A new UN­Aids Re­port shows that in the past 10 years, new HIV in­fec­tions have fall­en by 14.3 per cent in the Caribbean but be­low the 20 per cent glob­al de­cline. Da­ta show that the di­rect im­pact of an­ti­retro­vi­ral treat­ment has re­sult­ed in a 43 per cent de­cline in Aids-re­lat­ed deaths, well above the 20 per cent glob­al de­cline in the past 10 years. The Caribbean HIV epi­dem­ic, one of the old­est in the world, is be­gin­ning to change course be­cause of the de­clin­ing num­ber of new HIV in­fec­tions and in­creas­ing num­ber of peo­ple liv­ing with HIV in this re­gion. In 2009, there were be­tween 230,000 and 290,000 peo­ple liv­ing with HIV in the Caribbean, an es­ti­mat­ed 260,000 in the wider Caribbean in­clud­ing Guyana, Be­lize and Suri­name.

Da­ta show that an es­ti­mat­ed 18,000 peo­ple be­came new­ly in­fect­ed with HIV in the Caribbean, few­er than 21,000 in 2001. In 2009, 12,000 peo­ple died from Aids-re­lat­ed ill­ness­es. This num­ber is clos­er to half of what it was in 2001, ie, 21,000. This is a 43 per cent de­cline. "These da­ta show that pre­ven­tion is work­ing and treat­ment is hav­ing a pos­i­tive im­pact on lives of peo­ple liv­ing with HIV," said Ernest Mas­si­ah, di­rec­tor of the UN­Aids Caribbean Re­gion­al Sup­port Team. How­ev­er, the chal­lenge is how to ac­cel­er­ate the progress ac­com­plished dur­ing these past 10 years.

At the end of 2009 an es­ti­mat­ed:

260,000 (230,000-290,000) peo­ple were liv­ing with HIV in the wider Caribbean.

18,000 new in­fec­tions oc­curred dur­ing that year.

12,000 peo­ple died from Aids-re­lat­ed ill­ness­es.

Pre­ven­tion is work­ing

The 2010 re­port con­tains ba­sic da­ta from 182 coun­tries and in­clud­ed coun­try-by coun­try score­cards. The re­port gives new evi- dence that in­vest­ments in HIV pre­ven­tion pro­gram­ming are pro­duc­ing sig­nif­i­cant re­sults in some Caribbean coun­tries. From 2001 to 2009, the rate of new HIV in­fec­tions sta­bilised or de­creased in five coun­tries: Haiti, Be­lize, Do­mini­can Re­pub­lic, Ja­maica and Suri­name. Da­ta show that the de­cline in new HIV in­fec­tions is the re­sult of safer sex prac­tices. For ex­am­ple, in the Do­mini­can Re­pub­lic HIV preva­lence de­clined from 0.6 per cent in 2002 to 0.3 per cent in 2007 among young peo­ple. How­ev­er, da­ta show that in coun­tries like the Ba­hamas, Bar­ba­dos and T&T, the adult HIV preva­lence re­mained high or has in­creased.

In T&T, for eg, there is no change in HIV in­ci­dence be­tween 2001 and 2009, and 12,000 new HIV in­fec­tions oc­curred in that coun­try dur­ing that pe­ri­od. Over­all 50 new HIV in­fec­tions oc­curred every day in the Caribbean. Over­all, pre­ven­tion pro­grammes do not reach the most-at-risk pop­u­la­tions and sub­se­quent­ly the preva­lence of HIV among these pop­u­la­tions, ie, men who have sex with men, fe­male and male sex work­ers, crack-co­caine users and pris­on­ers, is very high and these most-at-risk pop­u­la­tions al­so have sex­u­al in­ter­ac­tions with the gen­er­al pop­u­la­tion, es­pe­cial­ly the fe­male pop­u­la­tion with MSM, main­ly be­cause of so­cial pres­sure an non-ac­cep­tance of mar­gin­al-ised be­hav­iours.

There­fore, more ef­fort is nec­es­sary to reach out to these key pop­u­la­tion groups in the so­ci­ety if the pre­ven­tion pro­grammes have to achieve greater im­pact.

Pre­ven­tion of moth­er-to-child trans­mis­sion of HIV

In 2009, a to­tal num­ber of 4,400 preg­nant women liv­ing with HIV have ben­e­fit­ed from in­ter­ven­tions to pre­vent HIV trans­mis­sion to their ba­bies. This rep- re­sents a 59 per cent cov­er­age from 22 per cent in 2005. The im­pact of these pro­grammes is that few­er chil­dren are born with HIV in the Caribbean.

Treat­ment

In 2009, a to­tal num­ber of 110,000 need­ed treat­ments but on­ly 52,400 re­ceived, which rep­re­sent 48 per cent cov­er­age rate us­ing the re­vised WHO stan­dards. This has re­sult­ed in the 43 per cent re­duc­tion in deaths due to Aids-re­lat­ed ill­ness­es. Still 52 per cent, ie 57,600 peo­ple who need treat­ment are not ac­cess­ing ser­vices.

New HIV in­fec­tions slow­ing but slight­ly out­pace treat­ment suc­cess

For every five peo­ple put on ART (an­ti­retro­vi­ral ther­a­py) in 2009, there were sev­en new HIV in­fec­tions. There­fore pre­ven­tion pro­grammes need to have the re- quired at­ten­tion in terms of in­ter­ven­tions among key pop­u­la­tions and al­lo­ca­tion of re­sources. For ex­am­ple, less than 40 per cent of the to­tal Aids bud­get al­lo­cat­ed by all coun­tries in 2008-2009 were used for pre­ven­tion pro­grammes.

There has been a de­cline in Aids-re­lat­ed deaths

The num­ber of deaths due to Aids-re­lat­ed ill­ness­es de­clined from 21,000 in 2001 to 12,000. This is the di­rect ben­e­fit from treat­ment pro­grammes and their cov­er­age went from one per cent in 2004 to 48 per cent in 2009. How­ev­er, there is still a need to scale up treat­ment, as every day 33 peo­ple died of Aids-re­lat­ed ill­ness­es in 2009.

Hu­man rights as part of the Aids strate­gies but no re­al change

All coun­tries have in­te­grat­ed some el­e­ments of hu­man rights in their na­tion­al ef­forts to re­spond to HIV. How­ev­er, 11 out of the 16 Caribbean states have laws that crim­i­nalise con­sen­su­al same sex sex­u­al en­coun­ters and two coun­tries have re­stric­tions on trav­el of peo­ple liv­ing with HIV.

Stig­ma and dis­crim­i­na­tion re­main a chal­lenge and need to be ad­dressed at all lev­els to sup­port the scale-up to­wards uni­ver­sal ac­cess. Gay men, trans­gen­der peo­ple, sex work­ers, peo­ple liv­ing with HIV and crack-co­caine users are all con­fronting stig­ma and dis­crim­i­na­tion in their dai­ly life.

Sus­tain­abil­i­ty

The Caribbean re­gion­al re­sponse re­lies heav­i­ly on ex­ter­nal re­sources.

Dur­ing the past five years, 72 per cent of all re­sources al­lo­cat­ed to HIV were from ex­ter­nal sources. This needs to be changed and na­tion­al au­thor­i­ties have to com­mit na­tion­al re­sources to re­spond to HIV if gains made have to be sus­tained and ex­pand­ed. Change is need­ed through new ap­proach­es such as in­te­gra­tion of in­ter­ven­tions, de­cen­tral­i­sa­tion of ser­vices, fo­cus of na­tion­al at­ten­tion and re­sources on pop­u­la­tion groups where new HIV in­fec­tions are oc­cur­ring.

Ernest Mas­si­ah