Supporting the Caribbean to strengthen the health sector response towards universal access to HIV/STI prevention, treatment and care
Since the beginning of the HIV epidemic, PAHO has provided technical support to the Americas to respond to the epidemic. In the Caribbean, this technical cooperation was provided by several PAHO entities, including the PAHO Country Offices and Technical Centers, the Caribbean Epidemiology Center (CAREC), and the Caribbean Food and Nutrition Institute (CFNI). In August 2007 PAHO reorganized its Technical Cooperation (TC) strategy to better respond to the current situation in the Caribbean and the emergence of the Pan Caribbean Partnership for HIV, and established the PAHO HIV Caribbean Office (PHCO). The PHCO was given the mandate to rationalize, coordinate and manage the delivery of technical cooperation in HIV/STI in the broader Caribbean. The establishment of the PHCO represents PAHO’s ongoing commitment to provide strong and integrated support to the Caribbean for a sustained and comprehensive health sector response to HIV/STI through a decentralized approach.
PHCO’s geographical scope is Pan-Caribbean, and includes the Dutch-, English-, French-and Spanish-speaking Caribbean. The Technical Cooperation is framed by the PAHO Caribbean HIV/STI Plan for the Health Sector, 2008 to 2012. The Plan was endorsed by the Ministers of Health of the region, and is fully aligned with the Caribbean Regional Strategic Framework (CRSF). PHCO has technical functions in the area of HIV/STI care and treatment, prevention, planning and surveillance. PHCO is also responsible for providing technical support, oversight and coordination of the PAHO HIV/STI Technical Cooperation with the Caribbean. Additionally, it is expected to foster strategic alliances with external partners to promote a harmonized approach towards the development of a strong health sector response to HIV/STI.
The Caribbean HIV/STI Plan for the Health Sector identifies four strategic lines of action:
- Health systems strengthening
- Strengthening, expanding and reorienting health services
- Improving access to medicines, diagnostics and other commodities
- Improving information and knowledge management, including surveillance, monitoring & evaluation, and dissemination.
Within these strategic lines of action, and based on the priorities of member countries, PHCO identified the following priority activities for immediate action:
- Elimination of Vertical Transmission of HIV and Syphilis in the Caribbean
- Access to comprehensive HIV/STI health services for vulnerable populations
- Strengthening the capacity of the Caribbean for surveillance and strategic information for the health sector
- Health System Evaluation
Elimination of vertical transmission of HIV and Syphilis in the Caribbean
Over the past years the Caribbean has demonstrated a strong commitment to reduce the mother-to-child transmission of HIV. This has resulted in a significant increase in the coverage of HIV screening of pregnant women, and prophylactic treatment to prevent transmission of HIV from the HIV positive pregnant woman to her infant. However, significant gaps remain and an estimated 29 percent of pregnant women are not screened for HIV. Additionally, only an estimated 36 percent of HIV positive women receive treatment to prevent transmission. As a result of these missed opportunities, an estimated 1500 to 2000 infants are annually infected with HIV during pregnancy, delivery or breastfeeding.
In 2008 PAHO proposed to key stakeholders to consider elimination of mother-to-child transmission in the region and to include congenital syphilis in a combined approach to improve maternal and child health services and address the unfinished agenda for elimination of congenital syphilis in the region.
The Caribbean adopted this proposal and currently PAHO and UNICEF (in collaboration with UNAIDS and UNFPA) are providing joint UN support to the region for implementation of this initiative. A Technical Working Group has been established consisting of regional experts and stakeholders, to coordinate the development and implementation of the elimination initiative. PHCO provides secretariat support for the Technical Working Group.
The elimination initiative envisions generations free of HIV and syphilis. It aims to eliminate vertical (mother-to-child) transmission of HIV and syphilis as public health problems in all countries and territories of the Caribbean by the year 2015. The proposed strategy to achieve this target builds on the technical guidance issued by the World Health Organization and other technical organizations and consists of four strategic lines of action:
- Enhancing capacity of MCH and newborn services for the early detection, care and treatment of HIV and Syphilis in pregnant women, their partners and infants;
- Strengthening Surveillance of HIV and Syphilis in MCH services and health information systems
- Integrating HIV/STI interventions with sexual/reproductive health and other relevant services;
- Health Systems Strengthening
The Caribbean has a history of leadership and success in public health mobilization. The region has been a pioneer in the elimination of measles and polio, and through adoption of this initiative has now become the first region in the developing world to pursue the target of elimination of vertical transmission of HIV as a public health problem. PAHO remains committed to support the elimination initiative through PHCO and the PAHO country offices.
Access to comprehensive HIV/STI health services for vulnerable populations
Political, socio-economic, behavioral and cultural factors contribute to increased vulnerability of sub-groups to HIV infection, resulting in higher prevalence of HIV among these vulnerable populations. Elevated HIV prevalence among men who have sex with men, sex workers, migrants, prison inmates, and drug users are documented in studies conducted in the Caribbean. The majority of these groups also face significant barriers to accessing health services, including financial and geographical barriers, stigma, and discrimination.
It is widely recognized that improving access to comprehensive prevention, treatment, care and support services for vulnerable populations is essential to achieve the Universal Access targets. PHCO is undertaking various actions to support countries and the region to improve access to health services for vulnerable populations, including strengthening data collection, training of health workers, and direct support to networks and service providers.
Strengthening the capacity of the Caribbean for surveillance and strategic information for the health sector
Over the past years there has been an unprecedented increase in external financial and technical resources for HIV available at regional and country levels from a wide range of development partners involved in the Caribbean response to the epidemic. These additional resources have brought opportunities but they have also created challenges related to harmonizing technical approaches and developing as well as expanding interventions and models of health care delivery that are evidence based, high quality, cost-effective and sustainable.
PHCO is supporting the countries introduce case-based surveillance as a key strategy to generate the information needed for monitoring and strengthening of HIV treatment, care and support. Other areas of support include facilitating a process to harmonize HIV surveillance frameworks in the region, strengthening patient monitoring, and developing mechanisms for monitoring HIV Drug resistance and Early Warning Indicators.
Health System evaluation
Within the context of strengthening and reorienting health systems, PAHO has developed a practical tool for evaluating the health system, using the HIV response as entry point. The conceptual frame of reference for the evaluation tool is based on the six health systems “building blocks” identified by the World Health Organization service delivery health workforce; information; medical products, vaccines and technology; financing; leadership and governance. The tool is designed to facilitate an evaluation of the technical and operational components of the HIV/STI response, while at the same time providing an opportunity to identify and analyze general health systems challenges.
The health systems evaluation is a participatory process that engages internal stakeholders to assess performance with assistance from external experts. The experiences from health systems evaluations conducted and in progress indicate that the process is very empowering and generates information, capacity and commitment for strengthening the health sector in general, and the HIV/STI response towards Universal Access in particular.
Human rights, gender, stigma and discrimination
As a cross-cutting strategy, PHCO approaches health as a human right and promotes a human-rights based approach in all initiatives and activities. In line with the PAHO gender-equality policy, PHCO aims to mainstream gender in all its activities. This includes fostering awareness regarding the differential information and service needs of men and women, building capacity to address gender inequalities, addressing the intersection between HIV and gender-based violence, and supporting gender analysis. PHCO also recognizes that stigma and discrimination are among the major barriers to achieving Universal Access, and continues to focus on the reduction of stigma and discrimination in the health sector.
Originally published in DVCN Critiques Vol. 3, NO. 1, Washington DC 2009