Confronting AIDS in the Caribbean: Major New Efforts Underway
By Daniel Epstein, photo by Armando Waak
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Expectations are high that a series of major new efforts underway will control AIDS in the Caribbean region. Al-though the region has the highest prevalence of HIV outside of sub-Saharan Africa, the epidemic lags far behind that in Africa and is relatively well contained, according to a Pan American Health Organization (PAHO) publication on AIDS.
Small geographically, the Caribbean population exceeds 6 million, and an estimated 500,000 people have HIV/AIDS, a major cause of death for the 15-to-44 age group in several countries. About 80,000 Caribbean children have been orphaned by AIDS, according to PAHO estimates.
Mr. Edwin Carrington, secretary-general of the Caribbean Community (CARICOM), says the increasing number of persons infected with the deadly virus HIV/AIDS is "one of the most pressing issues of concern in the Caribbean and the wider world." He adds, "As we move into the 21st century, one of the major threats to our human development efforts is the HIV/AIDS epidemic."
"We do not have a choice in the matter–we must act now," says Prime Minister Owen Arthur of Barbados. "The Caribbean has never lost a generation of its most talented young people because of war or natural disaster. It is in danger of doing so because of the pandemic of AIDS. With it goes the hope, promise, and idealism of the best educated and most creative minds in the history of the Caribbean people."
Partnering in a Strategic Approach
A Coalition of Governments. A new coalition to fight AIDS regionally was launched in February at the CARICOM Heads of Government meeting in Barbados. The coalition seeks "to significantly scale up the response to HIV and AIDS in the Caribbean," according to Dr. Edward Greene, assistant secretary-general of CARICOM. "An expanded response involving governments, business, and the international community is essential if the spread of the epidemic is to be reversed."
The new Caribbean Regional Strategic Plan of Action for HIV/AIDS is designed to give governments the tools to intervene quickly to prevent the spread of AIDS, with programs focused on high-risk groups, as well as treatment for those living with AIDS. "We have a strategic regional plan that the governments of the Caribbean support, but we will need support from the international community to implement it," says Barrington Wint, CARICOM’s former health manager for the Caribbean.
The coalition’s goal is to reduce the number of new HIV infections, provide care for people already infected, reduce AIDS-related discrimination, and increase the ability of communities, nongovernment organizations, and others to respond to the epidemic. Specific targets include cutting by 50 percent HIV transmission from mother to child by 2003, and reducing by 25 percent HIV prevalence among 15- to 24-year-olds by 2005. By 2005, 90 percent of young people 15 to 24 should have access to information, education, and services to help reduce their vulnerability to HIV infection.
"AIDS in the Caribbean has reached a watershed moment," says Dr. Peter Piot, executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS). "Without decisive action, the epidemic and its impact will cause untold harm for decades ahead. But the Pan-Caribbean Partnership against HIV/AIDS represents the chance to build a better future."
PAHO’s Role. Also in February 2001, the Pan American Health Organization launched its strategic plan for AIDS throughout the Caribbean. PAHO’s Caribbean Epidemiology Center (CAREC), which serves as the Caribbean’s health monitoring and disease prevention agency, is strengthening surveillance and research to get better information about where the epidemic is heading, is implementing HIV/AIDS policies, and is improving the delivery of diagnosis and preventive services programs to reduce the incidence of the disease.
These services will be important to the coalition’s activities. PAHO experts say that continued tracking of the HIV epidemic through unlinked anonymous testing of different population groups is an important public health measure, providing invaluable information that will enable nations to plan prevention and care services for those who most need it.
Several PAHO efforts are at the forefront of treatment advances for AIDS in the Caribbean and elsewhere. One is a Regional Revolving Fund for Strategic Public Health Supplies, which allows PAHO member countries to obtain low prices. Another is the PAHO Directing Council’s mandate to promote infrastructure and technology to facilitate the sharing of information on databanks that have pricing information on antiretroviral drugs.
An important PAHO innovation is a new comprehensive "building blocks" approach that provides guidance for comprehensive care of people living with HIV and AIDS, including clinical management, nursing care, counseling and emotional support, and social support. It sets scenarios for appropriate and feasible care alternatives.
The strategy is designed to meet the full spectrum of needs of persons living with HIV/AIDS–physical, mental, emotional, and spiritual–in addition to providing pharmaceutical products and other medical procedures that may suppress clinical symptoms and replication of the virus. It stresses that even in areas where resources are limited, it is possible to provide a standard of care that ensures the maintenance and improvement of the quality of life and productivity of persons living with HIV/AIDS. The strategy was announced at the International AIDS Conference in Durban, South Africa, July 9, 2000, and has evoked expressions of interest from several agencies.
According to Dr. Fernando Zacarías, Coordinator for the Regional Program on AIDS and Sexually Transmitted Diseases at PAHO, "This is a common sense strategy based on reality and technical knowledge. It is designed to improve care and support for persons living with HIV/AIDS and their families." He emphasizes that, in every instance, there is something that can be done to improve the care provided to persons living with HIV/AIDS. The model presents a step-by-step approach to strengthening and improving care to ensure that the best quality care is available in the changing health care environment.
According to Dr. C. James Hospedales, director of CAREC, trends in the number of people testing positive for HIV "in groups at high risk and the general population have been going up, and this does not augur well. HIV/AIDS models, developed by CAREC in collaboration with the health economics unit at the University of the West Indies, suggest that if we do not have more success with prevention efforts, AIDS will have a very significant impact on mortality in the coming two decades, and that up to 5 percent of the gross national product could be spent on AIDS. This is as much as some countries spend currently on health overall."
The key tasks for the health sector, Dr. Hospedales says, are to provide services for persons with sexually transmitted diseases to help reduce the"gateway" effect, to improve surveillance of these diseases and HIV/AIDS, and to make certain people living with HIV/AIDS are cared for.
Dr. Hospedales says that the fight against HIV/AIDS is one of CAREC’s major milestones, "one which is arguably the watershed event in the life of the organization, in that the necessary response to this challenge caused CAREC to adopt a more explicit health promotion and public communication thrust."
"The HIV/AIDS challenges today include the prevention of sexual transmission; prevention of mother-to-child transmission; improving care and support, including access to antiretroviral drugs; and decreasing stigma and discrimination. The successes of the program to date have meant that the region has avoided the huge adverse impact as in some other parts of the world where large numbers of the population have been literally wiped out. But there is no cause for complacency. HIV/AIDS continues to spread and constitutes a real threat to the region’s development," Dr. Hospedales says.
Support from the World Bank. At the April 2001 Summit of the Americas in Quebec, Canada, World Bank President James D. Wolfensohn announced the World Bank’s US$150 million plan to support the fight against HIV/AIDS in the Caribbean, fulfilling its pledge last September at a high-level meeting of country delegations and international organizations to significantly increase support for HIV/AIDS activities in Caribbean countries.
"Caribbean countries must take the lead, and the international community must work together to support the region in this effort," said World Bank Vice President for Latin America and the Caribbean David de Ferranti at the meeting. "We must be serious about prevention. We also must remember that treatment is a critical part of a comprehensive approach. It is just as important to prolong and care for the lives of those who are already HIV-positive or dying of AIDS, as it is to protect those without it," he said.
Focus on Quality, Humane Care
"Combating the epidemic in the region also requires focusing on the dignity of people already infected and living with HIV/AIDS," says Dr. George Alleyne, director of the Pan American Health Organization. "This includes improving their access to quality, humane care and treatment."
The world AIDS epidemic, according to Dr. Alleyne, "has reached alarming proportions. We estimate that HIV or AIDS has infected more than 34 million people worldwide, and already some 19 million have died as a result of this disease. In the Region of the Americas, one in every 200 persons between 15 and 49 years of age is HIV-infected. In the Caribbean, one in every 50 people has the infection, and it is clear that the incidence of HIV among men continues to increase worldwide."
"It’s virtually a fend-for-yourself world out there for people living with HIV and AIDS in the Caribbean," says Ms. Claudette Francis, who is executive director of Community Action Resource (CARe), a national network in Trinidad and Tobago, and technical adviser to CRN+, a Caribbean network of people living with HIV/AIDS. This is true for orphaned children as well, she adds, mentioning a home in Trinidad set up to deal with abandoned children that now has about 30 HIV-positive children up to 12 years old.
"These children themselves are not on antiretroviral treatment in any organized fashion, there is no one consistently buying medication for children, and they are just treating opportunistic infections," says Ms. Francis. "I’m not sure there are appropriate personnel to deal with children’s mental health issues either, and this is the same situation that adults in the Caribbean face." Ms. Francis emphasizes the need for "changes in attitude that influence self-concept, self-esteem, and thus survival of people with HIV and AIDS."
Lessons Learned
The strategic, collaborative approach in the Caribbean takes into account what has and has not worked elsewhere to prevent and contain the AIDS epidemic.
"The main lessons," says Dr. Hospedales, "are that the health sector alone cannot cope with HIV/AIDS, that a broad-based alliance under strong political leadership is the key to success, and that we must act as soon as possible to save lives and money and to prevent infection among those most likely to contract and spread HIV. We also must promote healthy living and safer sex as a survival skill, de-regulate condom sales, and realize that people with HIV/AIDS have a key role."
According to UNAIDS, heterosexual HIV transmission in the Caribbean is driven by the "deadly combination" of early sexual activity and frequent partner exchange by young people. Age mixing–younger women having sex with older men–is also an important factor. At one surveillance center for pregnant women in Jamaica, for example, the pre-valence of HIV in girls in their late teens is almost twice that of older women.
Since a regional AIDS program was set up by CAREC, "the program has made huge strides in helping the development of national policies, plans, and programs, and in establishing a Caribbean surveillance system," Dr. Hospedales says. "High levels of awareness now exist of HIV/AIDS in the population and how it is spread. We have a safe blood supply."
The Caribbean countries are also increasing their work with nongovernment organizations as part of the major effort against AIDS. "Guyana, for example, recently had a survey of sex workers carried out by … guess who? Sex workers themselves. They went out in a van and surveyed the sex workers," Dr. Hospedales says.
Advances are also being made among men who have sex with men, a group that is now the focus of workshops on safe sex. Such an approach was difficult before because of homophobia and legislation against homosexuality in many Caribbean countries.
Country-Specific Efforts
Preventing mother-to-child transmission is crucial, and several of the wealthier Caribbean countries, such as the Bahamas and Barbados, have done very well with this approach.
The Guyana Ministry of Health is making an effort to reduce mother-to-child transmission of HIV in that country, proposing to offer HIV testing to all women attending prenatal clinics and antiretroviral drugs to mothers and newborns who test positive, and replacement therapy if the mothers choose this.
Young people in the English-speaking Caribbean initiate sex at a particularly young age, which may help explain the high prevalence of HIV in this region, according to a UNAIDS report. Youth studies conducted between 1990 and 1999 in Barbados, Jamaica, and Trinidad and Tobago show that most youths first had sex when they were between 13 and 15 years old, with some boys starting as young as 10.
Teenage girls are especially likely to suffer from early risky sex, the UNAIDS report says. They are physiologically more susceptible to HIV than older women, and they may be less able to negotiate condom use, especially in relationships with older men. In addition, sex with older men is risky because the men are likely to have had more previous sex partners and are therefore more likely to have been exposed to HIV.
In Trinidad, most young boys had sex with girls their age or younger, but 28.5 percent of girls said they had sex with older men. Perhaps as a result, five times more girls than boys between 15 and 19 are HIV-positive in Trinidad and Tobago, the report says.
Dr. Hamza Rafeeq, minister of health of Trinidad and Tobago, speaking at CAREC’s 25th anniversary ceremony last year, said, "If we do not indulge in careless sexual practices, the seemingly inexorable upward spiral of HIV incidence and death from AIDS will be halted, and another generation of healthy and productive Trinidadians and Tobagonians, and consequently, a most viable state, would be assured."
Though the statistics are worrisome, PAHO experts say there is considerable reason for hope. Given access to adequate information and support services, young people are willing and able to delay sex and to make sure that they have safe sex when they do choose to become active.
Treatment Successes
Since effective combination therapy for HIV became available in 1995, many countries in the Americas have worked hard to increase access to these drugs for people with HIV and AIDS. Some countries in Latin America and the Caribbean lead the developing world in providing access to antiretroviral therapy, but there are wide differences between countries. Some cannot even provide treatment for common infections arising from weakened immune systems resulting from AIDS, while others are legally bound to provide cutting-edge combination therapy to all who need it.
Without preventive actions, around one-third of pregnant women infected with HIV will pass the virus to their infants during pregnancy, in childbirth, or through breastfeeding. HIV-infected women who do not breastfeed cut the risk substantially. Oral antiretroviral therapy can be given to the mother in the last month of pregnancy to reduce the rate of transmission to under one in 10.
Countries that have implemented and monitored programs to reduce HIV transmission from mother to child have recorded successes. For example, the Bahamas, which uses a modified version of a complex regimen used in North America, has cut mother-to-child transmission rates from 28 percent to 12 percent.
These programs work only if a mother knows she is HIV-infected before delivery. Between 75 and 100 percent of women in most Caribbean countries are in contact with a clinic before giving birth, and many deliveries take place in hospitals. Almost all pregnant women in the Dominican Republic go to prenatal clinics, for example, and more than 95 percent give birth in hospitals. In contrast, 80 percent of women in Haiti give birth at home, and 30 percent receive no prenatal care at all.
The ministers of health of the Americas have long recognized the problem of the evolution of HIV/AIDS in the Americas and the challenges raised by the increasing numbers of people requiring comprehensive prevention and care services. At PAHO’s Directing Council in 2000, they agreed that the continued focus should be on preventing HIV transmission through sex, mother-to-child transmission, or needles used with illegal drugs. The ministers also called for resources for prevention and drugs.
Trinidad and Tobago’s prime minister, the Honorable Basdeo Panday, in an address at CAREC in October, said, "The government of Trinidad and Tobago is giving the highest priority to the issue of HIV/AIDS prevention. We continue to lose lives to HIV/AIDS at an increasingly alarming rate. This is the reality in the Caribbean, as it is in the rest of the world. HIV/AIDS is not the problem of any one nation. It is a problem confronting the world."
Daniel Epstein is a Washington, D.C.-based journalist in charge of media relations for PAHO’s Office of Public Information.