Latin America/Caribbean State of the Art

HIV/AIDSPart One

Paul R. De Lay, M.D.

Chief, HIV/AIDS Division

Global Bureau

USAID

March 13, 2001

HIV/AIDS

• Introduction

• The Epidemic and its Impact

• Interventions Appropriate for the Epidemic

Spread of HIV over time in Latin Spread of HIV over time in Latin America and the Caribbean, 1984 to America and the Caribbean, 1984 to

19991999

Estimated percentage of adults

(15–49) infected with HIV 2.0% – 6.0%1.0% – 2.0%0.5% – 1.0%0.1% – 0.5%0.0% – 0.1%trend data unavailable

outside region

AIDS deaths among children under-5 are resulting in higher Child Mortality Rates (2000).

Source: U.S. Census Bureau, International Data Base and unpublished tables.

Bahamas

Honduras

Brazil

Guyana

Haiti

0 50 100 150 200 250

Deaths under age 5 per 1,000 live births

Without AIDS

With AIDS

Life Expectancy with and without AIDS: 2000

Source: U.S. Census Bureau, International Data Base and unpublished tables.

Bahamas

Honduras

Brazil

Guyana

Haiti

0 10 20 30 40 50 60 70 80 90

Life expectancy at birth (years)

With AIDS

Without AIDS

Life Expectancy with and without AIDS: 2010

Source: U.S. Census Bureau, International Data Base and unpublished tables.

Bahamas

Honduras

Brazil

Guyana

Haiti

0 10 20 30 40 50 60 70 80 90

Life expectancy at birth (years)

With AIDS

Without AIDS

HIV-1 Seroprevalence Among Pregnant Women from Capital City or Major Urban Centers in

Selected Countries

ASIA & OCEANIA

THAILAND

BURMA

PAKISTAN

LAOS

INDIA

VIETNAM

LAC

HAITI

HONDURAS

GUYANA

BRAZIL

BELIZE

DOMINICAN REP.

ARGENTINA

BARBADOS

JAMAICA

TRIN. & TOB.

0 10 20 30 40 50

% Seropositive

AFRICA

BOTSWANA

SOUTH AFRICA

LESOTHO

MALAWI

SWAZILAND

ZIMBABWE

ZAMBIA

NAMIBIA

RWANDA

BURUNDI

ETHIOPIA

KENYA

UGANDA

TANZANIA

COTE D'IVOIRE

CAR

LIBERIA

MOZAMBIQUE

BURKINA FASO

TOGO

NIGERIA

CHAD

CONGO

CAMEROON

GABON

BENIN

CONGO, (ZAIRE)

0 10 20 30 40 50

% Seropositive

HIV Seroprevalence for Pregnant Women in Latin America is low except for in a handful of countries.

Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.

1986 1988 1990 1992 1994 1996 1998 2000

0

5

10

15HIV Seroprevalence (%) in selected Latin American Urban areas: 1986-1998

Cite Soleil, Haiti

San Pedro Sula, Honduras

Rio de Janeiro, Brazil

Sao Paulo, Brazil

Guyana

Santo Domingo, Dominican Rep.

Characteristics of HIV Epidemics in LAC Region

• Complex (mix of concentrated and generalized)

• ? Mature

• Surveillance issues

Factors that influence the spread of HIV

• Viral Factors

-HIV-1 strains

-Viremia

• Local Genital Factors-Presence of STDs

-Male circumcision

-Use of vaginal products

• Sexual Behavior-Rate of partner exchange

-Sexual mixing patterns

-Type of intercourse

-Size of and rate of contact with core groups

-Level of condom use

• Demographic Factors-% sexually active age groups to other age groups

-Male to female ratio

-Urban:rural%

-Migration patterns

• Economic and Political Factors-Level of poverty

-War and social conflicts

-Status of transport and mobility of population

-Performance of health care system

-Response to epidemic

(from Piot-1994)

Comparison of average number of clients per sex worker versus % of young men to utilized sex workers

0

0.5

1

1.5

2

2.5

3

3.5

4

0 10 20 30 40 50 60

% males using sex workers

Ave

rag

e #

of

CS

cli

ents

/day

Indonesia

Philippines

Cambodia

Thailand

Comparison of HIV prevalence among female SWs and # clients per day

05

1015202530354045

0 0.5 1 1.5 2 2.5 3 3.5 4

Average # clients/SW/day

% H

IV i

n f

emal

e S

Ws

IndonesiaPhilippines

Cambodia

Thailand

Infectious Disease ControlBasic Principles 1:

• Modes of transmission

• Stages of the epidemic

• Epicenters/ “hot zones” Concept of “core transmitters”

• Those most likely to transmit/Those most likely to contract (“TMLTC”)

LAC Countries by Major Mode of TransmissionIDU MSM Heterosexual

Argentina Argentina Bahamas

Bermuda Brazil Barbados

Brazil Costa Rica Dominican Republic

Uraguay Dominica Guatemala

Mexico Guyana

Panama Haiti

Peru Honduras

Venezuela Jamaica

Stages of the Epidemic

• Nascent

• Concentrated

• Generalized

• Mature

Basic Principles-2

• Primary goal is to reduce:

1. Risk behaviors (through intensive interpersonal communications/ mass communication to achieve behavior change)

2. Efficiency of transmission (through reduction of cofactors, e.g. STDs, use of male/female condoms, microbicides)

Basic Principles-3

• The most effective way to reduce risk behaviors and the efficiency of transmission is to “target” those most likely to transmit or contract infection--in practice, this is achieved through an emphasis on “Risk Populations” and “Risk Locations.”

RISK POPULATIONS• Commercial sex workers

• Male migrant workers (e.g. truckers, construction workers, seafarers, urban skilled and unskilled)

• Military/police

• Civil servants

• Men who have sex with men (MSM)

• Injecting drug users

• University students

• STD patients (private and public sector)

• Youth (young men and women), single women

RISK LOCATIONS

• Brothels, bars, hotels, massage parlors, beauty salons, night clubs

• Truck stops, border crossings, bus terminals, train stations

• Military bases/Harbors

• Video parlors

• Worksites (mines, construction sites)

Essential Technical Elements of an HIV/AIDS Program

Prevention• Blood safety• Universal precautions• Sexual risk reduction• Harm reduction• Condom social marketing• STI management• Voluntary Counseling and

Testing• Stigma reduction• PMTCT• Surveillance and M&E

Care and Mitigation• Palliative care• Psychosocial support• Treatment of OIs• OVC• Use of ARVs• Other mitigation

activities

Supporting Elements for an HIV/AIDS Program

• Policy Reform(government commitment, allocation of resources, dealing with discrimination, stigma)

• Biomedical Research(STD Diagnostics, microbicides, Mother-to-child transmission interventions, preventive and therapeutic vaccines)

• Social Science Research• Surveillance (biologic and behavioral)• Improved distillation and use of research and

“lessons learned”

Limitations of Family Planning Settings

“…inherently weak interventions for often the wrong populations…”

• Behavior Change – (dual protection-can it work?)

• STI management – significant number of asx cases– vaginal discharge syndromic algorithm

lacks sensitivity and specificity

Summarizing Recommendations for

Interventions

Epidemiologic Scenario

Intervention

Concentrated

-MSM

-IDU

VCT

Improved targeting

Generalized Improved targeting

VCT

PMTCT

ALL Improve surveillance

???CARE?????

-end of Part One

Part Deux next………..