucia, and Trinidad and Tobago have not yet completed disbursing

funds.

the status of HIV in the CARIBBEAN