POVERTY & HIV/AIDS IN THE CARIBBEAN FINAL REPORT
Submitted by: HEU, CENTRE FOR HEALTH ECONOMICS
Faculty of Social Sciences The University of the West Indies Republic of Trinidad and Tobago Submitted to: CARICOM Secretariat Pan Caribbean Partnership Against HIV/AIDS (PANCAP) Guyana
May 2009
ACKNOWLEDGEMENTS
A cknowledgements The University of the West Indies, HEU, Centre for Health Economics wishes to acknowledge and thank the World Bank for its financial support of this study through the IDA/PANCAP Grant number H-077-0-6R and the PANCAP for its support. Special acknowledgements are due to Mr. Edward Emmanuel Programme Manager, PANCAP Coordinating Unit and the staff of the PANCAP Coordination Unit for facilitating the research team throughout the project.
Finally, the HEU would like to thank the various authors, research specialists, research assistants, project coordinating assistant, editor and administrative staff who worked tirelessly to contribute to this work. Special thanks are due to the lead authors:
Dr.
Ewan Scott, Professor Karl Theodore and Dr. Althea La Foucade. We also give special acknowledgement to the contribution of other team members including Mr. Overton Grant, Mr. Adrian Jeffers, Ms. Josette McDavid, Mr. Machel Pantin, Ms. Bommie Rao and Ms. Tishana Simon,
Our appreciation to Ms. Richelle Winchester and Ms. Cheryl Theodore for administrative support on the project.
Karl Theodore Professor of Economics, Director, HEU, Centre for Health Economics The University of the West Indies St. Augustine
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EXECUTIVE SUMMARY
E X E C UT I V E SUM M A R Y Independent of each other, poverty and HIV/AIDS have the capacity to reverse development processes in the Caribbean. The combined negative impacts of these two phenomena can present an even greater challenge for the region. The Caribbean is generally characterized by low income countries with HIV/AIDS prevalence rates varying from 0 to 3 percent. Poverty has plagued the Caribbean for decades despite national and international efforts and has been a main impediment to development prospects. In the Caribbean, the percentage of people living below the poverty line is within the range 14-39 percent. Poverty is not simply having an income below the poverty line which can be solved with increases in incomes, but it is a multidimensional concept which explains human deprivation from a number of necessities such as shelter, health care, education and a job. This paper seeks to explore the poverty and HIV/AIDS situation in two countries, Guyana and Trinidad and Tobago. There are pre-established links between poverty and health and poverty and HIV/AIDS in the literature. Even though there is no claim that there is a uni-causal relationship between poverty and HIV/AIDS, the relationship between the two can be described as bidirectional. In the context of HIV, poverty increases vulnerability on two fronts. The first resulting from the lack of resources or facilities to prevent or treat HIV while the second, results from the need to generate income which may be via activities that increases the individual’s risk of contracting the disease. In fact, studies in Africa have shown that the risk of contracting HIV/AIDS increases with growth in poverty levels. In addition, the impacts of HIV such as loss of income, death of bread winners and increasing expenditure on medical services are all contributors to poverty. Given the relationship between poverty and HIV/AIDS described above, it may seem that HIV infection rates for lower income regions/countries would be higher than for higher income regions/countries. However, the international literature and available data paint a different picture. For example, the Bahamas, a high income country, has a relatively high HIV prevalence rate while Cuba, a middle income country, has a low prevalence rate. In THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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EXECUTIVE SUMMARY
fact, studies in the past have shown that HIV prevalence rates are higher for higher socioeconomic groups and there are positive relationships between HIV and education and HIV infection and economic resources for some regions/countries. Trinidad and Tobago and Guyana despite having similar histories of economic performance and similar HIV/AIDS pictures differ vastly in terms of income and growth levels. The data show that both countries have been through periods of wealth accumulation followed by a debt crisis. In addition both have experienced declining levels of poverty as measured by the percentage of population living below the poverty line and both countries have high HIV prevalence rates. Another similarity is that poverty seems to be regionalized in both cases. In Trinidad, the Eastern and Southern parts of the island are the poorest areas while in Guyana; the rural areas experience deeper poverty. In the context of HIV/AIDS, both countries have had increasing numbers of AIDS cases and AIDS deaths since 1985 but with the existence of treatment, these numbers began to fall in 2005 and 2001 respectively. HIV/AIDS is one of the leading causes of death in Guyana while in Trinidad and Tobago it is ranked sixth. The female sub-population is more vulnerable to the HIV/AIDS epidemic while the younger women are more at risk than their older counterparts in Guyana and Trinidad and Tobago. The number of AIDS orphans seems to be quite severe in both countries which bring to the forefront the issues of the intergenerational gap and the role of care-givers. Trinidad and Tobago and Guyana have programmes in place to reduce mother to child transmission of the disease with both countries achieving some level of success in this area in early 2000s. Commercial Sex Workers (CSWs) and men who have sex with men (MSM) have been identified in the two countries as at-risk subpopulations for HIV, with poverty being acknowledged as having a crucial role to play in the entrance of women into commercial sex work. In Tobago, tourism has been as a means for the spread of the disease while in Guyana, migration of commercial sex workers has been a contributing factor. In Guyana, internal migration of gold miners (including Amerindians) and their interaction with prostitutes (some of which are Amerindians) have been linked to the spread of HIV within this group. In Trinidad and Tobago however, Carnival has been identified as a
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EXECUTIVE SUMMARY
time when unsafe sexual practices are quite common, making it a possible channel for the spread of the epidemic. Trinidad and Tobago and Guyana share some commonalities in their HIV/AIDS response. However, Guyana’s HIV response is funded through aid. The two countries have recorded varying success rates in their HIV/AIDS programmes and initiatives. This paper presents an empirical analysis aimed at identifying and quantifying the link between HIV/AIDS and poverty in Trinidad and Tobago and Guyana. For Trinidad and Tobago two analytical tools were used, a Granger Causality Test to identify the presence of any relationship among the variables and a Vector Auto-Regression Model to determine the direction and magnitude of the identified relationships. Four variables were used for both tests; growth rate of HIV, growth rate in total unemployment (as a proxy for a measure of poverty), growth rate in female unemployment (since there has been a feminization of the disease) and growth rate in per capita domestic product. For Guyana, an internal geographic analysis was done using population, poverty and HIV/AIDS statistics by region. The results for Trinidad and Tobago indicate that HIV/AIDS and poverty reinforce each other, with poor vulnerable women being a significant driver of the disease while also bearing the burden of its impact. The data for Guyana shows that there is a negative relationship between AIDS cases and poverty, even when adjusted for population, since the poorest regions accounted for only a small percentage of the total AIDS cases. However, a clear direct link between poverty and HIV/AIDS in Guyana could not be established given the level of aggregation at which the empirical investigation was carried out. In light of the results obtained, there is a strong case for governments in the region to maintain policies that sustain employment as well as, introduce income support programmes for newly unemployed individuals. Countries in the region should also continue to focus on HIV prevention for all while, establishing policies that are geared toward fairly keeping persons living with HIV/AIDS in the workplace. Finally, there is a
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EXECUTIVE SUMMARY
need to incorporate strategies that empower women, given the feminization of the disease.
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TABLE OF CONTENTS
Table of C ontents A cknowledgements ......................................................................................................................... i E X E C UT I V E SUM M A R Y ........................................................................................................... ii T able of C ontents.......................................................................................................................... vi L ist of T ables................................................................................................................................. iv L ist of F igur es ................................................................................................................................ v T E R M S OF R E F E R E NC E .......................................................................................................... vi SE C T I ON I .................................................................................................................................... 1 I NT R ODUC T I ON ......................................................................................................................... 1 C ontext and Objective............................................................................................................... 1 A Quick L ook at H I V /A I DS in the C ar ibbean........................................................................ 2 Study Outline ............................................................................................................................. 5 SE C T I ON I I ................................................................................................................................... 6 A R E V I E W OF T H E L I T E R A T UR E ON POV E R T Y A ND H I V /A I DS ................................. 6 I ntr oduction ............................................................................................................................... 6 Pover ty ........................................................................................................................................ 7 Poverty and HIV/AIDS…HIV/AIDS and Poverty…the Bi-Causal Relationship ................ 8 A W eak L ink between Pover ty and H I V /A I DS within Nations? ........................................ 10 SE C T I ON I I I ............................................................................................................................... 13 SOM E I SSUE S PE R T A I NI NG T O POV E R T Y A ND H I V /A I DS I N T H E C AR I B B E A N .. 13 Pover ty in the C ar ibbean ........................................................................................................ 13 T he E ffect of H I V /A I DS on Pover ty ...................................................................................... 19 F ur ther E vidence fr om the C ar ibbean .................................................................................. 20
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TABLE OF CONTENTS
SE C T I ON I V ................................................................................................................................ 22 G UY A NA A ND T R I NI DA D A ND T OB A G O: SI M I L A R H I V /A I DS SI T UA T I ONS, DI F F E R I NG I NC OM E S............................................................................................................. 22 I ntr oduction ............................................................................................................................. 22 T he I ncome Positions of G uyana and T r inidad and T obago............................................... 23 T he Pover ty Position in G uyana and T r inidad and T obago ............................................... 24 T H E H I V /A I DS E PI DE M I C : SI M I L A R I T I E S AND DI F F E R E NC E S ............................. 27 A I DS Deaths............................................................................................................................. 28 F eminization of the Disease .................................................................................................... 31 T he Or phans of G uyana and T r inidad and T obago ............................................................ 33 T he I nter gener ational G ap and W omen ............................................................................... 35 H I V /AI DS Pr evalence among Pr egnant W omen.................................................................. 35 C ommer cial Sex W or ker s (C SW s) in G uyana and T r inidad and T obago......................... 37 M en who have Sex with M en (M SM ) .................................................................................... 37 T our ism & M igr ation.............................................................................................................. 38 Substance A buse ...................................................................................................................... 38 Special I ssues............................................................................................................................ 39 Internal Migration in Guyana ............................................................................................... 39 The Indigenous People of Guyana......................................................................................... 40 Carnival in Trinidad and Tobago.......................................................................................... 40 Response to HIV/AIDS in Guyana and Trinidad and Tobago............................................... 41 SE C T I ON V ................................................................................................................................. 47 A N E M PI R I C A L A NA L Y SI S OF T H E POV E R T Y -H I V /A I DS R E L A T I ONSH I P I N G UY A NA A ND T R I NI DA D A ND T OB A G O........................................................................... 47 E M PI R I C A L A NA L Y SI S F OR T R I NI DA D A ND T OB A G O ............................................ 47 A n I nter nal G eogr aphic A nalysis....................................................................................... 47
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Data and M ethod: T ime Ser ies A nalysis ........................................................................... 50 R esults................................................................................................................................... 52 A N E M PI R I C A L A NA L Y SI S OF G UY A NA ....................................................................... 55 A n I nter nal G eogr aphic A nalysis....................................................................................... 55 C ONC L USI ON ........................................................................................................................ 58 SE C T I ON V I ................................................................................................................................ 59 I M PL I C A T I ONS F OR POL I C Y R E SPONSE ......................................................................... 59 POL I C Y I M PL I C A T I ONS .................................................................................................... 60 Unemployment and Pover ty ar e I nimical to the F ight A gainst H I V /A I DS.................... 60 A ll A r e at R isk…A ll to be T ar geted................................................................................... 60 Poor W omen… .................................................................................................................... 61 Policies Aimed at Keeping those with HIV/AIDS in the Workplace.............................61 B I B L I OG R A PH Y ....................................................................................................................... 63
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LIST OF TABLES
L ist of Tables PAGE Table 1.1
HIV Prevalence Rates in Selected Caribbean Countries (2007) ..............3
Table 3.1
A Gauge on Poverty in the Caribbean .....................................................15
Table 3.2
Matrix of HIV/AIDS Prevalence and Income Level ...............................20
Table 4.1
Poverty Estimates 2005............................................................................25
Table 4.2
Guyana Poverty Gap (%) .........................................................................26
Table 4.3
The Leading Causes of Death in Trinidad and Tobago for 2001 ............31
Table 4.4
Orphan Estimates in Guyana and Trinidad and Tobago ..........................34
Table 4.5
HIV Prevalence among Pregnant Women in Guyana..............................36
Table 4.6
HIV Prevalence among Female Sex Workers (1987 - 2005: Selected years) ..................................................................37
Table 4.7
HIV/AIDS Projects/Programmes in Guyana ...........................................43
Table 4.8
HIV/AIDS Projects/Programmes in Trinidad and Tobago ......................45
Table 5.1
Population, HIV/AIDS and Income Statistics for Trinidad and Tobago...............................................................................................48
Table 5.2
Augmented Dickey-Fuller (ADF) Unit Root Test of Time Series ..........51
Table 5.3
Granger Causality Tests of HIV cases, Female and Total Unemployment Trinidad and Tobago (1983 – 2006) ........................................................53
Table 5.4
Vector Auto-Regression Estimates of HIV cases, Female and Total Unemployment. Trinidad and Tobago (1983 – 2006) .............................54
Table 5.5
Population and Poverty Statistics for Guyana .........................................55
Table 5.6
HIV/AIDS Statistics for Guyana, by Region ...........................................56
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LIST OF FIGURES
L ist of F igures PAGE Figure 1.1
Adult HIV Prevalence Rates in Selected Caribbean Countries (2007) ......................................................................................3
Figure 2.1
Relationship Between Poverty and HIV/AIDS........................................10
Figure 3.1
The HIV/AIDS Link With Poverty ..........................................................16
Figure 4.1
Gross National Income (GNI.), Purchasing Power of Parity (current international $) ...........................................................................23
Figure 4.2
GNI. per capita, PPP (current international $) .........................................24
Figure 4.3
AIDS Cases Reported Yearly ..................................................................27
Figure 4.4
AIDS Mortality ........................................................................................28
Figure 4.5
The Causes of Deaths in the Adult Population of Guyana for 2001 – 2003 ........................................................................................29
Figure 4.6
The Causes of Deaths for 5 – 9 Year Olds in Guyana .............................30
Figure 5.1
Reported AIDS Deaths and Average Income by Administrative Area. Trinidad and Tobago ................................................................................49
Figure 5.2
HIV Incidence and Average Income by Administrative Area In Trinidad and Tobago ................................................................................49
Figure 5.3
Growth Rate of HIV incidence. Trinidad and Tobago 1986-2008 ..........51
Figure 5.4
Growth Rate of Total Unemployment. Trinidad and Tobago 1986-2008 Growth Rate of Female Unemployment ..................................................52
Figure 5.5
AIDS Cases per Thousand and Marginality Index Ranking by Region .................................................................................................57
Figure 5.6
Incidence per Thousand and Marginality Index by Region in Guyana ...57
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TERMS OF REFERENCE
T E R M S OF R E F E R E NC E 1) Document and analyze the region-wide relationship between per capita income and HIV/AIDS in the Caribbean taking into consideration the international literature on this subject. 2) For the two Caribbean cases – Guyana and Trinidad and Tobago – depict the similarity in the HIV/AIDS picture together with the stark difference in income positions 3) Select and depict two Caribbean cases, one with a strong link between the overall income level and HIV/AIDS, and one where the link is not strong. 4) For each of the cases in two (2) above, analyze the relationship between poverty and selected drivers of the epidemic drawing conclusions as warranted. 5) Derive the policy implications for the HIV/AIDS response in each of the countries selected. 6) Prepare the study for submission to a referred academic journal.
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INTRODUCTION
SE C T I ON I I NT R ODUC T I ON C ontext and Objective There is no question that where Caribbean socio-economic development is concerned, poverty and HIV/AIDS are both major countervailing forces.
For this reason it is
important that the response to each of these phenomena be guided by an understanding of the relationship that holds between them. The development process will certainly face an almost insurmountable challenge if the two phenomena work in tandem. Even where the link between them is not in itself very strong, development can be seriously impeded by their joint impact. This is because the link between poverty and specific drivers of the epidemic may be very significant. The HIV/AIDS experience in the Caribbean is one where there are cases of low income countries with very low incidence of HIV/AIDS (Cuba) and cases of low income countries with very high incidence of HIV/AIDS (Haiti). Understanding the poverty HIV/AIDS link becomes crucial within this context. For this project the main objective is to consider the poverty and HIV/AIDS situation in two countries—Guyana, which is a low income country with a high incidence of HIV/AIDS, and Trinidad and Tobago, which is a higher income country also with a high incidence of HIV/AIDS.
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INTRODUCTION
A Quick L ook at H I V /A I DS in the C ar ibbean In 2007, there were 230,000 HIV infections, of which 20,000 were new cases (UNAIDS 2008). Moreover 14,000 persons died from the disease in that very year. It appears that HIV/AIDS has sunk into the lives of the people of the Caribbean without sparing one country in the process.
The lives of many have been lost through heterosexual
transmission, bisexual and homosexual activities, injecting-drug-use transmission and from mother to child. Commercial sex workers also fall into the mix, with cultural beliefs of some resonating through high incidence rates. Though laws prohibit sodomy, prisoners engage in such practices resulting in high prevalence rate in this risk group. According to the Jamaica UNGASS Report, in Jamaica, the prevalence rate among prisoners was 3.3 percent in 2007, while St. Vincent had a higher rate of 4.1 percent among male prisoners (St. Vincent and the Grenadines Ministry of Health and Environment 2008). The prevalence rates for the countries of the Caribbean suggest that each country is at a different level of the disease. Countries such as Cuba have managed to keep their prevalence rates low, while others have had a general epidemic (one which affects the entire population) for some time. Table 1.1 below illustrates.
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INTRODUCTION
T A B L E 1.1 H I V Pr evalence R ates in Selected C ar ibbean C ountr ies (2007) C ountr y
Y ear
A dult Pr evalence 3 1.2 2.1 0.1
Bahamas Barbados Belize Cuba
2007 2007 2007 2007
Dominican Republic Guyana Haiti Jamaica Suriname
2007 2007 2007 2007 2007
1.1 2.5 2.2 1.6 2.4
Trinidad and Tobago
2007
1.5
Source: UNGASS Country Reports (various years) and UNAIDS Report on the Global AIDS epidemic (2008)
FIGURE 1.1
Source: UNAIDS Report on the Global AIDS epidemic (2008) THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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INTRODUCTION
Both the World Health Organization and CAREC have stated that the disease is being increasingly feminized, hence having greater influence on the lives of Caribbean women. This may be so for some Caribbean countries such as St. Lucia, but for others men dominate the number of HIV/AIDS incidences. Dominica, Grenada and St. Vincent and the Grenadines serve as examples of countries of this, where men bear the burden of the disease. In any case, for most Caribbean countries, the epidemic at the beginning of the 1980s was focused among men. Overtime there has been a shifting towards the female subpopulation, especially the young.
In Barbados, though generally men are most
negatively affected, for the age groups of 15-29, females lead in incidence rates. This may suggest an occurrence of early sexual initiation among young females. Injecting drug use is not considered a major contributor to the epidemic in the Caribbean, with the exception of Bermuda and Puerto Rico. Crack-cocaine, on the other hand, can be linked to HIV/AIDS with data suggesting high prevalence rates among users. Jamaica, Trinidad and Tobago are instances of such countries. It is reasonable to expect that migration also has a role in the epidemic. In some countries, such as Turks and Caicos, HIV/AIDS is concentrated among immigrants. Aruba also faces similar challenges with a great arrival of migrants yearly.
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INTRODUCTION
Study Outline The report begins with a brief discussion of the context and rationale for the study (Section I). Section II follows with a review of the literature on poverty and HIV/AIDS. In Section III—Some Issues Pertaining to Poverty and HIV/AIDS in the Caribbean— the key issues related to poverty and health and poverty and HIV/AIDS, in the Caribbean in general is documented. The theoretical framework for analysis of the link between poverty and HIV/AIDS is laid out. This is followed by a presentation, in Section IV, of the two Caribbean cases—Guyana and Trinidad and Tobago—where we depict the similarity in the HIV/AIDS picture together with the stark difference in income positions. In presenting the discussion on the latter, some of the major drivers of the twin epidemics of HIV/AIDS and poverty are identified. We then utilize the information on the international literature on poverty/income and HIV/AIDS and employ econometric techniques to analyze the empirical information on the relationship between per capita income and HIV/AIDS and present the first set of empirical results on the relationship between poverty and HIV/AIDS in Trinidad and Tobago and Guyana.
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LITERATURE REVIEW
SE C T I ON I I A R E V I E W OF T H E L I T E R AT UR E ON POV E R T Y A ND H I V /A I DS I ntr oduction Conventional wisdom tells us that lower income persons are most at risk of contracting HIV. HIV/AIDS has struck hardest in the developing world and some of the lowest income countries in the world have the highest HIV prevalence rates. In the world today, 3 billion people live on less than US$2 per day, 1 billion people are unable to sign their names or read and approximately half of humanity experience water problems affecting their health and general livelihood (Global Issues). This is the face of the world’s poverty. Whether poverty is defined socially, statistically or from a relative standpoint, it has certainly affected most of the world’s population 1. The link that has arisen between poverty and HIV/AIDS over the past twenty six years has led the United Nations (2005) to conclude that “Poverty and HIV/AIDS are interrelated.”(United Nations 2005, 3) The literature confirms both the quantitative and qualitative aspects of this dynamic relationship. However, the exact nature of the relationship is somewhat ambiguous. Indeed the manner in which the relationship exists varies. This is particularly true for the Caribbean where the limited studies done have not really delved deeply into the relationship between HIV/AIDS and poverty.
1
This may be more than half of the world’s population given the World Banks definition on Poverty being those who live on less than 3 United States dollars a day.
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LITERATURE REVIEW
Pover ty In this study we take the position that a full appreciation of the link between poverty and HIV/AIDS begins with an appreciation and recognition of the face(s) of poverty and the link between poverty and health. The faces of poverty are many, some too painful to describe. As the World Bank (2008) notes “Poverty is hunger. Poverty is lack of shelter. Poverty is being sick and not being able to see a doctor. Poverty is not having access to school and not knowing how to read. Poverty is not having a job, is fear for the future, living one day at a time. Poverty is losing a child to illness brought about by unclean water. Poverty is powerlessness, lack of representation and freedom” (World Bank, Under “Poverty Reduction and Equity”) Therefore the problem of poverty is not simply having an income below the poverty line, and it is not solved only by economic growth. Those engaged in the fight against poverty will find resonance with Aristotle's statement that “…wealth is evidently not the good we are seeking, for it is merely useful for the sake of something else." Poverty is decidedly one of, if not the main obstacle to the development of the Small Island Developing States (SIDS) of the Caribbean. Persistent and growing poverty is characteristic of the countries of the region. Indeed, George Beckford’s concept of ‘persistent poverty’ remains a very relevant one in the Caribbean today, and this despite periods of economic growth and many poverty reduction programmes (PRPs). Along with the efforts by international agencies and governments to reduce poverty in the Caribbean, as we will show later, there have been increases in the poverty rates for many countries with an estimated average rate for the region of about 25% of the population. Studies have established a definite link between poverty and the health status of countries. With the small Caribbean region holding the unenviable position of second in THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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LITERATURE REVIEW
the world for prevalence of HIV/AIDS, questions arise concerning the dynamics of the HIV/AIDS and poverty experience of the region. Poverty and HIV/AIDS…HIV/AIDS and Poverty…the Bi-Causal Relationship While there is general agreement that poverty is not the sole determinant of the spread of HIV/AIDS, the international literature suggests that there is definitely a link between HIV/AIDS and poverty. However, there is no claim that what we have is a uni-causal relationship between the two—poverty alone cannot be used to explain the HIV/AIDS epidemic, or vice versa. In fact, there is more of a bi-directional relationship between Poverty and HIV/AIDS. According to Ekkehard Kürschner (2002), “…the spread of HIV is attributed to a wide range of factors, which include behavioural factors, the quality and access to services and programmes aimed at prevention, care, social support and the mitigation of impact, as well as social and socio-economic factors.” (Kürschner 2002, 7) The United Nations Population Fund website highlighted the fact that “HIV/AIDS accompanies poverty, is spread by poverty and produces poverty in its turn.” (UNFPA, under “Poverty and Gender Inequality: Catalyst for the Spread of HIV/AIDS)
Moreover, “Poverty's companions encourage the infection: undernourishment; lack of clean water, sanitation and hygienic living conditions; generally low levels of health, compromised immune systems, high incidence of other infections, including genital infections, and exposure to diseases such as tuberculosis and malaria; inadequate public health services; illiteracy and ignorance; pressures encouraging high-risk behaviour, from labour migration to alcohol abuse and gender violence; an inadequate leadership response to either HIV/AIDS or the problems of the poor; and finally, lack of confidence or hope for the future.”(Gilbert 2002, 170) THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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LITERATURE REVIEW
This is quite an extensive list of the instigators and drivers of the epidemic. What the literature clearly shows, however, is that as a result of the condition of poverty, people become more vulnerable to HIV/AIDS, since these are the people who have less access to the necessary facilities to prevent or treat HIV. Moreover, because of poverty and the inadequate access to productive resources and opportunities for enhancing productivity, individuals gravitate toward income-earning activities that place them at relatively high risk of contracting the virus. This was reiterated by Ekkehard Kürschner (2002) in his discussion of the link between HIV/AIDS and poverty where he noted that “…poor people are more vulnerable to HIV/AIDS.” (Kürschner 2002, 6) Whatever the direction of the relationship, the combined impact of poverty and HIV/AIDS can only be thoroughly described by those whose lives are/were intertwined with families, friends or neighbours, who lived with and died as a result of the epidemic. Stigmatization, disintegration of family structure, loss of income, increased expenditure on medical services and supplies and the death of breadwinners(Ganyaza-Twalo and Seager 2005), are only some of the challenges that those who are close to the disease face. HIV/AIDS appears to interact strongly with poverty and this interaction has increased the depth of vulnerability of those households already vulnerable to shocks (Ganyaza-Twalo and Seager 2005). Poverty, characterized by limited human and monetary resources, is therefore exhibited as a risk factor to HIV/AIDS. On the other hand, HIV/AIDS impacts negatively on the wealth status (and therefore poverty status) of households through a kind of erosion mechanism. The diagram below provides a simple framework for explaining the bi-causal relationship mentioned above. Taking into account nutrition, the risk-taking behaviour of individuals, the expenses related to living with the disease (morbidity) and the consequences of dying from the disease, HIV/AIDS and poverty are related to each other in more than one way. These are factors that apply as much in the Caribbean as they do in the rest of the world.
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LITERATURE REVIEW
F I G UR E 2.1: R elationship B etween Pover ty and H I V /A I DS Healthy Person
Migration
Infection
Risk Factors: • • •
Transactional sex Unsafe sex Drug use
HIV Positive
P Poor Nutrition
O
Rising need for nutritious food
V
Morbidity: • AIDS
• •
Depletion of Assets Medical cost of illness Children out of school
Children deprived of Education Intergenerational Poverty
Burden of Care: Source: Adapted from Seager,Ganyaza-Twalo and Tamanse (undated) Women and elderly
E R T
Y
-Loss of Income due to death of breadwinner
A W eak L ink between Pover ty and H I V /A I DS within Nations? Death
-Funeral Costs wisdom may lead one to conclude that Given the foregoing discussion, conventional -Orphaning of children who without within nations, higher HIV infection rates would be found in the lower income regions. income cannot go to school
However, the international literature and regional data seem to suggest otherwise. The empirical evidence from studies done in the 1980’s and 1990’s indicates that HIV prevalence rates are higher in higher socio-economic groups. According to the United Nations (2005), in some African countries the HIV prevalence rate in urban areas can be twice as high as that in rural areas. The publication also reports a possible reason: although rural and uneducated youth and adults are less likely to use condoms, they are THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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LITERATURE REVIEW
also less likely to engage in higher-risk sexual activities than their urban and higher educated counterparts. Hargreaves and Glynn (2002) suggest that an increase in the education level can impact on the risk of HIV infection either positively or negatively, depending on the different influences on behaviour. The observation was based on a review of several studies on the relationship between education and HIV. Out of 18 studies done in African nations, only 2 reported a negative relationship between education and HIV (one of which was significant). Three studies dealt with the relationship between HIV and education in urban and rural settings.
In two of them—for Tanzania and Zambia—there was a
positive relationship between HIV and education, and a greater chance (odds ratio) of correlation in the rural areas. In another study, HIV and education had a negative relationship in urban areas and a positive link in the rural areas (Hargreaves and Glynn 2002). Where a positive link was found, the authors suggest that persons, especially men, with greater levels of education may have more disposable income which, in turn, allows them greater access to travel and increased opportunity for contact with commercial sex workers. In Thailand, however, several studies conducted between 1991 and 1995 found a significant, negative relationship, or “protective effect” between education and the risk of contracting the HIV.
Some of these findings are consistent with research by Gillespies, Kadiyala and Greener (2007), where they found positive correlations between HIV infection and economic resources. This link however, is believed to be changing. In addition to the correlation between the epidemic and poverty, studies in sub-Sahara Africa have revealed that at the macroeconomic level, there exists a relationship between HIV prevalence and national wealth that is weak. At a microeconomic level, the results have been diverse with respect to poverty being a major driver of the epidemic. Some studies done using ethnographic methodologies have concluded that the risk of contracting HIV/AIDS increases with growth in poverty levels. Kambou, et al (1993) however, elucidated that HIV/AIDS would not have a great effect on income per capita.
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LITERATURE REVIEW
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SE C T I ON I I I SOM E I SSUE S PE R TA I NI NG T O POV E R T Y A ND H I V /A I DS I N T H E C A R I B B E A N Pover ty in the C ar ibbean Poverty has extended its reach across the globe and has negatively affected many in the process.
Identified by the World Bank Poverty Manual (2005) as the pronounced
deprivation in wellbeing, this definition of poverty suggests a consideration that goes beyond that of income, and which deals with malnutrition, literacy and even safety. To get a general view of the poverty levels in the Caribbean, Table 3.1 below displays the percentage of the population living below the poverty line for selected countries.
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
T A B L E 3.1 : A G auge on Pover ty in the C ar ibbean
Country
Years
Percent of people under the National Poverty Line 2
Poverty Gap 3
British Virgin Islands
2002
16
-
2003
22
1.4
Barbados
1996
14
2.3
Belize
1996
33
8.7
2002
33.5
11
Antigua and Barbuda
2005
18.3
-
Anguilla
2002
23
6.9
Dominica
2002
39
10.2
Grenada
1998
32
15.3
Guyana
1993
35
16.2
Jamaica
2001
17
St Kitts
1999/2000
-
2.5
Nevis
1999/2000
32
2.8
St. Lucia
1995
25
8.6
2005
28.8
6.63
St. Vincent and the Grenadines
1995
38
12.6
Trinidad and Tobago
2005
16.7
-
Turks and Caicos
1999
26
5.7
Sources: Various Country Poverty Assessments
2 3
The Poverty line of each country was determined individually. (- ) represents no data available
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
With 50 million people in Latin America and the Caribbean living below US$1 a day according to the World Development Indicators (WDI) website, the figures given in the aforementioned table are not surprising. Defined as a measure of the depth of poverty, with a range between 1.4% and 16%, the poverty across the region varies considerably. This may also be said for the percentage of people living under the poverty line where the range is between 14% and 39%. Poor sanitation, overcrowding, lack of public utilities and government neglect, have been found to be the cause of the deprivation that some Caribbean people face. Many factors increase the vulnerability of segments of the population to poverty. With most countries relying heavily on one or two commodities or services for income, external conditions have left most nations vulnerable. Consider, for example St. Lucia’s reliance on the banana industry. The recent termination of the European Union banana regime has had consequences on nations that were certainly not foreseen by the agreement. In the case of Antigua and Barbuda, for example, the fallout of immigration from the neighboring country of Dominica has caused increased poverty levels. The history of the Caribbean has shown emigration to be a standard coping mechanism, while illegal activities have always been seen as one option in the quest for a survival strategy. In a similar vein male parent absenteeism has added to the problem, resulting in women being drawn into transactional sex in order to “put food on the table.” Crowning it all, even natural disasters are a threat to the economic wellbeing of the Caribbean’s citizens, with yearly hurricanes making countries more vulnerable. The literature on poverty has for a long time highlighted the fact that poverty is a multidimensional phenomenon with income being one, albeit a crucial one, of the different dimensions. In seeking to deepen our understanding of the links between HIV/AIDS and poverty it may therefore be useful to couch the discussion within a framework portraying the links between HIV/AIDS and quality of life. The diagram below illustrates such a framework.
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F I G UR E 3.1: T he H I V /A I DS L ink W ith Pover ty NON-INCOME CAPABILITIES
QUALITY OF LIFE
DISPOSABLE HOUSEHOLD INCOME
LABOUR INCOME
NON-LABOUR INCOME
HEALTH EXPENDITURE
HIV/AIDS
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
The diagram highlights the assumption that the quality of life depends on both income and non-income factors. The work of Amartya Sen has highlighted the non-income determinants of the quality of life. The experience of discrimination and voicelessness in the society is undoubtedly a factor in quality of life enjoyed and although these maybe related to income it is reasonable to presume that at equivalent levels of income persons or groups that differ in respect of the non-income characteristics mentioned will differ in respect of poverty. What is shown in the diagram is that HIV/AIDS impacts on the disposable income of households through three possible channels: labour income, non-labour income and the diversion of expenditures into areas of health. Severally or together these factors will determine disposable income. The diagram also shows that HIV/AIDS can impact directly on the non-income capabilities of individuals. The literature on stigma and discrimination is especially strong in elaborating this. As shown in the diagram, sometimes the non-income capabilities end up impacting on income. For example, discrimination may sometimes lead to employment termination while in other cases it may simply lead to ostracization of infected persons or their family members.
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
T he E ffect of Pover ty on H I V /AI DS In the diagram we portray, by means of a set of broken lines, the postulate that poverty can lead persons into contracting HIV. It is known that migration and risky practices can serve as one of the main portals to infection. In the Caribbean migrants comprise 3 percent of the population(ECLAC 2005). While this migration may be viewed as a factor in the greater unification of the region, there are other sides to the story. In countries such as the Turks and Caicos, Haitians flow into small towns and villages, some living in bushes and squalor, to escape the life of deprivation in their home country. These immigrants place heavy demands on the health and other social services of the country. Of the number of HIV positive pregnant women who visit the antenatal clinics in the Turks and Caicos, Haitians account for the majority of cases. In general, HIV infection is concentrated among the immigrant subpopulation. There are anecdotal reports of a somewhat worrying dimension of this situation--that locals reportedly go into these bushes to molest the Haitian women. A similar situation obtains in Jamaica. As indicated in Figure 2.1 above, risky practices such as transactional sex heighten the chance of infection. Women in the Caribbean strive through poverty to provide for their children, most time without a male partner as provider. In St. Lucia, women enter into casual relationships to avoid living without basic necessities. In a study done by Phillips in Montserrat, it was reported that with a greater intensity of poverty, girls are required to get involved in transactional sex. A similar situation may be found in Jamaica where schoolgirls purposely engage in sexual activities with taxi drivers in exchange for items needed for school. It was reported by Hope (2007) that the parents of these girls could not provide for them. Drugs also play a role. Poverty drives persons into the underground activities. The St. Lucia Country Poverty Assessment interviewees attested to this fact, while information from Nevis suggests that youths may have succumbed to drug use as a means of dealing with their deprivation.
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
T he E ffect of H I V /AI DS on Pover ty The impact of HIV/AIDS on poverty is portrayed in the diagram above. It is well established that people living with HIV/AIDS need more nutrition because of the increase in their metabolic rate. Leading off from this need for healthier diets, the use of healthier food can become a major financial trial for the poor as these foods tend to be more expensive 4.
Moreover, when people, especially bread-winners, who live with
HIV/AIDS, become sick and die from a variety of opportunistic diseases, this can leave the rest of the family poorer than before. In St. Vincent and the Grenadines AIDS deaths arise out of Pneumonia, Wasting Syndrome and Taxoplasmosis, these being the top three. In addition, it was reported in the United Nations Special Session on HIV/AIDS in 2001, by the First Lady of Haiti, that over a 7 year period, care for PLWHA cost close to 182 million dollars. Jamaica also has a similar case as medical cost to HIV/AIDS patients where US$ 64 per day (Thompson 2003). With such financial struggles, children are negatively affected. According to its UNGASS Report for the year 2008, in St. Vincent and the Grenadines of the orphans who lost their parents to the epidemic, and who were of the age to attend school, 8 percent did not do so. One possible outcome here would be intergenerational poverty. It is quite often the case that the burden of care rests on women or the elderly. With the passing of their grandchildren’s parents, the elderly may be required to act as breadwinner and caregiver, even when their resources are inadequate.
4
This was revealed in a study published by the Journal of the American Dietetic Association
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
F ur ther E vidence fr om the C ar ibbean So far we have explored the qualitative aspect of the interaction between HIV/AIDS and poverty. It would certainly be beneficial to have a quantitative perspective on the issue of the strength of the relationship between HIV/AIDS and poverty in the Caribbean. Such a perspective would be treated with later in the report—Section V. For now, we begin by using a matrix linking HIV/AIDS to the level of income. T A B L E 3.2: M atr ix of H I V /A I DS Pr evalence and I ncome L evel H I V /AI DS Pr evalence R ange Low Epidemic
L ow
G r oss National I ncome per C apita (PPP) M iddle L ower Upper Cuba
H igh
Antigua and Barbuda
Dominica Aruba St. Kitts and Nevis Cayman Islands St. Lucia Grenada St. Vincent and the Grenadines
Bermuda
Guyana
Jamaica
Bahamas
Dominican Republic
Belize
Barbados
Suriname
Trinidad and Tobago
Concentrated
Generalized Epidemic
Haiti
Source: World Bank List of Economies ,The Caribbean HIV/AIDS Epidemic and the Situation in Member Countries of CAREC.
According to the World Health Organization’s publication “Guidelines for Sexually Transmitted Infections Surveillance”, there are three types of HIV/AIDS epidemics: low, concentrated and generalized. We now briefly discuss each of these. Low Epidemic. In this form HIV/AIDS appears to have existed for a number of years with no real influence on any of the subpopulations. Limited to populations most at risk, for example, sex workers, the methods by which the disease can be spread are practiced by individuals at low levels, (one example being drug use). THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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POVERTY AND HIV/AIDS IN THE CARIBBEAN
For this epidemic type HIV prevalence would not surpass 5 percent in any of the subpopulations. ďƒ˜ Concentrated Epidemic. With a prevalence rate exceeding 5 percent in at least 1 subpopulation and less than 1 percent among pregnant women, this form of the HIV/AIDS epidemic does not affect the general population. However, subgroups do experience a rapid spread of the disease highlighting the intensity of those practices that can bring about the virus. ďƒ˜ Generalized Epidemic. Well established in the general population, high risk activities thrive and prevalence rates for women are above 1 percent. From the matrix in Table 3.2, the generalized epidemic is seen to cover all income groups. For the low and concentrated epidemics, this type of income group coverage does not occur, with the focus being primarily on that of upper-middle and high income categories. This is important to note, since it means that for the Caribbean countries examined, low and lower-middle income countries should not be encountering low HIV/AIDS prevalence rates. Our analysis so far should be pointing to low income countries having high prevalence rates. This, however, is not what the table shows us. What we see is a high income country like the Bahamas having a generalized epidemic. It may also be tempting to deduce from the matrix that population size may be an important determining factor, with large populations more prone to a generalized epidemic. With Cuba however, showing a low epidemic, such a conclusion would be incorrect. The results from this preliminary analysis are therefore mixed and the question of the precise quantitative relationship between HIV/AIDS and income per capita requires a more involved analysis.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
SE C T I ON I V G UYA NA A ND T R I NI DA D A ND T OB A G O: SI M I L A R H I V /A I DS SI T UAT I ONS, DI F F E R I NG I NC OM E S I ntr oduction In this section, we take a closer look at the poverty and HIV/AIDS data for two Caribbean countries—Guyana and Trinidad and Tobago. In the case of Guyana, the situation is one of relatively low levels of income coupled with relatively high prevalence of HIV/AIDS. In the case of Trinidad and Tobago, the situation is one of relatively high levels of income co-exiting alongside relatively high levels of HIV/AIDS.
The two countries differ significantly in terms of income status. Guyana is classified as a Highly Indebted Poor Country (HIPC) while Trinidad and Tobago enjoyed a Gross Domestic Product estimated at 1310 percent more than that of Guyana’s in 2004 according to the WDI website.
In Trinidad and Tobago and Guyana, the first cases of HIV/AIDS were recorded in 1983 (CAREC/PAHO/WHO 2004) and 1987 (Government of Guyana Presidential Commission
on HIV/AIDS 2007) respectively. Despite the disparities in income, the HIV/AIDS pictures in both countries are somewhat similar, with major issues relating to regionalism, feminization of the disease, intergenerational gaps and the effect on younger segments of the population coming to the forefront. It should be noted, however, that there are still significant differences between these two countries that make the manifestation of the epidemic seem all the more unique in each case.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T he I ncome Positions of G uyana and T r inidad and T obago The histories of economic performance of Guyana and of Trinidad and Tobago are similar—the 1970s being a period of wealth accumulation due to the focus on certain primary commodities—oil for Trinidad and Tobago and for Guyana sugar, gold, bauxite and rice—and both countries thereafter seeking aid from international financial institutions to recover from the Debt Crisis of the 1980s. Despite this likeness, the values of income earned by each country are very far apart as displayed by Figure 4.1. F I G UR E 4.1: G r oss National I ncome (G NI ), Pur chasing Power of Par ity
25000000000 20000000000
GNI, PPP (current international $) Trinidad and Tobago
15000000000
GNI, PPP (current international $) Guyana
10000000000 5000000000 0
19 8 19 0 8 19 3 8 19 6 8 19 9 9 19 2 9 19 5 9 20 8 0 20 1 04
GNI PPP (current international $)
(cur r ent inter national $)
Years
Source: World Development Indicators
Not only is the GNI of Guyana much smaller than that of Trinidad and Tobago in absolute terms but, with a population of 0.74 million, as compared to Trinidad and Tobago’s 1.33 million in 2006, so too is its GNI per capita (Figure 4.2). Moreover, from both diagrams, growth appears to be relatively stagnant in Guyana with an annual average growth rate of 0.6 percent(Environmental Protection Agency 2004). Guyana has been acclaimed as the second poorest country in the Caribbean after Haiti (Allen et al.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
2008) while Trinidad and Tobago,, according to a website that ranks and records
countries, on the other hand, is the second richest country after the Bahamas 5 .
18000 16000
GNI per capita, PPP (current international $) Trinidad and Tobago
14000 12000 10000 8000
GNI per capita, PPP (current international $) Guyana
6000 4000 2000
2004
2001
1998
1995
1992
1989
1986
1983
0
1980
GNI per capita, PPP (current international $)
F I G UR E 4.2: G NI per capita, PPP (cur r ent inter national $)
Years
Source: World Development Indicators
T he Pover ty Position in G uyana and T r inidad and T obago Although income is a widely used indicator of poverty, the level of equality in distribution of income is arguably just as important. Though Trinidad and Tobago has a GNI per capita that has grown by more than 200 percent from 1980 to 2006, pockets of poverty persist. Poverty estimates for 2005 confirm the concentration of poverty in specific geographic areas and among certain sub-groups of the population (Kairi Consultants Ltd. 2007).
5
aneki.com (accessed June 2 , 2010)
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.1: Pover ty E stimates 2005 Per centage of I ndividuals
T r inidad and T obago T otal (% )
Position
Trinidad (%)
Tobago (%)
Indigent
1.2
-
1.2
Poor
15.4
19
15.5
Poverty Count Index (PCI)
16.7
Source: Kairi Consultants (2007) and Analysis of Trinidad and Tobago Survey of Living Conditions (2005)
An indigent is an impoverished person who lacks the necessities of life such as food. Interesting enough, while Tobago registered a higher percent of poor persons, Trinidad had a higher percentage of indigents (Table 4.1). Trinidad and Tobago, in 2005, had 16.7 percent of households living below the poverty line within the given year (Kairi Consultants Limited 2007), a fall from 21 percent in 1997 according the WDI website. Within Trinidad, however, there is a regionalization of poverty. With the Eastern and Southern parts of the island being the poorest areas, most of the country’s poor is found in Sangre Grande which has 39.1 percent of its population living below the poverty line. Guyana experiences high poverty rates, but has had an improvement with a decline in the proportion of the population below the poverty line from 43.2 percent in 1993 to 35 percent in 1998(The World Bank, WDI online database). There has also been a regionalization of poverty, as also seen in Trinidad and Tobago (refer to Table 4.2).
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.2: G uyana Pover ty G ap (% ) R egion 1993 G ap 1999 G ap Georgetown
8.7
5.4
Other Urban
6.3
3
Rural Coastal
14.4
11.3
Source: Guyana’s Assessment Report on the Barbados Programme Action Plus 10 (2004).
Table 4.2 shows an overall reduction in the depth of poverty of Guyana but with the rural interior experiencing deeper poverty.
As noted in the Guyana Poverty Reduction
Strategy Paper, isolation from economic activity may account for the comparatively higher incidence of poverty in rural areas. Communication facilities are limited, with other forms of infrastructure almost non-existent, and the supply of goods and services is grossly inadequate.
Given that 71.6 percent of the total population lived in rural
communities in 2002 (Government of Guyana Presidential Commission on HIV and AIDS 2006), this may be of extreme concern to policy-makers.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T H E H I V /A I DS E PI DE M I C : SI M I L AR I T I E S A ND DI F F E R E NC E S In terms of AIDS cases reported, there was a rise in numbers until 2004-2005 when reported cases started to fall in both countries (refer to figure 4.3). This may be, in the case of Trinidad and Tobago as well as Guyana, as a direct result of increased access to treatment. F I G UR E 4.3: A I DS C ases R epor ted Y ear ly
AIDS Cases Reported
900 800 700 600 500
Guyana
400
Trinidad and Tobago
300 200 100
19 83 19 86 19 89 19 92 19 95 19 98 20 01 20 04 20 07
0
Years
Source: Status and Trends, Analysis of the HIV/AIDS Epidemic 1982-2002, UNGASS Country Progress Report Trinidad and Tobago 9January 2006-December 2007) .
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
A I DS Deaths In Trinidad and Tobago, 6 persons died due to AIDS in 1986, while in 2006 there was an accumulated 3,487 deaths that can be attributed to the epidemic. Each year, from 1983 to 2001, there was a persistent rise in deaths with the exception of 1997. From then, both Guyana and Trinidad and Tobago has recorded decreases in AIDS related deaths. F I G UR E 4.4: A I DS M or tality
500 450
AIDS Deaths
400 350 300
Guyana
250
Trinidad and Tobago
200 150 100 50 0 2001
2002
2003
2004
2005
Years
Source: UNGASS Country Progress Report (2007) and PAHO Regional Core Health Initiative, Ministry of Health Annual Statistical Report 2002-2003.
The fact remains however, that HIV/AIDS is one of the leading causes of death. In Guyana, for the period 2001 to 2003, HIV/AIDS was the third leading cause of death in adults. Figure 4.5 displays the top 7 leading causes of deaths and their percentages.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T he C auses of Deaths in the A dult Population of G uyana for 2001-2003 Cerobrovascular Disease-10.9% Ischemic Heart Disease10.3% HIV/AIDS-8.8% Diabetes-7.5% Hypertensive Disease4.2% Suicide-4% Heart Failure and Complications-3.8% All other Diseases50.5%
Source: Health in The Americas 2007.
In the case of children, HIV/AIDS ranks as the second leading cause of death to those 5 to 9 years old as illustrated in figure 4.6.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
F I G UR E 4.6: T he C auses of Death for 5-9 Y ear Olds in G uyana
Land Transport-18.9% HIV/AIDS-17% Congenital Malformation8.5% Accidental Drowning4.7% Undetermined Intent7.5% Other causes
Source: Health in The Americas 2007.
Given these statistics, it is not surprising that for 20-59 year olds in Guyana, HIV/AIDS was the leading cause of death at 17.7 percent (PAHO 2007). Trinidad and Tobago’s scenario does not seem to match that of Guyana’s as HIV/AIDS ranked sixth among the leading causes of death in 2001. Table 4.3 can attest to this fact with the leading cause of death being Ischemic Heart Disease.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.3: T he L eading C auses of Death in T r inidad and T obago for 2001 Disease
R ank
Number
Ischemic Heart Disease
1
1631
Diabetes Mellitus
2
1340
Malignant Neoplasm
3
1211
Cerebrovascular Disease
4
972
External Causes
5
569
HIV
6
541
Hypertensive Diseases
7
406
Source: Health in the Americas 2007
F eminization of the Disease The female sub-population is more vulnerable to the HIV/AIDS epidemic in more ways than one. Biological and physiological susceptibility exist while social and economic disadvantages contribute to a disproportionate prevalence among women as compared to men. In Trinidad and Tobago, the male to female ratio in 2006 was 51:49. Female cases were much higher (60.2 percent) than that of males in the age group 15-34(Trinidad and Tobago National AIDS Coordinating Committee 2008). Although Guyana has recorded a reducing sex ratio in both HIV and AIDS the country is still experiencing the feminization of HIV/AIDS since there are a higher number of annual reported cases among females than males. Such outcomes can be credited to cultural factors. In Guyana as well as Trinidad and Tobago, there is a cultural acceptance of multiple partner relationships. According to an AIDS Indicator Survey 2005 done on Guyana, 1.4 percent of all females had sex with more than one partner in the 12 months prior to the survey. Substantially more of the male population did the same with a rate of 9.4 percent. A similar survey done in Trinidad and Tobago also proved to be quite revealing with THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
respect to drivers of the HIV/AIDS epidemic. This survey showed that 85.31 percent of both men and women had multiple sexual relationships 12 months prior to the interview. In addition to cultural aspects, the socio-economic situation of a female can also lead to compromises and acceptance of behaviours of her male partner which in turn expose her to a higher risk of infection. Within the population there would be women who depend on men financially and thus, would have no say in the practice of safe sex.
In both countries, younger women are more at risk than their older counterparts. Younger women can become infected more easily because of thinner mucous membranes along the genital tract. Moreover, in both countries, there are more AIDS cases in women 15-24 years old than men. In the case of Trinidad and Tobago, 69.8 percent of new cases of HIV are derived from females aged 15-29. Another contributing factor to this phenomenon may be the existence of “The Sugar Daddy”—young girls have relationships with older men, who in turn provide financial support to the girls and may even contribute to the girls’ household. In Tobago, because of the rising occurrence of sex in exchange for various goods and services such as food, teenage girls tend to, at the time of first sexual intercourse, have partners an average of four years older. The scenario is the same for Trinidad with older men being preferred as sex partners since items can be attained from such relationships. These older men, however, are likely to have had more previous partners and, therefore, are more likely to have been exposed to HIV and other sexually transmitted infections (Gupta, 2003).
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T he Or phans of G uyana and T r inidad and T obago According to the 2004 Report on Global AIDS Epidemic, an orphan is: “…a child under the age of 18 who has had at least one parent die.” (UNAIDS 2004, 62) The occurrence of orphaning has been widely observed in high HIV/AIDS prevalent countries regions. In both the Caribbean and Latin America, the number of children who are orphans due to HIV/AIDS declined over the period 1990 to 2003. Table 4.4 presents data for Guyana and Trinidad and Tobago.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.4: Or phan E stimates in G uyana and T r inidad and T obago 1990
1995
2001
2005 6
Number of Children 0-14(1,000's)
268
248
231
225
Total Orphans as a % of Children
6.7
7.2
8.7
9.8
<100
1000
4000
7000
â&#x2030;&#x2C6;0
5.7
20.8
33
Number of Children 0-14
407
384
312
278
Total Orphans as a % of Children
4.6
4.9
5.7
6.2
Total Number of AIDS Orphans
1000
2000
2000
2000
2.9
9.3
22
26.4
Guyana
Total Number of AIDS Orphans (Absolute #) AIDS Orphans as a percentage of Total Orphans Trinidad and Tobago
AIDS Orphans as a percentage of Total Orphans Source: UNAIDS, UNICEF AND USAID (2002)
Table 4.4 above shows estimates of orphans in both countries with the proportion of AIDS affected children also being analyzed. In Guyana, there was a surge in the number of AIDS orphans from 1990 to 1995. This trend continued into 2001 and 2005. In Trinidad and Tobago, the situation also appears severe with a more than tenfold increase in AIDS orphans as a percentage of total orphans from 1990 to 2001.
6
This is a prediction made in 2002.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T he I nter gener ational G ap and W omen With Trinidad and Tobago having its highest number of AIDS deaths occurring in the age group 20-59 years and Guyana having the highest number of AIDS cases being reported in the 34-39 age group, it is understandable that the issue of orphans would arise in both countries. But who takes care of these orphans? Though there are homes available for children without parents, for example, The Cyril Ross Home in Trinidad and Tobago, the major input is from the grandparents of orphans. For another period in their life they are required once again to take on the role of care-giver, though now in their elderly state. This is especially applicable to grandmothers who bear the burden of providing for the needs of their orphaned grandchildren.
H I V /AI DS Pr evalence among Pr egnant W omen Pregnant women who are infected by HIV/AIDS can transmit the infection to their unborn babies. To prevent this, both countries have Prevention of Mother to Child Transmission (PMTCT) programmes. In Trinidad and Tobago pregnant women have access to Voluntary Counseling and Testing (VCT) and can attain free anti-retrovirals if positive. The year 2006 saw 86.07 percent of HIV positive pregnant women receiving such treatment (Trinidad and Tobago National AIDS Coordinating Committee 2008). The period 2003 to 2006 had hopeful outcomes for Guyana as the HIV prevalence in pregnant women fell quite significantly over this period (see Table 4.5).
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.5: H I V Pr evalence among Pr egnant W omen in G uyana Y ear
Pr evalence
2003
3.1
2004
2.5
2005
2.2
2006
1.6
Source: UNGASS Country Report: Republic of Guyana(2007)
Trinidad and Tobago saw a similar positive result as there was a drop in prevalence from 1.9 percent in 2001 to 1.6% in 2005 (UNAIDS and WHO 2008). It should be noted however, that in the years prior to these declines, there was an actual rise in the trend of HIV prevalence among pregnant women, for both Guyana and Trinidad and Tobago.
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C ommer cial Sex W or ker s (C SW s) in G uyana and T r inidad and T obago Commercial Sex Workers (CSWs) are one of the most vulnerable groups to HIV/AIDS. For Guyana, the 1990s saw a rise in prevalence among this sub-population though some improvement has been recorded since the turn of the century as shown by Table 4. 6. T A B L E 4.6: H I V Pr evalence among F emale Sex W or ker s (1987-2005: Selected year s) Y ear
Pr evalence
1987
0
1992
25
1997
47
2000
43
2001
31
2005
26.6
Source: Status and Trends, Analysis of the HIV/AIDS Epidemic 1982-2002, UNGASS Country Report: Republic of Guyana
A study reported in the Journal of Acquired Immunodeficiency Syndrome (JAIDS) in 2006 found that among sex workers, only 81.6 percent of those who knew they were HIV positive always use condoms, with 16.9 percent using the contraceptive sometimes (Allen et. al. 2006). Migration appears to be a sub-factor in relation to HIV/AIDS and CSWs, but this will be discussed later on in this paper. It should be acknowledged that poverty has a crucial role to play in the entrance of women into this illegal sector.
M en who have Sex with M en (M SM ) Men who have sex with men, another most-at-risk sub-population, were the first to contract HIV/AIDS in the 1980s. Camara (2002) reports that the
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“First reported Caribbean AIDS cases in Haiti, Jamaica, Trinidad and Tobago were among gay men who had sex with North American gay men in North America or in the Caribbean.” (Gosine 2008) (This statement also touches on the topic of migration which will be later discussed). More recently—in 2004/2005—it was been reported that in Guyana 21.25 percent of MSM in the capital city were infected with HIV (Government of Guyana Presidential Commission on HIV and AIDS 2007). The corresponding figure for Trinidad and Tobago was 20 percent (Trinidad and Tobago National AIDS Coordinating Committee 2008). This is compounded by implications of the findings of a survey done in 2004, that only 47 percent of gay men used condoms the last time they had sex with a male partner.
T our ism & M igr ation Tourism has served as a means for the spread of the epidemic. Tobago is a prime example of this case. In 1993, Tobago reported only eight cases of HIV infection. However, as the island became known as an alternative to traditional tourist destinations in the Caribbean, the incidence of HIV infection rose dramatically (Voisin and DillonRemy 2001). For Guyana, migration of commercial sex workers has also contributed to the spread of HIV/AIDS.
Allen et. al. (2006) found that sex workers located in
Georgetown also worked in Trinidad and Tobago, Barbados, Suriname, French Guyana and St. Martin.
There is also evidence of migration of commercial sex workers in
Trinidad and Tobago. In local newspapers there have been repeated reports of sex workers from abroad who are also illegal immigrants. In the Express Newspaper, a 2008 article highlighted the arrest of 11 Columbian prostitutes (Charran 2008).
Substance A buse The sub-epidemic of drug use in the Caribbean is reportedly not as extreme as in the rest of the world. However, Trinidad and Tobago and Guyana face challenges related to the use of drugs. UNAIDS (2006) has in fact identified crack cocaine as a factor in the HIV/AIDS epidemic in Trinidad and Tobago. One in five crack cocaine users were THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
found to be HIV positive (Reid, 2006) and 30 percent of new HIV infections were from cocaine users in 1999. While crack-cocaine dominates, other drugs like alcohol and marijuana are also contributing factors. In fact, Trinidad and Tobago consumes 3.22 litres of pure alcohol per capita. “Substance abuse is well known as contributing to impaired judgment and the need to support the individual’s addiction create vulnerability to commercial and unprotected, casual, and non-consented sex.”(UNAIDS 2005, 5). A similar situation obtains in Guyana.
In a study done by the Division of Health
Sciences Education and the bilateral Public Health Strengthening in Guyana Programme, 172 persons from across the country were interviewed. Ninety (90) percent of those surveyed used cocaine on a daily basis. In addition, 88 percent had used alcohol with that same percentage having used marijuana. In this study 13.4 percent were commercial sex workers. Though the topic of CSWs and HIV/AIDS has already been discussed, from observing other surveys, it seems that in the context of substance abuse, the topic needs to be revisited. In the study by Allen et. al. (2006) which was referred to previously (see subsection on commercial sex workers) it was found that of those who knew their HIV positive status, 13 percent exchanged sex for drugs while only 4.3 percent of those who were HIV negative did the same in the twelve months prior to the survey. Cocaine again appears to be the principal substance used as 23.1 percent of the survey’s participants tried the drug. In terms of the abuse of alcohol, 17.5 percent of the CSWs regularly got high on alcohol. Marijuana had the lowest rate of utilization with a percentage of 8.3.
Special I ssues Internal Migration in Guyana In Guyana there is a migration of males from the coastal areas into the Amazon region to work in gold mines. These men stay in gold mining camps for periods of 6 to 8 weeks and return to their homes for 2 weeks of rest (Palmer, 2002). In an anonymous survey, a 6 percent seroprevalence rate was found among miners. The presence of prostitutes can THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
be directly linked to such an outcome. The mining bosses hire young women to act as â&#x20AC;&#x153;temporary wivesâ&#x20AC;&#x2122; for the miners. If these women are not allowed on camp, they are set up close by in other camps or work in the bars of villages nearby.
The Indigenous People of Guyana Unlike Trinidad and Tobago, Guyana has a substantial Amerindian population. An estimate of 8 percent of the total population, the indigenous people of Guyana also faces the crisis that is HIV/AIDS. Living mostly in region 1, 7, 8 and 9, as shown on the map, data shows a relatively low prevalence of HIV/AIDS. This, however, may be because of under reporting which hides the reality which is HIV/AIDS. Poverty appears to be an integral driving force behind the epidemic where approximately 80 percent of the Amerindian population lives below the poverty line. Unemployment causes Amerindian men to work in mines (which have a high prevalence) together with women working as prostitutes.
In the survey done on sex workers by JAIDS which was previously
discussed, 2.1 percent of the commercial workers questioned were Native American. Substance Abuse also comes into play with sexual activity starting at an early age. Moreover, culture is a crucial contributor to the epidemic as parents refuse to speak to their children about sex and men are permitted to have more than one sexual partner.
Carnival in Trinidad and Tobago Carnival in Trinidad and Tobago has become a premier event to locals as well as visitors from all over the world. North Americans and Europeans flock to the country to embrace two days of revelry. But behind all the enjoyment, HIV/AIDS and unwanted pregnancy arise. Sexual relationships with tourists develop in and only for the Carnival season, with both local men and women taking part. Money is passed but the locals do not see themselves as prostitutes but opportunists. There is, however, proof that people are worried about their status at this time and also there may be an indication of unsafe practices.
In 2007, the then technical director of the National Aids Coordinating
committee, Dr. Amery Browne, highlighted the rise in HIV and Sexually Transmitted Infections (STIs) screening during and preceding Carnival. THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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Response to HIV/AIDS in Guyana and Trinidad and Tobago Trinidad and Tobago and Guyana are both similar and different in their response to the pandemic that is HIV/AIDS. The most common programme is that of the Prevention of Mother-to-Child-Transmission (PMTCT).
In Guyana, 57 programme sites were
established in 8 regions by the end of 2005. In Trinidad and Tobago, pregnant women receive free screening test and free treatment for themselves and their newborn children .Guyana has had a National Aids Programme (NAP) since 1989 and has launched the Genital Urinary Medicine Clinic, the National Laboratory for Infectious Diseases and the National Blood Transfusion Service. While Trinidad and Tobago has developed the “What’s Your Position” campaign, Guyana has the Behavioural Change Communications Strategy. Both programmes seek to widen the knowledge of citizens with regards to the HIV/AIDS epidemic and to reduce stigmatization.
Moreover, both countries
implemented programmes under the auspices of their country’s leader.
Within these similarities there exist differences that raise serious questions about the commitment of Trinidad and Tobago to the reduction of its prevalence rates given that the country is ranked higher in HIV/AIDS incidences in the world. Forty five percent of all funds that come into Guyana go towards HIV/AIDS. Past and ongoing programmes include that of: •
Free healthcare and other forms of aid for Orphans and Vulnerable Children (OVC).
•
Support groups for People Living with HIV/AIDS (PLWHA)
•
The promotion of safe injections through the use of new needles and syringes for each patient
•
Blood safety is ensured by the establishment of high standards in this area
•
Targeting of Most at Risk Populations (MARP), for example CSWs
•
Local Manufacturing of ARVs
•
Expansion of ARV treatment to facilities across the country with a special focus on prisoners
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
•
And a National Day of Testing held in November each year
Moreover, Guyana is one of the fifteen focus countries which receive aid from the President’s Emergency Plan for AIDS Relief (PEPFAR). Started in 2003 as a five year programme and extended another five years in April of 2008, Guyana has benefited from a 22 million dollar donation made by the United States Congress. Treatment services account for 24 percent of the grant with blood safety and HIV counseling comprising of the remaining amount. In addition to PEPFAR, Guyana has gained support from other international agencies as well (this can be seen in the table below).
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
T A B L E 4.7: HIV/AIDS Projects/Programmes in Guyana Pr oject Name/M ajor A r eas of A ssistance Pr oject F unding Status Sour ces Strength of the expanded Response to HIV & AIDS in Guyana
Ongoing
PAHO/WHO
Youth Peer Education as an Expanded Response to HIV & AIDS in Guyana
Ongoing
PAHO/WHO
HIV entails an enormous loss of human and economic and poses a substantial threat to the economic and social growth of the nation
Ongoing
World Bank
HIV/AIDS/STI Youth Project-A behaviour change intervention
Completed
USAID
Technical support in surveillance, monitoring and evaluation and laboratory
Ongoing
CAREC
HIV/AIDS prevention
Completed
CIDA
Strengthening national capacity to respond to HIV/AIDS
N/A
European Union (EU)
Multifaceted support for HIV/AIDS prevention, treatment, care and support; training; HMIS; upgrade laboratory capacity; strengthen surveillance system; quality care for persons living with HIV/AIDS; expand care and treatment; reduce stigma and discrimination; condom social marketing Small grant for HIV/AIDS
Phase 1 Completed
GFTAM
N/A
JICA
Technical support through regional institutions
Ongoing
PANCAP
Coordinate HIV/AIDS activities of the UN Theme group; strengthening capacity for UNGASS reporting
Ongoing
UNAIDS
Policy development; mainstreaming HIV/AIDS in instrument development Caribbean-Central American project for HIV prevention among youth as part of adolescent health programme
Ongoing
UNDP
Completed
UNFPAOPEC
Strengthen coordination and M&E of PMTCT services; support knowledge of women, children, and health care workers; support care and treatment and support for HIV positive children; youth friendly health services; support for OVCs
Ongoing
UNICEF
Source:Pancap website under “Project Matrix” and Report on HIV/AIDS 2005, the Presidential Commission on HIV/AIDS
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Though Guyana has covered the wide spectrum of factors that HIV/AIDS involve, there have been some failures. In the 2006-2007 UNGASS Country Report, the Presidential Commission on HIV and AIDS admitted to facing major challenges in the Monitoring and Evaluation (M&E) of the disease.
With issues such as unclear roles and
responsibilities and limited number of qualified personnel, at the time of the writing of the report an operational plan to address such inhibitors was being prepared. Unlike Guyana, Trinidad and Tobago is not a recipient of PEPFAR support.
Aid,
however, is attained from the EU, the ILO, the Clinton Foundation, USAID, UNICEF and UNIFEM. Non-governmental organizations also perform a crucial role in providing peer education; counseling and home-based care for People Living with HIV/AIDS (PLWHA). The table below provides a summary of some of the projects that is ongoing in Trinidad and Tobago in the realm of the HIV/AIDS epidemic.
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T A B L E 4.8: HIV/AIDS Projects/Programmes in Trinidad and Tobago
Pr oject Name
Pr oject Status
Sour ces of F unding
Enhanced Access to Psychological Counselling and Referral to Services for Vulnerable and At-Risk Children and Adolescents
Ongoing
UNICEF
Let’s Dance-Revolution
Ongoing
UNICEF
Caribbean Consultation on HIV/AIDS Strategy and Resources for a Coordinated Regional Response
Completed
European Commission and UNAUDS
T&T: HIV/AIDS Prevention and Control Project
Ongoing
World Bank
HIV/AIDS entails an enormous loss of human and economic and poses a substantial threat to the economic and social growth of the nation
Ongoing
World Bank
Project Name
Project Status
Sources of Funding
Ongoing
Pan Caribbean Programme Acceleration Funds
Supporting Persons living with or affected by HIV/AIDS and their Families
Ongoing
Pan Caribbean Programme Acceleration Funds
Youth Information and Support centre at the International Conference on PLWHA
Ongoing
UNICEF
HIV/AIDS Awareness Campaign
Ongoing
UNICEF
Caribbean Consultations on HIV/AIDS
Ongoing
N/A
Expanded Responses to HIV/AIDS among Young People
Source: Pancap under “Project Matrix”
Though Trinidad and Tobago appears to have a reasonable hold on the programmes that are needed to combat HIV/AIDS, M&E in the country is quite restricted. According to the 2006-2007 UNGASS report for Trinidad and Tobago:
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SIMILAR HIV/AIDS, DIFFERENT INCOMES
“Monitoring and Evaluation (M&E) remains a challenge to the national HIV/AIDS response. This is mainly because of the lack of M&E culture that exists among certain key stakeholders in the HIV and AIDS response.” (NACC 2008, 27) In the next section, we examine the poverty and HIV/AIDS nexus in Guyana and Trinidad and Tobago from an empirical standpoint.
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
SE C T I ON V A N E M PI R I C A L A NA L Y SI S OF T H E POV E R T YH I V /A I DS R E L AT I ONSH I P I N G UYA NA A ND T R I NI DA D A ND T OB A G O
While there has been an extensive discussion on possible links between poverty and HIV/AIDS in the Caribbean—as evident from the preceding discussion (particularly Sections III and IV), to date there has been virtually no empirical work in this area. In this section we will summarize the results of the first attempt to fill this gap. More specifically we present the results of an empirical analysis aimed at identifying and quantifying the link between HIV/AIDS incidence and poverty in the Caribbean. Separate analyses are done for Trinidad and Tobago and Guyana.
E M PI R I C A L A NA L Y SI S F OR T R I NI DA D A ND T OB A G O
A n I nter nal G eogr aphic A nalysis TABLE 5.1 below shows population, HIV/AIDS and income statistics by administrative areas for Trinidad and Tobago. The area of St. George is the largest and most populous. It contains the nation’s capital Port of Spain, and is the area that is most affected by HIV/AIDS. St. George, the richest administrative area, had by far the most reported cases of AIDS deaths in the country. It also had the highest number of deaths per thousand and was second only to Tobago in new HIV cases per ten thousand. The administrative area that had the lowest number of AIDS deaths and the lowest number of
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
new HIV cases per thousand was Mayaro/Nariva. This administrative area also has the second lowest average income level in Trinidad and Tobago and the highest poverty rank.
T A B L E 5.1: Population, HIV/AIDS and Income Statistics for Trinidad and Tobago. A dministr ative Population Deaths A r ea (000's) (A I DSr elated) [20062007] St. George Caroni Victoria St. Patrick Mayaro/Nariva St. David/ St. Andrews Tobago
Deaths New per HIV T housand cases per 10,000 (2000 2002)
Pover ty A ver age r ank I ncome [1997] ($T T )
460.5 193.5 181.1 116.4 34.2
120 7 8 1 0
0.261 0.036 0.044 0.009 0.000
32.43 6.04 10.13 8.62 5.97
1 2 1 1 5
2,825 2,683 2,401 2,408 1,954
66.6 54.1
2 13
0.030 0.240
11.97 40.12
3 2
1,916 2,623
Sources: Deaths- UNGASS country report: Republic of Trinidad and Tobago, UNGASS 2008; Poverty Rank- The Impact of HIV/AIDS on Trinidad and Tobago, HEU 2004; Average Income, Population – CSO; New HIV cases - National Surveillance Unit, Annual Report 2000, 2001, 2002
The scatter plots below (Figures 5.1 and 5.2) show the relationship between income and HIV/AIDS by administrative area in Trinidad and Tobago. The graphs show a positive trend between both HIV indicators and income. The HIV incidence and average income plot shows an “R squared” value that is much lower than the graph plotting AIDS deaths against income. These results do not necessarily mean that increased income increases the chances of contracting HIV in Trinidad and Tobago, but they do strongly suggest that the relationship bears further investigation.
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F I G UR E 5.1 Reported AIDS Deaths and Average Income by Administrative Area. Trinidad and Tobago.
F I G UR E 5.2 HIV Incidence and Average Income by Administrative Area In Trinidad And Tobago.
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Data and M ethod: T ime Ser ies A nalysis We use data provided by the Caribbean Epidemiology Centre (CAREC)/PAHO/WHO on the number of HIV+ cases reported since the advent of the disease in 1983 through to 2007. Official estimates of poverty for Caribbean countries over this period are sparse and intermittent. In view of this, we use the number of unemployed persons as a proxy measure for poverty. This is easily justified given the high correlation of poverty and unemployment in the Caribbean context.
Given the low wealth inheritance of the
majority of the population, unemployment leaves people vulnerable to poverty. Moreover, the phenomenon of the working poor is real and significant in the Caribbean, highlighting the fact that the unemployed are most likely to be poor. Given that the disease is primarily a sexually transmitted one, and that in recent times there has been a feminization of the disease, we also use female unemployment over this time period as an additional variable in the analysis.
The unemployment data were obtained from
UNDATA.
The analytical tools used include a Granger Causality Test to identify the presence of any relationships among the variables, and a Vector Auto-Regression Model to determine the direction and magnitude of the identified relationships. The tests were performed on four (4) variables of interest: growth rate of HIV (gr_hiv) growth rate in total unemployment (gr_tue); growth rate in female unemployment (gr_fue); and growth rate in per capita gross domestic product (gr_gdppc).
The data series were converted into annual growth rates which were found to be stationary. Unit root test results are summarized in Table 5.2. The series are shown in Figures 5.3 and 5.4.
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
T A B L E 5.2: Augmented Dickey-Fuller (ADF) Unit Root Test of Time Series V ar iable
A DF test E quation* t-Statistic 5% C r itical V alue gr_hiv (C,2) -3.45 -3.01 gr_tue (C,0) -3.18 -3.00 gr_fue (C,0) -3.81 -3.02 gr_gdppc (C,t,0) -3.90 -3.63 *indicates whether the test equation includes a constant, c, a linear trend, t, and the lag length.
F I G UR E 5.3
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
F I G UR E 5.4 40 30 20 10 0 -10 -20 -30 86
88
90
92
94
96
98
00
02
04
06
Growth Rate of Total Unemployment. Trinidad and Tobago. 1986 - 2008 Growth Rate of Female Unemployment
R esults For the Granger Causality Test we reject the null hypothesis of ‘no causation’ if the pvalue is less than 0.05. The test results suggest that for Trinidad and Tobago there seem to be a two-way link between female unemployment and the incidence of HIV (Table 5.3). There is also the suggestion that the incidence of HIV does have an impact on the level of overall employment but the reverse impact is not indicated. Together these results may be indicating that HIV and poverty reinforces each other, with poor, vulnerable and powerless women being a significant driver of the disease while also bearing the burden of its impact.
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T A B L E 5.3: Granger Causality Tests of HIV cases, Female and Total Unemployment. Trinidad and Tobago (1983 â&#x20AC;&#x201C; 2006)*
Null H ypothesis:
Obs
FStatistic
Pr ob.
GR_TUE does not Granger Cause GR_HIV GR_HIV does not Granger Cause GR_TUE
21
0.81218 9.07012
0.4614 0.0023
GR_FUE does not Granger Cause GR_HIV GR_HIV does not Granger Cause GR_FUE
20
4.28253 12.3473
0.0338 0.0007
* A lag length of 2 was chosen for these tests.
The estimates from the Vector Auto-Regression are presented in Table 5.4. These results seem to confirm the relationships suggested by Granger causality. Increases in the level of female unemployment are shown to have a strong positive impact on the growth rate of HIV incidence with the impact manifesting in a short period of time. The obvious correlation between female and total unemployment may be responsible for the opposite sign on the coefficients of the latter in the HIV growth rate equation. But taking this into consideration, the magnitude of the net effect is still suggestive of increases in unemployment having the effect of increasing the growth rate of HIV incidence.
The incidence of HIV is also shown to have a significant positive effect on the growth in unemployment in general and female unemployment in particular. The process by which the disease impacts on socio-economic status is however somewhat slower than the reverse relationship.
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T A B L E 5.4: Vector Auto-Regression Estimates of HIV cases, Female and Total Unemployment. Trinidad and Tobago (1983 – 2006)* G R _H I V
G R _T UE
G R _F UE
GR_HIV(-1)
0.088167 (0.06519) [ 1.35241]
0.007032 (0.02094) [ 0.33592]
-0.006693 (0.02923) [-0.22900]
GR_HIV(-2)
0.055268 (0.06630) [ 0.83361]
0.137433 (0.02129) [ 6.45502]
0.150765 (0.02972) [ 5.07246]
GR_TUE(-1)
-2.519301 (0.95148) [-2.64777]
-0.909152 (0.30555) [-2.97546]
-1.036593 (0.42655) [-2.43018]
GR_TUE(-2)
0.118395 (0.76721) [ 0.15432]
-0.357355 (0.24637) [-1.45045]
-0.192253 (0.34394) [-0.55897]
GR_FUE(-1)
2.760612 (0.76765) [ 3.59618]
0.794354 (0.24652) [ 3.22231]
0.676297 (0.34414) [ 1.96519]
GR_FUE(-2)
-0.237884 (0.68624) [-0.34665]
0.463204 (0.22037) [ 2.10190]
0.333629 (0.30764) [ 1.08447]
C
6.403456 (5.29202) [ 1.21002]
-9.433332 (1.69943) [-5.55088]
-7.168828 (2.37242) [-3.02174]
Adj. R-squared
0.410289
0.768886
0.638589
* Standard errors in ( ) & t-statistics in [ ]
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A N E M PI R I C A L A NA L Y SI S OF G UY A NA
A n I nter nal G eogr aphic A nalysis Guyanaâ&#x20AC;&#x2122;s population is concentrated in the coastal regions where 88% lives. Region 4, which contains the capital Georgetown, holds the largest share of the population and is the most densely populated (TABLE 5.). It is also ranked in the second lowest poverty range. T A B L E 5.5: Population and Poverty Statistics For Guyana Population Population Population per R egion name R egion (000's) (% ) sq. km (2002)
M ar ginality I ndex7 R ank
Barima-Waini
1
24.28
3.2%
1.2
1
PoomerronSupernaam
2
49.25
6.6%
8
4
Essequibo Islands
3
103.06
13.7%
27.5
6
Demerara-Mahaica
4
310.32
41.3%
139
7
Mahaica-Berbice
5
52.43
7.0%
12.5
5
East Berbice Corentyn
6
123.70
16.5%
3.4
7
Cuyuni-Mazaruni
7
17.60
2.3%
0.4
3
Potaro-Siparuni
8
10.10
1.3%
0.5
2
Upper TakutuUpper Essequibo
9
19.39
2.6%
0.3
2
Upper DemeraraBerbice
10
41.11
5.5%
2.4
8
Source: Guyana Bureau of Statistics Population and Housing Census, 2002
7
The marginality index was calculated using a number of indicators, including: literacy rates, school attendance, availability of utilities etc.
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
Region 1, with 3.2% of the population, is the poorest region. Regions 7, 8 and 9 are also home to small populations with high poverty levels.
TABLE 5. below displays the total number of AIDS cases reported by region in Guyana for 1989 to 2006. In total 5,429 AIDS cases were reported over the period. T A B L E 5.6: HIV/AIDS Statistics for Guyana, by Region R egion name
C umulative R epor ted A I DS C ases (1989-2006)
R egion
A I DS cases per 000
New cases I ncidence of H I V per (2007) thousand
Barima-Waini
1
21
0.87
1
0.04
PoomerronSupernaam
2
99
2.01
38
0.77
Essequibo Islands
3
388
3.76
73
0.71
Demerara-Mahaica
4
3744
12.06
657
2.12
Mahaica-Berbice
5
132
2.52
37
0.71
East Berbice Corentyn
6
422
3.41
76
0.61
Cuyuni-Mazaruni
7
72
4.09
18
1.02
Potaro-Siparuni
8
6
0.59
4
0.40
Upper TakutuUpper Essequibo
9
14
0.72
4
0.21
Upper DemeraraBerbice
10
358
8.71
43
1.05
-
173
-
42
-
Unknown
Sources: AIDS Cases – UNGASS Country Report: Republic of Guyana; New Cases of HIV - Guyana National Aids Programme Secretariat
Almost 70% of these cases were reported in region 4. The nation’s poorest regions, 1, 8 and 9, together account for only 41 of the total cases reported in Guyana. This data indicates a negative relationship between AIDS cases and poverty. When these figures THE UNIVERSITY OF THE WEST INDIES, HEU, CENTRE FOR HEALTH ECONOMICS 2009.
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
are adjusted for population the same trend is found. HIV incidence rates, per capita, in 2007, are also highest in region 4 and lowest in the most poverty stricken regions. Figure 5.5 below displays cumulative AIDS cases per thousand and marginality index ranking by region and Figure 5.6 displays HIV incidence per thousand and marginality index ranking by region respectively. F I G UR E 5.5: AIDS Cases per Thousand and Marginality Index Ranking by Region
F I G UR E 5.6: Incidence per Thousand and Marginality Index By Region in Guyana.
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EMPIRICAL EVIDENCE FOR GUYANA AND TRINIDAD AND TOBAGO
C ONC L USI ON In the case of Trinidad and Tobago, the results do indicate that there is a two-way relationship between female unemployment and the incidence of HIV/AIDS. The results also indicate that HIV/AIDS exerts a negative impact on overall employment.
In
summary, the results indicate that HIV/AIDS and poverty reinforce each other, with poor, vulnerable women being a significant driver of the disease while also bearing the burden of its impact.
In the case of Guyana, at the level of aggregation at which the empirical investigation was carried out, we have not been able to establish a clear, direct link between poverty and HIV/AIDS. This does not rule out that the more familiar position which supports such a link will not be confirmed at a more disaggregated level. At present however, the data for such investigation in Guyana do not exist.
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IMPLICATIONS FOR POLICY RESPONSE
SE C T I ON V I I M PL I C AT I ONS F OR POL I C Y R E SPONSE The review of the international literature on the relationship between HIV/AIDS and poverty suggests that while there is a general sense that the two phenomena are related, there is some ambiguity regarding the exact nature of the relationship. This ambiguity is particularly evident when it comes to the direction and strength of the relationship. The literature has shown that, in some cases, there is a tendency for the risk of contracting HIV/AIDS to increase at higher levels of education and increases in material wealth. A number of possible reasons are suggested, including the fact that increased mobility (via greater opportunities to travel on business and as tourists) and income may at times facilitate riskier behaviour. However, the literature also suggest that poverty, and all that goes with it, makes individuals more vulnerable to contracting HIV/AIDS by increasing their overall vulnerability to engaging in risky behaviour especially with respect to income-earning activities. Moreover, once an individual contracts HIV, that in itself, could reinforce poverty or potentially take the individual into the ranks of the newly poor.
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IMPLICATIONS FOR POLICY RESPONSE
POL I C Y I M PL I C AT I ONS Unemployment and Poverty are Inimical to the Fight Against HIV/AIDS The findings of the study indicate that increases in unemployment have the effect of increasing the incidence of HIV/AIDS. There is also a suggestion that while HIV/AIDS exerts a negative impact on socioeconomic status—including employment and poverty status—the impact is slower than the reverse relationship. In other words, when one is unemployed and poor, one is more vulnerable to contracting HIV/AIDS and the period within which one may fall prey to the disease is shorter that the time it would take for a non-poor person who contracts the disease to become unemployed and poor as a result of the disease. The findings would suggest a strong case for governments of the region to maintain policies aimed at bolstering employment even in the face of the global economic crisis. There may also be merit to exploring the feasibility of designing and implementing income support programmes which target the newly unemployed.
All Are at Risk…All to be Targeted The results suggest the importance of continuing to educate all segments of the population on prevention options. In the case of Trinidad and Tobago, the results show relatively high levels of HIV/AIDS even in the midst of relatively high levels of income. While it is true that the case of St. George is special, with this area having sub-areas with high levels of income co-existing alongside sub-areas of pockets of concentrated poverty, the experience of this geographic area reinforces the need for awareness building targeting all segments of the population.
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IMPLICATIONS FOR POLICY RESPONSE
However, Some Groups Continue to Need Special, Concentrated Attention…
Poor Women… The results suggest that HIV and poverty reinforce each other, with poor, vulnerable women being a significant driver of the disease while also bearing the burden of its impact. Further, the results of the analysis suggest a two-way link between female unemployment and the incidence of HIV. Of added significance for policy is the finding that increases in the level of female unemployment have a strong positive impact on the growth rate of HIV incidence with the impact manifesting in a relative short period of time. While it is certainly true that women have made great strides in education and in the workplace, the fact is that there are many women who continue to eke out a living while being classified as “unemployable”. What this suggests, is that, at the national level, any serious policy intervention aimed at curtailing the incidence of HIV/AIDS has to be holistic in nature and has to incorporate strategies for empowering women via improvements in the income earning capacity of women, removal of prejudices in employment practices which unfairly exclude women from employment in some areas, social support aimed at enabling mothers to earn an income while knowing that their children are properly cared for at affordable prices, adequate levels/values of means-tested welfare payments where applicable.
Policies Aimed at Keeping those with HIV/AIDS in the Workplace The findings also suggest a need for policy aimed at fairly keeping Persons Living with HIV/AIDS in the workplace. We emphasize ‘fairly” because it would be important to ensure that employers are not forced to retain employees merely because of their HIV/AIDS status. There are two issues here. The first is the issue of stigma and discrimination. The point being made is that since the study has shown an unambiguous link between HIV/AIDS and unemployment we need to ensure that we do not allow the
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IMPLICATIONS FOR POLICY RESPONSE
stigma and discrimination mechanism free reign in the workplace. Countries should be encouraged to align their workplace policies to the principles outlined by the ILO on this matter. The second issue is an interesting one but one which is clearly in need of further research. We refer to the possibility that PLWHAs who are made unemployed because of their status may be more prone to risky behaviour for one of many reasons: they may want to take â&#x20AC;&#x153;revengeâ&#x20AC;? on the society; they might see themselves as no longer having anything worth living for; or they may simply be responding to their now more vulnerable socioeconomic status. Partly because of anecdotal evidence in respect of the behaviour of PLWHAs it would be important to strengthen the empirical basis of any conclusions we might draw on this matter.
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