Are we progressing on HIV/AIDS control?

24 Nov 2010

The World AIDS Day, an opportunity for a collective reflection, by Francisco Roquette, PhD and Mariana Mansur, PhD.

It has become a sad but nonetheless crucial tradition to celebrate 1st of December as the World AIDS Day each year around the world as one of the most recognized international health days. This is a special day for raising awareness and celebrating achievements such as increased access to treatment and prevention services. Most importantly, it is a great opportunity to ask ourselves the following question: what are we doing about it?

In the Caribbean, it is estimated that there were between 210,000 and 270,000 people living with HIV in 2008, and around 12,000 have died of AIDS as per 2008 year estimates. Despite the gains associated with antiretroviral treatments (ART) over the last decade, HIV/AIDS remains the leading cause of death among young and middle-aged adults in the Caribbean. Between 2001 and 2008, there was no significant decline in the number of new HIV infections. The overall prevalence figures hide important and evolving dynamics, including that the number of women living with HIV is increasing. Currently, women – and especially young women – account for half of those with the virus. Reflecting global patterns, heterosexual sex is now the main route of transmission throughout the region, and it has been established that women and young people are particularly vulnerable. Many people still wrongly think that HIV/AIDS is a ‘gay thing’, and that sex between men plays a major role in the region’s epidemic; the truth is that it has been estimated that men who have sex with men account for 12% of HIV infections. At the same time, the dehumanization of sex – mainly through irresponsible sexual practices from both men and women – has also led to this state of affairs in the Caribbean and we salute Pope Benedict’s recent statement in which His Holiness considers that the use of condoms to reduce the risk of infection is a “first step on the road to a more human sexuality”, rather than not to use it and risking the lives of others (“Light of the World” interview with Peter Seewald).

Belize is considered the third most affected country in the region, with an adult HIV prevalence estimated in 2.1%. The cumulative number of reported HIV infections in Belize from 1986 to the end of 2009 was 5,045. During 2009, the total number of new HIV infections was 365 indicating a relative decrease when compared with new 425 cases in 2008.

The objective of this press release is to provide an overview of the different actions taken by many actors in responding to the crisis: The need for a coordinated response to HIV and AIDS has long been recognized. Most nations have established National AIDS Commissions (NAC), strategic plans, legislation and HIV-related programs and services. In Belize, the NAC is mandated by the government to play a key role in effectively coordinating multi-sector programs and strengthening national response to the epidemic.

1) HIV Prevention:

Voluntary Counseling and Testing (VCT): Most countries in the Caribbean have opened VCT centers, and international agencies such as the United Nations and funds like the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) have provided grants to expand such services in a number of countries, being Belize one of them with a successful experience.

Preventing Mother-To-Child Transmission (PMTCT) – More than 90% of pregnant women in 11 Caribbean countries are now tested for HIV every year. About 52% of pregnant women received services for the prevention of mother-to-child transmission of HIV, which led to an 18% reduction in new HIV infections among children in 2008. In 2009, 59% of HIV infected pregnant women requiring treatment for PMTCT in the Caribbean received it. In Barbados and the Bahamas, a combination of increased voluntary counseling and testing services and improved access to ARV drugs has helped to significantly reduce the rate of mother-to-child-transmission. Belize counts with excellent results in this area. In 2008 all the pregnant women were counseled for HIV and 93% agreed to take an HIV test. The 87% of pregnant women needing ARVs received it in 2009. Additionally, 48 babies out of 52 deliveries from HIV positive mothers received prophylaxis at the time of delivery. (UNGASS 2010 report)

HIV prevention among risk groups in the Caribbean: There is a general lack of HIV prevention campaigns targeting sex workers and men who have sex with men in the Caribbean – two key risk groups in the region. HIV prevalence amongst men who have sex with men (MSM) varies between Caribbean countries. In Cuba MSM account for 80% of all reported HIV cases, Dominica (70%), Trinidad and Tobago (20%) and the Dominican Republic (11%). Homophobia and cultural taboos about sex between men are major barriers to reaching this group with prevention campaigns. UNAIDS reports that more than three-quarters of the Caribbean countries have laws that may hinder the provision of prevention and treatment services to vulnerable and high-risk populations. This includes banning sex between men and not providing condoms to certain groups, such as prisoners. Prevention is also lacking among commercial sex workers. The Caribbean is a popular tourist destination, and several countries, such as the Dominican Republic, Jamaica and Trinidad and Tobago, have reported that tourism is linked to rising HIV infection rates in certain areas. Commercial sex work involving local clients also plays a significant role in some areas.

Stigma and discrimination in the Caribbean: HIV-related stigma and discrimination are common in the Caribbean. In some cases, prejudice towards people living with HIV is linked with homophobia; sex between men carries a high risk of HIV transmission and, as elsewhere, people often associate HIV with homosexuality, despite the fact that the majority of infections occur through heterosexual sex. This prejudice is causing a great deal of stress and suffering to people who are living with HIV and their families, who often face social isolation. Stigma stops people who are at risk of infection from accessing information on prevention and testing, and reduces people’s willingness to buy condoms or alter their sexual behavior. It also prevents people from accessing counseling services, support groups and treatment.

Reflections on gender inequality: Gender violence is another shadowy, destructive force that blocks progress on controlling the spread of HIV. Violence makes women and girls more vulnerable to HIV. It makes it difficult or impossible for them to negotiate condom use and even saying no to sex. It prevents women from getting adequate care and treatment services and to prevent HIV infections.

2) HIV/AIDS Care and Treatment services:

Governments across the region provided ART to 51% of people in need in 2008 – up from just 1% in 2004. In Belize, a total of 630 persons were on free ART provided by the government at the end of 2008, with a 49% of ART coverage out of the total estimated population in need of treatment. By the end of 2009, a total of 855 persons were on ART and the coverage rate of the estimated population in need was 61.3% at the end of 2009.

3) The way forward:

There is still a long way to go before HIV and AIDS are under control in the Caribbean. Gaps exist in testing, treatment and prevention programs, and stigma and discrimination are having a negative effect. Monitoring and reporting of the epidemic is consistently poor, which makes it difficult to gain an understanding of the trend of HIV in the region. HIV now disproportionately affects young women, men who have sex with men, transgendered persons, and sex workers across ethnicity, race and class barriers. And, there are still laws in place that criminalize sexual behaviors, reinforcing stigmas and making it difficult to respond comprehensively to HIV.

Since 2001, the Caribbean region has received approximately US $1.2 billion in grants to fight HIV/AIDS. Donors meeting in New York last October announced funding of US $11.7 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria for the years 2011-2013. These financial resources will allow the Global Fund to further support countries as they work to meet the Millennium Development Goals related to health. Belize will start the implementation of Round 9 in December 2010, with an overall goal of to “Halt the spread of HIV with a special emphasis on young people 15–24”.

What can be done for the Caribbean to achieve the Millennium Development Goals for HIV by 2015?

In 2010, why is HIV still treated differently from other diseases? One reason is that in the region it is still difficult to discuss sex, sexual orientations and sexual norms and behaviors. Discussion does not lead to promiscuity or ill health: on the contrary, information on how to protect ourselves and partners safeguards the public’s health. The stigma associated with HIV is an attitude from the early 1990s, when fear informed ignorance. This is also linked to long prejudice and rejection of what is perceived and judged as abnormal sexual behavior and wrongful sexual orientation. It is precisely these stigmas that threaten the public’s health: they prevent people from getting tested, and from seeking treatment, if needed.

True development will require significant achievement on all the MDGs. Trade, health, education, poverty, and environmental sustainability and gender relations, interact with each other. An educated, healthy population with equal opportunity for all, with environmental stability and economic prosperity is not unattainable.

The Caribbean countries will join the initiative launched by United Nations towards the vision of zero new HIV infections, targeting the “hot spots” where HIV is most likely to spread. Communities have to be mobilized to fight stigma. HIV testing and treatment must be integrated into primary health care for the family.

Now is the time to scale up. It is the time to face up to our responsibilities, to show integrity, to keep our commitments:

  • It is time to scale up ARV treatment for those in need
  • It is the time to stop babies being born with HIV
  • It is the time to end discrimination against the most vulnerable
  • It is the time to achieve universal access.